Gyn 2 Flashcards
What is amenorrhea, what is the most common type, what needs to be ruled out and what do you need to be sure of to properly assess, amenorrhea?
defined as pathological absence of menstruation (usually endocrine dysfunction)
There are primary and secondary subtypes, secondary is most common (menses ceases >3-6 months & other symptoms are ruled out: pregnancy, lactation, menopause)
MAKE SURE the female has had her first menses!!! REALLY IMPORTANT QUESTION TO ASK
etiology of amenorrhea can be divided into two categories: ___ and ___? which is most common?
anovulatory (MOST COMMON)- ovulation and menses absent - generally functional cause, mild decrease in E or ovulatory (LESS COMMON)- no menses, normal hormone function
There are 4 broad aspect causes of anovulatory amenorrhea - what are they?
- Hypothalamic Dysfunction - Anorexia nervosa, Severe stress
- Pituitary Dysfunction -
Galactorrhea, Benign Pituitary Tumor - Ovarian Failure/Dysfxn -
Autoimmune disorders, Addison’s dz, DM - Other Endocrine Dys - Hyperthyroidism (shuts down menstruation), Hypothyroidism (elevated prolactin), Obesity
what tests would you order for amenorrhea?
pregnancy test (-)
**FFT (free T3, free T4, TSH) & prolactin
FSH and estradiol levels
TVUS
if virilzation (PCOS, Cushing's, androgen secreting tumor) - Free testosterone and DHEA
What additional questions should be asked in diagnosing amenorrhea?
Hx of: Endometriosis, Uterine Surgery, Celiac Disease
Medication - antidepressents (drug-induced virilization), antipsychotic drugs, phenothiazines, anti-HTN, opioids
What are key features of Cushing’s disease
moon facies
truncal obesity
abdominal striae
thin extremities
what are key features of hirsutism, what causes this?
male pattern hair growth in women (face, chest, back)
-excess androgens, testosterone.
What are red flags of amenorrhea?
delated puberty (r/o genetic disorder) virilization (PCOS, Cushing's, androgen secreting tumor) visual field defects (prolactinoma)
what are the most common causes of secondary amenorrhea?
Pregnancy!!!!!
PCOS
Obesity
Thyroid Dysfunction
Dysfunctional Uterine Bleeding (DUB) is defined as? What periods of life does it occur? How it it diagnosed?
DUS - abnormal uterine bleeding in the absence of clinical or US evidence of structural Abnormalities (fibroids, polyps , cancer, hyperplasia)
occurs in anovulatory states (puberty, >45 y/o)
PCOS is also a common cause of involution
Diagnosis of Exclusion
There are two types of DUB, Anovulatory and Ovulatory - what are the differences?
Anovulatory - unopposed estrogen. No progesterone. excessive proliferation of the endometrium
Ovulatory - prolonged progesterone secretion - most likely due to LOW ESTROGEN levels
What tests would you order to help diagnose DUB?
Pregnancy
CBC & ferritin
TVUS - r/o structural abn
Serum salivary progesterone - day 21 - if <3 ng/mL= anovulation
What increases in the uterus that contributes to primary dysmenorrhea?
too much prostaglandin - it causes constriction of blood vessels which causes cramping.
This is the MOST COMMON form of dysmenorrhea
What are the most common causes of secondary dysmenorrhea?
secondary is due to underlying pelvic abnormalities
- endometriosis is most common
- adenomyosis
- Fibroids
compare and contrast primary and secondary dysmenorrhea
both have pain at or around time of menses
primary has - normal pelvic exam, symptoms occurring when ovulatory cycles begin, peaks in the late teens, early 20s, with response to medical therapy
secondary - pelvic exam is abnormal, more likely to require surgical intervention
what are red flags for dysmenorrhea
new or sudden onset pain
unremitting pain
fever
vaginal d/c
What are common ssx of PMS
weight gain breast swelling and pain bloating anxiety anger
What is diagnostic criteria for PMDD?
must have > 5 of the following most of the week before menses with at least one being from the first 4 in this list:
- feelings of sadness, hopelessness, self-depreciation
- tense (on edge) feeling or anxiety
- emotional liability with frequent tearfulness
- irritability or anger leading to interpersonal conflicts
- loss of interest in daily activities
- decreased concentration
- fatigue, lethargy, lack of energy
- change in eating habits (binging)
What 3 symptoms need to have 2/3 to be present for PCOS diagnosis?
hyperandrogenism
anovulation
polycystic ovaries (TVUS)
what metabolic abnormalities are observed in PCOS?
“the pivotal underlying issue is the woman’s inability to process insulin in the liver and muscles due to a probable genetic susceptibility that causes hyperinsulinemia”
hyperinsulinemia - glucose issues
abn lipid
obesity
metabolic syndrome
what labs/imaging needs to be ordered for diagnosis of PCOS?
salivary/serum E,P,T,DHEA,cortisol Thyroid Prolactin Fasting Glucose/insulin TVUS
** women meeting the criteria need serum cortisol to rule out Cushing’s syndrome **
what is premature ovarian failure and what do we need to make sure to tell our patients?
premature ovarian failure is when ovaries do not produce enough estrogen despite high gonadotropin hormones in women <40
** Women need to know, when diagnosed with this condition, 10% of women STILL CONCEIVE WITHOUT MEDICAL INTERVENTION!!! **
what is diagnostic of premature ovarian failure?
serum FSH, estradiol - IF FSH is >20 IU/mL and E < 20 pg/mL
repeat in 1 month
If the same? DIAGNOSTIC
always rule out pregnancy.
what is the hallmark of perimenopause?
change in menses, change in bleeding pattern - if she’s consistent normally - it’s a change in the cycle
usually begins in the 40s
what are the common ssx of menopause?
changes in bleeding patterns with menses
hot flashes/sweating
vaginal dryness, atrophy
recurrent night sweats
what health problems are associated with menopause?
OSTEOPOROSIS!!!! - if she's celiac, she'll see bone loss in the vertebrae due to lack of mineral absorption - run a bone mineral density in women over 65 CVD - increased fasting blood glucose - Boston Heart Panel - check lipids BREAST CANCER - each decade of life, increased risk
diagnosis for menopause is..
clinical
cessation of menses (age >50) with hx of irregular menses
- FSH consistently increasing levels, suggestive of menopause
-POST MENOPAUSAL WOMEN ARE AT INCREASED RISK FOR OSTEOPOROSIS
evaluate these women - thyroid, adrenal dysfunction, celiac
what risk factors are associated with menopause?
> 7 oz alcohol/week menses cessation > 6 mo cigarette smoking Rheumatoid Arthritis sedentary lifestyle low BMI
What are secondary causes of amenorrhea? What labs would you order to rule them out?
BABY - test beta-hCG
Hypothalamic - test FSH and Prolactin, prolactin rules out a pituitary tumor
PCOS - test insulin
also - test the thyroid, always.
If anything suggests virilization - what condition should be your first thought?
PCOS
For Dysfunctional Uterine Bleeding (DUB), what hormone is high? what test would you order?
Estrogen levels would be high, with a lack of opposition from Progesterone. Test Progesterone levels.
Also test Ferritin to assure she hasn’t become anemic
serum P, E
When during the cycle is PMS observed while also being diagnostic for PMS?
onset occurs a week before menses, during the luteal phase.
symptoms are relieved by onset of menses.
What hormones are high when a patient is diagnosed with PCOS?
LH will be 2-3x higher than FSH (opposite of what it would be normally)
PCOS presents with a few key features - what are these?
What labs would you order and why?
hyperandrogenism (hirsuitism!! male pattern baldness, facial hair..)
hyperinsulinemia (resulting in low glucose levels)
cystic stones visualized TVUS
Test salivary hormones with this condition. While also testing glucose levels
What is the normal age for menopause? what are common symptoms?
45-55
hot flashes, vaginal dryness, osteoporosis
What is the definition of perimenopause?
cessation of menses due to non-iatrogenic ovarian failure before the age of 40
When PID presents, what does it look like? what would physical exams reveal?
it’s essentially an ascending vaginitis issue
pt presents with fever, pain and discharge
on PE you’ll find
- inguinal LA tender to palpation
- a fever greater than 101
- CMT
- BL adnexal tenderness
