week 9- gyn 2 Flashcards
• What are 4 types of abnormal menstruation?
o Amenorrhea
o Dysfunctional uterine bleeding (DUB)
o Dysmenorrhea (primary or secondary)
o Premenstrual syndrome (PMS)
• What is amenorrhea? 2 types? 2 etios?
o pathological absence of menstruation
o usu dt endocrine dysfxn → anovulation
o or dt genital anatomic AbN (ovulatory amenorrhea)
o Primary: no menarche by 16, > 2yrs after the onset of puberty or if no signs of puberty by 14
o Secondary: menses cease 3 - 6 mos, not pregnant, lactating, or menopausal
o Etio: anovulatory, ovulatory
• What is anovulatory amenorrhea?
o Both ovulation & menses are absent
o Mc, dt functional causes
o HPA intact, ovaries functional, gonadotropin secretion is → mild E deficiency
o Causes: hypothalamic, pituitary, ovarian, other endocrine dos, some genetic dos
o Hypothalamic causes: multifactorial, mb unknown factors
o Endocrine causes: altered level free testosterone, androgens, or E dt: Lack of SHBG (chronic Lv dos, obesity, PCOS, DM), Excessive extraglandular prod of E (obesity), Ovarian or adrenal androgen excess, PCOS
• What is ovulatory amenorrhea? 2 types?
o Less common
o Dt anatomical genital AbN, normal hormonal function
o Ovarian fxn normal, external genitalia & secondary sex characteristics dev normally
o Acquired uterine abn: Acquired endometrial lesions (Asherman’s syndrome, endometrial TB), Obstructive fibroids and polyps
o Congenital genital abn: Cervical stenosis (rare), Imperforate hymen, Male pseudohermaphroditism (rare), Transverse vaginal septum (rare), Vaginal and uterine aplasia (rare)
• What could cause hypothalamin dysfxn w anovulatory amenorrhea? Pituitary dysfxn? *=chronic
o H: Anorexia nervosa, Excessive exercise, Hypothalamic chronic anovulation, Kallmann’s syndrome (rare), Prader-Willi syndrome (rare), Psychogenic factors (severe stress), Tumors (hamartomas, gliomas), Weight loss (acute), Undernutrition (chronic)
o P: Galactorrhea* (hyperprolactinemia), Benign pituitary adenoma, Hypopituitarism* (dt Sheehan’s syndrome, head trauma, tumor), Isolated gonadotropin deficiency, Panhypopituitarism, Pituitary tumors* (Forbes-Albright syndrome), Antipsychotic drugs (olanzapine)
• What could cause ovarian failure/dysfx with anovulatory amenorrhea? Other endocrine? Genetic dos? *=chronic
o Ov: AI, Chemo and pelvic irradiation, Congenital thymic aplasia, Galactosemia, Gonadal dysgenesis (very rare), Metabolic dos (Addisons dz, DM), Viral infx (mumps)
o Other: Congenital or adult-onset adrenal virilism, Cushing’s, Drug-induced virilization (antidepressants), Hyperthyroid, Hypothyroid, Obesity, PCOS*, Tumors producing androgens, estrogens, or hCG
• How do you diagnose amenorrhea?
o Eval girls w No signs of puberty by 14, If no menarche by 16, 2 yrs since onset of puberty
o Women of reproductive age: if 2nd amenorrhea (3-4% of women), (+) preg test, Missed menses 3 mos, < 9 menses/yr (avg 46 d), Sudden change in menstrual pattern
• How do you take hx for amenorrhea?
o Menstrual hx very important: have they ever had a menses before?
o Possibility of pregnancy
o Risk factors:
o Genetic cause of primary: abn growth and dev, FHx genetic defects
o Hypothalamic: wt change, Dietary deficiencies, Excess exercise, Enviro stress
o asherman’s: Hx D & C, endometritis, obstetric hx, uterine surgery, meds that can cause virilism or galactorrhea (antidepressants cause drug-induced virilization, antipsychotics, phenothiazines, certain anti-hypertensives, opioids)
o endocrine d/os
• what are ssx of endocrine dos that can cause amenorrhea?
o Thyroid: fatigue, cold/heat intolerance, constipation, dry/moist skin, conc, myxedema, palpitations, nervousness, tremor, insomnia/hypersomnia
o Virilization – hirsutism, temporal balding, deepening voice, mm mass, clitoral enlargement, in previously normally dev 2nd sex characteristics ( breast size, vaginal atrophy); consider true hermaphroditism, pseudohermaphroditism, gonadal dysgenesis, PCOS, virilizing ovarian or adrenal tumor, Cushings, adrenal virilism, genetic do
o estrogen deficiency: hot flashes, vaginal dryness, sleep disturbances, fractures, ↓ libido
o Obesity in hirsute women: prob PCOS
o Cushngs: Moon facies, truncal obesity, abd striae, thin extremities
o Assess 2nd sex characteristics using Tanner method
o Assess for nipple d/c & galactorrhea – prob hyperprolactinemia
• What do you look for on PE for amenorrhea cc? red flags?
o Vitals, ht & wt BMI, waist circumference
o Thyroid: enlargement, tenderness, nodularity
o Breast exam: nipple d/c
o Anatomic genital d/o’s
o Ambiguous genitals – virilization, true hermaphroditism, male or female pseudohermaphroditism
o Fused labia or clitoromegaly: exposure to androgens in 1st tri, congenital adrenal virilism, true hermaphroditism, drug-induced virilization.
o In girls not yet sexually active: external genital exam only; only do speculum/bimanual exam if other assessment does not reveal cause
o Absent cervix & uterus, ext genitalia is N, 2nd sex characteristics are not fully dev: androgen insensitivity syndrome
o Reproductive age women 2nd amenorrhea: Vitals (hypothermia, bradycardia, hypertension), BMI, waist:hip ratio, Thyroid exam, DTR’s, skin, abdominal, Pelvic exam
o RF: Delayed puberty (r/o genetic do), Virilization (PCOS, Cushing’s, androgen secreting tumor), Visual field defects (prolactinoma)
• What labs are done for amenorrhea?
o Preg test
o Thyroid study: FFT (free T3, free T4, TSH), prolactin. TSH > 3.5 =hypo. Thryroid dz common, hypo ↑ prolactin levels in 40% of women (dt ↑TRH, TSH)
o Prolactin: ↑ (>20 ng/mL) w/o thyroid dz mb pituitary tumor [microadenoma (10mm)] → MRI
o FSH & estradiol: > 30 suggests POF, retest in 1 mo before making dx. ↓FSH & estradiol indicate hypothalamic anovulation/amenorrhea
o Free testosterone, DHEAS,
FSH/LH: Mild of either suggest PCOS. FSH/LH normal ratio 3:1, in PCOS will be 1:3.If LH or FSH 200 ng/dL mb ovarian/adrenal tumor
o DHEA 500 g/dL mb adrenal tumor, adult-onset adrenal virilism
o Metabolic: CMP (systemic dos), CBC (anemia), ESR, celiac panel
o Bone age: for primary amenorrhea only
• What is work-up of labs are normal with primary amenorrhea?
o TVUS → normal uterus = hypothalamic anovulation
o If TVUS → uterus absent = Rokitansky syndrome
o If TVUS → uterus enlarged = imperforate hymen
o Karyotype testing if genetic defect is suspected
• How can you determine if there’s an E deficiency with amenorrhea?
o Progenertone challenge: Provera 5-10 mg po qd x 5 days OR Micronized progesterone 100-200+/day x 5 days; see if it induces a period
o Bleeding: she has E, but anovulation
o No bleed: no E, or some obstruction with outfow
o Many gyn expterts think doesn’t have consistent results, not necessary if run FSH and estradiol
o isn’t as dependable so most don’t use it routinely.
• What is the mc cause of primary amenorrhea?
o Physiologic/constitutional delay of puberty
o Functional hypothalamic chronic anovulation (excessive exercise, eating dos, stress)
o Delayed growth may accompany these sxs
• what are mc causes 2nd amenorrhea?
o Pregnancy - #1, Breast feeding
o PCOS, Obesity,
o Thyroid dysfx, Pituitary dysfx (hyperprolactinemia), Hypothalamic dysfx (excessive exercise, eating dos, stress), Ovarian failure/ insufficiency
o Use/Abuse drugs (OCP, anti-depressants/psychotics, Depo-Provera)
o Remaining etiologies far less common
• What is chronic anovulatory syndrome?
o seen w anorexia, weight loss, low protein intake, exercise with body fat levels below 10%, chronic illness, hypothalamic anovulation, hyperprolactinemia, hypopituitism, pituitary tumors, Cushings, hypo/hyperthyroid, obesity, PCOS, tumors that produce hormones and mb psychogenic.
• What drugs could cause hyperprolactinemia with amenorrhea? Other possible finding?
o Affect DA (Anti-HTN, Anti-psychotics (2nd gen or conventional)
o Cocaine, Estrogens, GI Drugs, Hallucinogens, Opioids, TCAs
o Mb also galactorrhea
• What drugs could cause drug-induced virilization w amenorrhea?
o Hormones and certain other drugs that affect the balance of estrogenic and androgenic effects
• How can body habitus indicate causes of amenorrhea?
o ↑BMI (>30): virilization, extrogen excess, PCOS
o ↓BMI (<18.5): chronic do, dieting, eating do; Functional hypothalamic anovulation dt anorexia nervosa, starvation, bulimia w freq vomit; ssx: Hypothermia, bradycardia, hypotension, Reduced gag reflex, palatal lesions, subconjunctival hemorrhages
o Short stature: turner’s; Primary amenorrhea, webbed neck, widely spaced nipples
• What skin abnormalities could help dx cause of amenorrhea? Other possible findings
o Warm, mosit: hyperthyroid; aslo tachycardia, tremor
o Course, thick, loss eyebrow hair: hypothyroid; Bradycardia, delayed DTRs, weight gain, constipation
o Acne: virilization, Androgen excess dt PCOS, androgen-secreting tumor, Cushing’s, adrenal virilism, drugs
o Striae: cushings; Moon faces, buffalo hump, truncal obesity, thin extremities, virilization, HTN
o Acanthosis nigricans: PCOS; obesity, virilization
o Vitiligo/hyperpigmented palm: addison’s; orthostatic hypotension
• What are some general findings suggesting estrogenic or androgenic abn, w amenorrhea?
o sxs of E def: hot flashes, night sweats, vag dryness, atrophy; dt Premature ovarian failure/primary ovarian insufficiency; risk factors: oophorectomy, chemo, pelvic irradiation
o hirsutism w virulism, 1st amenorrhea: Androgen excess dt PCOS, androgen-secreting tumor, Cushing’s, adrenal virilism, drugs; OR dt hermaphroditism, pseudohermaphroditism, gonadal dysgenesis, genetic d/o
o H,V w enlarged ovaries: Androgen excess dt 17-hydroxylase deficiency, PCOS, or androgen-secreting ovarian tumor
• What are some breast and genital abn seen w amenorrhea? Possible cause and other findings?
o Galactorrhea: hyperprolactinemia, pituitary tumor; Nocturnal HA, visual field defects
o Absent/incomplete dev breasts (& 2nd sex charact): normal adrenarche (1st anov amen dt isolated ovarian failure); absent adrenarche (1st anov amen dt HP dysfx); no adrenarche & impaired smell (kallmann syndrome)
o Delay brest dev and 2nd sex: constitutional delay of growth and puberty; FHx delayed menarche
o Normal dev, 1st amen: genital outflow obstruction; Cyclic abdominal pain, bulging vagina, uterine distension
o Ambiguous genitals: True hermaphroditism, Pseudohermaphroditism, Virilization
o Fused labia, clitoral enlargement at birth: Androgen exposure in 1st tri, mb congenital adrenal virilism, true hermaphroditism, drug-induced virilization
o Clitoral enlargement after birth: Androgen-secreting tumor (usu ovarian), Adrenal virilism, anabolic steroids; virilization
o Norm ext gen, incomplete dev 2nd sex (st breast, min pubic hair): Androgen insensitivity syndrome; Apparent absence of cx and uterus
o Ovarian enlargement (BL): Premature ovarian failure dt AI oophoritis (Sxs of E def); virilization (dt PCOS, 17-hydroxylase def)
• What lesion could indicate cause of amenorrhea?
o Pelvic mass (UL) → pelvic tumors, pelvic pain
• What is dysfunctional uterine bleeding?
o no clinical or US evidence of structural AbN, inflammation, CA, systemic do, preg/complication, OCPs, certain drugs (dx of exclusion)
o >50% cases > 45; in puberty (20% of cases); =common periods in life when anovulation occurs
o PCOS also common cause of anovulation.
o 90% are anovulatory, 10% ovulatory
• What is pathophysiology of an/ovulatory DUB?
o A: w/o progesterone secretion from corpus luteum → excessive proliferation of endometrium, eventually outgrows blood supply; sloughs and bleeds incompletely, irregularly, st profusely or long time. if repeatedly, endometrium → hyperplastic, mb dysplasia
o O: progesterone secretion is prolonged → irregular shedding of endometrium, dt ↓ E (near threshold for bleeding like during menses). Obese: can occur if ↑E → amenorrhea alt w irregular or prolonged bleeding
• What are ssx of DUB?
o Polymenorrhea: menses < 21 d
o Menorrhagia: > 7 d or > 80 ml
o Metrorrhagia: occur frequently & irregularly between menses
o Anov DUB: unpredictable times, patterns, no cyclic changes in BBT
o Ovu DUB: excessive bleeding w menses; usu sxs of ovulation (breast tenderness, midcycle cramping, change in BBT, st dysmenorrhea)
• What labs are done for DUB?
o Preg
o CBC & ferritin
o r/o coag dos in adolescents w DUB & anemia or hospitalized for bleeding
o LFTs
o Thyroid panel (FFT) & prolactin
o Serum/salivary PG, d 21, serum < 3 ng/mL = anovulation
o Serum/salivary T & DHEAS, r/o PCOS
o Pap if no test in >1 yr
o GC/CT if suspect PID, endometritis, cervicitis
• What imaging/procedures are done for DUB?
o TVUS: r/o structural AbN: >35 or unopposed prolonged E in younger, Risk factors for endometrial CA, Bleeding continues despite empiric hormonal tx
o EMB: R/O hyperplasia: >35 or unopposed E, obese, PCOS, DM, HTN, endometrial thickness > 4 mm, inconclusive TVUS findings
o Hysterectomy: if findings of adenomatous hyperplasia
• How is DUB diagnosed?
o If all clinically indicated tests are normal
• What is dysmenorrhrea? Ssx? Etio?
o uterine pain assoc w menses either primary (MC) or secondary (dt pelvic abn)
o w menses or precede by 1-3 d, peak 24 hrs after onset, subside after 2-3 d
o sharp, or cramping, throbbing, dull, constant ache
o may radiate to the legs
o H/A, N/D/V, constipation, ↓BP, urinary freq. S/t endometrial clots or casts
• What is primary dysmenorrhea?
o Begins adolescence, no underlying gyn structural do, st improves w age and preg
o Occurs in ovulatory cycles
o RFs for severe sxs: early menarche, long or heavy periods, smoking, FHx
o MOA: ↓ P→ lysosome breakdown → enzymes → ↑ PGs in uterus (endometrium/menstrual fluid) → ↑ uterine contractions & ischemia
o Factors: menstrual tissue thru os, narrow os, Malpositioned uterus, ↓exercise, Anxiety about menses
• What is 2nd dysmenorrhea?
o begin in adulthood, underlying pelvic AbN causes pain wi menstruation
o MC causes: Endometriosis (mc), Adenomyosis, Fibroids
o Other: Congenital malformations, Ovarian cysts and tumors, PID, Pelvic congestion, Copper IUD, Narrow os dt conization, cryotherapy, or LEEP; Pedunculated submucosal fibroid or endometrial polyp thru cervix
• What should you ask on hx for dysmenorrhea? PE? Red flags?
o Usu hx
o degree of disruption of daily life and presence of pelvic pain unrelated to menses
o Effect of contraceptives on pain: Paragard IUD ↑, OCP’s & Mirena IUD ↓
o Identify known causes such as endometriosis, adenomyosis or fibroids
o PE: pelvic exam
o RFs: New or sudden-onset pain, Unremitting pain, Fever, Vaginal d/c
• What is work-up for dysmenorrhea?
o Preg
o TVUS
o If suspect PID: cx culture or urine GC/CT
o If inconclusive and sxs persist, sonohysterogram (SIS) or hysterosalpingogram (HSG)
o →MRI
o →Hysteroscopy or laparoscopy
• What is tx for dysmenorrhea?
o Tons of ND treatments
o Anti-PG drugs (ASA, ibuprofen), caffeine, painkillers
o Low dose OCP
o Local heat, exercise
• What is PMS (premenstrual syndrome)? Etio?
o sxs in 2nd ½ of cycle (7-10 d before menses), relieved w flow onset
o Related to AbN responses to fluctuations of E and P
o Fluid retaining effects of E, P, aldosterone, ADH
o changes in CHO metabolism in luteal phase, and adrenal production of corticosteroids
o Possible hypoglycemia, hyperprolactinemia
o Possible serotonin connection
• What are ssx of PMS and PMDD?
o Intensity of sxs vary from pt to pt & from cycle to cycle
o Sxs last a few hrs to 10 d
o as many as 200 diff sxs assoc, MC >30, in some starts after childbirth
o common: wt gain, bloating, breast swelling and pain, H/A, fatigue, lethargy, anxiety, anger, irritability, depression, insomnia, salt/sugar cravings, emotional lability, pelvic heaviness/ pressure, backache
o less: dermatitis, acne, migraine/HA, vertigo, asthma, exacerbation of mental illness, paresthesias of extremities, N/V/D, constipation, syncope, palpitations, Changes in appetite
o generally very regular, rarely have severe cramping
• what is PMDD (premenstrual dysphoric do)?
o Severe PMS sxs
o marked depressed mood, anxiety, irritability, emotional liability
o mb Suicidal thoughts
o Interest in daily activities is greatly decreased
o severe enough to interfere w routine daily activities or overall fxn
• how are PMS and PMDD diagnosed?
o Both: PMS diary for 2-3 months
o PMDD: sx pattern for most of past yr, severe enough to interfere w daily activities and fxn
o >5 of following sxs for most of wk before menses, at least 1 of first 4:
o Feeling sad, hopeless, self-depreciation
o tense (on edge) feeling or anxiety
o Emotional liability w freq tearfulness
o Irritability or anger, ↑ interpersonal conflicts
o Loss of interest in daily activities →withdrawal
o ↓ concentration
o Fatigue, lethargy
o Changes in eating habits, including binging
o Insomnia or hypersomnia
o Feelings of being overwhelmed or out of control
o Physical sxs assoc w PMS
• What is ddx of PMS/PMDD? Labs? Tx?
o Ddx: Thyroid dz, Other hormonal dos, Affective dos
o Labs: No specific
o Tx: individual; diet, lifestyle, counseling, supplements (Mg, B vits, Ca, others), drugs (SSRI’s, OCPs)
• What is PCOS?
o Aka Hyperandrogenic Chronic Anovulation
o 5-10% of women
o Mb or no ovarian pathology: mb enlarged w 2-9mm follicular cysts w atretic cells
o Presents w anovulation & androgen excess
o Etio unclear: many metabolic AbN (hyperinsulinemia/glucose issues, lipid AbN, obesity, metabolic syndrome, E & T, P, AbN FSH:LH ratio [1:3 instead of normal 3:1])
o ** can’t process insulin in liver and muscles dt probable genetic susceptibility that causes hyperinsulinemia, all other factors are considered downstream
• What are ssx of PCOS?
o Usu start w menarche & worsen w time
o Irregular menses: oligomenorrhea, polymenorrhea, amenorrhea
o Hirsutism, acne, temporal balding
o Acanthosis nigricans
o Mild to severe obesity
o Mb enlarged ovaries/cystic ovaries
o Dx: signs of anovulation & hyperandrogenism
o Untx, serious: CVD, DM II, metabolic syndrome, endometrial CA, mb BR CA (due to ↑ E and T, hyperinsulinemia, ↓ P)
• What is work-up for PCOS?
o Preg o Salivary or serum E, P, T, DHEA, cortisol o Serum FSH/LH o Thyroid studies (FFT) and Abs o Prolactin o FG, GITT (insulin) & lipids o TVUS: string of pearls ovary
• How is PCOS diagnosed?
o Suspect if at least 2 typical sxs
o 2/3:
o Ovulatory dysfunction causing menstrual irregularity
o Clinical or biochemical evidence of hyperandrogenism
o >10 follicles per ovary on TVUS, usu in periphery, like string of pearls
o →serum cortisol to exclude Cushings
o → fasting serum 17-hydroxyprogesterone to exclude adrenal virilism
• What is tx for PCOS?
o Lots of ND treatments
o Conventional: OCPs, Metformin (also on our formulary)
o Prevent major sequelae of dz: CVD, Endometrial CA, DM II, Metabolic Syndrome, breast CA
