Office- Abnormal uterine bleeding/Infertility Flashcards
What are the causes of abnormal uterine bleeding?
Structural causes
P-Polyp
A- Adenomyosis
L- Leiomyoma
M- Malignancy/hyperplasia
Non structural causes
C- Coagulopathy
O- Ovulatory dysfunction
E- Endometrial
I- Iatrogenic
N- Not yet classifies
What is the most common differential for abnormal uterine bleeding in age group of 13-18?
- HPA axis immaturity- Anovulation
- Pregnant
- Infection
- Bleeding disorders- coagulopathies
- Tumors
- Hypothalamic dysfunction- stress, eating disorders, excess exercise
What is the most common differential for abnormal uterine bleeding in age group 19-39?
- Pregnancy
- Fibroids/polyps
- Hyperplasia/Malignancy
- Anovulation- PCOS
- Hormonal contraceptives
What are the most common differential diagnoses for abnormal uterine bleeding in age group 40 years and above?
- Malignancy/hyperplasia
- Fibroids/polyps
- Anovulation- declining ovarian function
- Atrophy
How do you evaluate abnormal uterine bleeding?
- Medical history
- Physical exam
- Lab workup
- hcg, CBC, TSH, cervical cultures, PT/PTT, endometrial biopsy - Imaging
- Transvaginal ultrasound, sonohysterogram, hysteroscopy, MRI
When is endometrial sampling indicated for abnormal uterine bleeding?
- Women >45 with AUB
- Women <45 with risk factors
- unopposed estrogen - Women who fail medical management of AUB
- Women with persistent AUB
What is the treatment for abnormal uterine bleeding?
HMB= OCPs, NSAIDS, TXA, IUD
Anovulation= OCPs, MPA, IUD
Acute and severe bleeding= IV estrogen, OCP taper, D&C
Chronic bleeding= endometrial ablation, UAE, hysterectomy
What is premenstrual syndrome?
A combination of physical and emotional symptoms women get after ovulation and before onset of menses
What is premenstrual dysphoric disorder?
Severe form of premenstrual syndrome with physical and emotional symptoms present after ovulation and with a few days of menstrual cycle.
What is the treatment for PMDD?
Dietary changes
- reducing caffeine, alcohol, salt, fat
- increasing vitamin B6, Ca/Mg, exercise, stress reduction
Medications:
- diuretics, SSRI, Danazol, GnRH agonists
What is galactorrhea?
Bilateral milky nipple discharge
What stimulates prolactin?
TRH
Nipple stimulation
What inhibits prolactin?
Dopamine
Prolactin inhibitory factor
What is the workup for galactorrhea?
Medication history
Breast exam
Prolactin level
TSH
Visual field test
MRI of pituitary fossa
How do you treat galactorrhea?
dopamine agonist
Cabergoline
Bromocriptine 2.5mg BID
When do you start workup for infertility?
Any time if there is anovulation or history of male infertility
or
<35: after 12 months of attempting
>35: after 6 months of attempting
What is the workup for infertility?
- Medical history
- Assess menses
- confirm adequate intercourse
- PMH
- FH - Workup
- Midluteal progesterone
- Test tubal status with HSG, laparoscopy
- Test semen
- Ovarian reserve testing if >35
How long does it take for ovulation after LH surge?
36 hours
How long does it take for ovulation after LH peak?
12 hours
What things can decrease your ovarian reserve?
Age>35
Smoking
Ovarian surgery
History of chemo
Family history of early menopause
Genetic condition
What is the dose of clomiphene?
Dose 50mg x 5 days starting on Day 5 of cycle
How does clomiphene work?
anti estrogen
Competes for estrogen binding receptors with minimal stimulation
Ovulation takes place 5-10 days after last pill.
Instruct to start intercourse every day or every other day 5 days after last pill
What are the side effects of clomiphene?
Headache
Dizzy
blurred vision
What is the dose of letrozole?
2.5mg/day for 5 days starting day 3 of cycle
How does letrozole work?
Aromatase inhibitor
Blocks synthesis of estrogen which reduces feedback at pituitary level
