GYN part 2 Flashcards
AMENORRHEA
Defined as pathological absence of menstruation.
Usu czed by an endocrine dysfxn resulting in anovulation
May also be caused by genital anatomic AbN (ovulatory amenorrhea)
Primary amenorrhea
lack of menarche at the age of 16, > 2yrs after the onset of puberty or if no signs of puberty by 14 yo
Most common cause of primary amenorrhea:
Physiologic/constitutional delay of puberty
Functional hypothalamic chronic anovulation (excessive exercise, eating d/os, stress)
Delayed growth may accompany these symptoms.
Chronic anovulation: complex causes in which diet, stresses, systemic disease, hypothalamic dysfxn, pituitary dysfxn, other endocrine dysfxn, exercise, environment, and body fat composition may play a part.
Secondary amenorrhea
menses cease > 3 - 6 months & the woman is not pregnant, lactating, or menopausal
Most common cause of secondary amenorrhea: pregnancy PCOS thyroid dysfunction ovarian insufficiency
etiology of amenorrhea
Typically divided into anovulatory & ovulatory
Anovulatory Amenorrhea
Both ovulation & menses are absent
Most common – results from functional causes
HP axis is intact, ovaries are functional, & gonadotropin secretion is ↓ → mild E deficiency.
Ovulatory Amenorrhea
Less common – results from anatomical genital AbN in women with normal hormonal function
Ovarian fxn is normal – external genitalia & secondary sex characteristics dev normally.
Causes of ovulatory amenorrhea
acquired - Asherman’s syndrome
congenital - Imperforate hymen
Cause of anovulatory amenorrhea
hypothalamic dysfunction - anorexia, excessive exercise, acute WT loss
pituitary dysfunction - galactorrhea
ovarian failure/dysfunction - AI, chemotherapy
endocrine disorders - hyperthyroidism, Cushing’s
Red flags for amenorrhea
Delayed puberty (R/O genetic disorder) Virilization (PCOS, Cushing’s syndrome, androgen secreting tumor) Visual field defects (prolactinoma)
DYSFUNCTIONAL UTERINE BLEEDING (DUB)
Definition - abnormal uterine bleeding in the absence of clinical or US evidence of structural AbN, inflammation, cancer, systemic d/o’s, pregnancy, complications of pregnancy, use of OC’s or certain drugs (dx of exclusion)
Most commonly occurs in women > 45 yo (> 50% of cases) & in puberty (20% of cases)
These are common periods in life when anovulation occurs.
PCOS is also a common cause of anovulation.
About 90% of cases are anovulatory and 10% are ovulatory
pathophysiology of DUB
Anovulatory – without progesterone secretion from the corpus luteum there is an excessive proliferation of the endometrium, eventually outgrowing its blood supply; it sloughs and bleeds incompletely, irregularly & sometimes profusely or for a long time. When this occurs repeatedly, the endometrium can become hyperplastic, sometimes with atypical or cancerous cells.
Ovulatory – progesterone secretion is prolonged; irregular shedding of endometrium results, most likely due to low estrogen levels – near threshold for bleeding like during menses. In obese women this can occur if estrogen levels are high, resulting in amenorrhea alternating with irregular or prolonged bleeding.
SSX of DUB
Polymenorrhea – menses < 21 days
Menorrhagia - > 7 days or > 80 ml
Metrorrhagia – occur frequently & irregularly between menses
Anovulatory DUB – tends to occur at unpredictable times & in unpredictable patterns & is not accompanied by cyclic changes in basal body temp.
Ovulatory DUB – tends to cause excessive bleeding during menstrual cycles – usually there are sxs of ovulation such as breast tenderness, midcycle cramping, change in basal body temp, & s/t dysmenorrhea.
History/PE/DX of DUB
Pregnancy test – even in young adolescent & perimenopause women CBC & ferritin – anemia Coagulation d/o’s should be R/O in adolescents who have DUB with anemia or require hospitalization for bleeding. Thyroid panel (FFT) & prolactin TVUS – R/O structural AbN Age ≥ 35 or if unopposed estrogen exposure in a younger woman Risk factors for endometrial cancer are present Bleeding continues despite use of empiric hormonal therapy.
DYSMENORRHEA
Definition: uterine pain associated with menses either primary or secondary
Etiology of dysmenorrhea
Primary (more common)
Secondary (due to pelvic abnormalities)
Primary Dysmenorrhea
Begins during adolescence, no underlying gynecological structural d/o.
Usually appears during adolescence and sometimes improves with age and pregnancy.
MOA: ↓ progesterone → lysosome breakdown → enzymes → ↑ prostaglandins in the uterus (endometrium/menstrual fluid) → ↑ uterine contractions & ischemia.
Secondary Dysmenorrhea
Usually beginning in adulthood Due to an underlying pelvic AbN causing pain with menstruation commonly: Most common causes: Endometriosis – most common Adenomyosis Fibroids
Red Flags for dysmenorrhe
New or sudden-onset pain
Unremitting pain
Fever
Vaginal d/c
PMS (PREMENSTRUAL SYNDROME)
Definition: symptoms that occur during the second half of the cycle (luteal phase 7-10 days before menses) and are relieved with the onset of the flow
Some common symptoms and signs of PMS
weight gain bloating breast swelling and pain
headache fatigue lethargy anxiety anger
irritability depression insomnia salt/sugar cravings
emotional lability pelvic heaviness/pressure backache
Etiology of PMS
Related to AbN responses to fluctuations of E and P
Fluid retaining effects of E, P, aldosterone and ADH
There are definite changes in CHO metabolism in the luteal phase, and in
adrenal production of corticosteroids
Possible hypoglycemia, and hyperprolactinemia
Possible serotonin connection
PMDD (PREMENSTRUAL DYSPHORIC DISORDER)
Definition/Presentation:
Severe PMS sxs occurring only during the 2nd half of the menstrual cycle ending with onset of menses or shortly thereafter
Mood is markedly depressed and anxiety, irritability, and emotional liability are pronounced
Suicidal thoughts may be present
Interest in daily activities is greatly decreased
Sxs are severe enough to interfere with routine daily activities or overall fxn
Diagnosis is clinical for Premenstrual Dysphoric Disorder (PMDD)
PMS - have her fill out PMS diary for 2-3 months
PMDD – a diary for 2 or more cycles to determine whether sever sxs occur regularly.
Must have ≥5 of the following sxs for most of the week before menses and at least 1 sx must be from the first 4 on the list:
Feelings of sadness, hopelessness, or self-depreciation
A tense (on edge) feeling or anxiety
Emotional liability with frequent tearfulness
Irritability or anger that persists leading to ↑ interpersonal conflicts
Loss of interest in daily activities, possibly causing withdrawal
↓ concentration
Fatigue, lethargy, or lack of energy
Changes in eating habits, including binging
Insomnia or hypersomnia
Feelings of being overwhelmed or out of control
Physical sxs associated with PMS
Also, the sx pattern must have occurred for most of the previous 12 months and sxs must be severe enough to interfere with daily activities and fxn
N LABS INDICATED
POLYCYSTIC OVARY SYNDROME (PCOS)
Overview:
Common female endocrinopathy – occurring 5%-10% of women
It is usually defined as a clinical syndrome
There may or may not be ovarian pathology – the ovaries may be enlarged and contain many 2-9mm follicular cysts containing atretic cells
Presents with anovulation & androgen excess causes - multiple metabolic AbN (hyperinsulinemia/glucose issues, lipid AbN, obesity, metabolic syndrome, ↑ E & T, ↓ P, AbN FSH:LH ratio [1:3 instead of normal 3:1])
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, all other factors are considered to be downstream*
SSX of PCOS
Sxs usually start with menarche & worsen with time
Irregular menses – oligomenorrhea, polymenorrhea, amenorrhea
Hirsutism, acne, temporal balding
Acanthosis nigricans
Mild to severe obesity
May have enlarged ovaries/cystic ovaries
Diagnosis can be made clinically if signs of anovulation & hyperandrogenism are present
Serious sequelae will occur if not dx & treated – CVD, DM II, metabolic syndrome, endometrial carcinoma, possibly breast cancer (due to ↑ E and T, hyperinsulinemia and ↓ P)
Labs/Imaging/Dx for PCOS
Clinical criteria
Pregnancy test
Salivary or serum E, P, T, DHEA, cortisol
Serum FSH/LH
Thyroid studies (FFT) and Abs
Prolactin
Fasting glucose/insulin or (GITT) & lipids
TVUS – may show multiple follicles 2-9mm on the periphery of ovary (string of pearls) – is not diagnostic without anovulation being present.
Dx is suspected if women have at least 2 typical symptoms
Dx requires at least 2 of the 3 following criteria:
Ovulatory dysfunction causing menstrual irregularity
Clinical or biochemical evidence of hyperandrogenism
More than 10 follicles per ovary on TVUS, usually occurring in the periphery, resembling a string of pearls
Women meeting the criteria need serum cortisol to exclude Cushing’s syndrome
To exclude adrenal virilism, run a fasting serum 17-hydroxyprogesterone
PREMATURE OVARIAN FAILURE/INSUFFICIENCY (POF/POI)
Definition – ovaries do not produce enough estrogen despite high levels of gonadotropin hormones (esp. FSH) in women < 40 yo
Etiology for Premature Ovarian Failure/Insufficiency
Autoimmune d/o’s Congenital thymic aplasia Galactosemia Gonadal dysgenesis – d/o’s that confer a Y Physical and environmental factors: Chemotherapy & pelvic irradiation Cigarette smoking Viral infxns (mumps)
SSX for POF/POI
Amenorrhea or irregular blding
Sxs of E deficiency – osteoporosis (fractures), atrophic vaginitis, ↓ libido
Dx is suspected in women < 40 yo with the above sxs
Labs for POF/POI
Pregnancy test
Serum FSH, estradiol – if FSH is > 20 IU/mL (but usually >30mIU/mL) & E < 20 pg/mL repeat in 1 mos if findings are the same ovarian failure is confirmed
MENOPAUSE
Definition - physiological or iatrogenic cessation of menses due to ↓ ovarian function
Physiologic menopause occurs when menses is absent for 1 yr.
Average age for cessation of menses in the US is 51, with the normal
range from 45-55.
