Wk 2 pt 2 highlights Flashcards
1) Define Amenorrhea
2) Define Abnormal Uterine bleeding (AUB)
3) What do both have in common?
1) Absence of menstruation
2) Difference in frequency, duration, & amount of menstrual bleeding
3) Both are the most common gynecologic disorders of reproductive-aged women.
-Pathophysiology often the same for both
1) Define primary amenorrhea
-When should you consider evaluating for this?
2) Define hypomenorrhea
1) No menarche by age 16
Evaluation considered if no menarche by age 15 or no menarche within 3 years of thelarche or no thelarche by age 13
2) Reduction in number of days or amount of menstrual flow
Amenorrhea:
1) Pregnancy is essential to first rule out (most common cause) with what assay?
2) Which test is qualitative? Which is quantitative?
3) Which is usually done first?
1) β-human chorionic gonadotropin (β- HCG)
2) Urine (qualitative) or blood (quantitative)
3) Urine hCG testing is typically done first
If abnl menses, abd pain, & +pregnancy test, always consider ___________ pregnancy
ectopic
1) Define Hypothalamic-pituitary (HP) dysfunction
2) What is not being stimulated? What is not being secreted?
3) What can it cause?
1) Disruption or alteration of pulsatile GnRH secretion
2) Anterior pituitary gland not stimulated to secrete LH & FSH
3) no menstruation
HP amenorrhea
1) What are the common causes of HP amenorrhea?
2) What can you not by history & physical alone?
3) How do you Dx?
1) Functional (ex: Stress, weight loss, excessive exercise, obesity)
2) Ovarian or genital outflow causes
3) Measure FSH, LH, estradiol, & prolactin levels
-FSH, LH, estradiol are low
-Prolactin normal usually (elevated in prolactin-secreting pituitary adenomas)
Give an example of ovarian dysfunction causing amenorrhea
Primary ovarian insufficiency
What does Primary ovarian insufficiency result in regarding hormones?
Blood levels of FSH & LH increase AND estradiol decreases as ovarian function ceases
1) Primary amenorrhea can be an example of what?
2) What are most cases due to? Explain
1) Alteration of genital outflow tract
2) Congenital abnormalities (Müllerian ducts)
Imperforate hymen & absence of uterus or vagina (Mullerian agenesis)
Secondary amenorrhea
1) What is the most frequent anatomic cause of secondary amenorrhea?
2) What is a risk for this?
3) What are most cases corrected with?
4) What may severe refractory cases require?
1) Asherman syndrome
2) Hx of D&C
3) Surgical lysis of adhesions
4) Estrogen postoperatively to stimulate endometrial regeneration
To establish amenorrhea cause:
1) If labs WNL (within normal limits) what test do you use?
2) What does this test establish?
3) What happens if withdrawal bleeding occurs with this test?
4) What if there’s no bleeding?
1) Use the “progesterone challenge” test
2) If patient has adequate estrogen, competent endometrium, & patent outflow tract
3) Patient is either anovulatory or oligo-ovulatory (i.e., PCOS)
4) Patient is either hypoestrogenic or has an anatomic condition
What causes would a progesterone challenge test that results in no withdrawal bleeding point to?
Asherman syndrome, premature ovarian failure or outflow tract obstruction
What is the main Tx for amenorrhea? Give 2 examples
Correct the underlying pathology (if possible)
1) Treat pituitary adenoma: hyperprolactinemia causing amenorrhea & galactorrhea
2) Treat underlying cause of hypothyroidism with thyroxine replacement
What is the main goal of amenorrhea Tx?
Fertility (if desired)
Give 2 examples of AUB etiologies
1) Amenorrhea due to HP dysfunction
2) Oligo-ovulation and anovulation with AUB
List 3 etiologies of AUB
1) Ovulatory dysfunction (most common cause overall)
2) Other nonstructural causes
3) Structural causes
How do you remember the structural and functional causes of AUB?
1) Structural = PALM
Polyp
Adenomyosis
Leiomyoma (fibroid)
Malignancy and hyperplasia
2) Functional: COEIN
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
1) What are the 2 main steps of diagnosing AUB?
2) What are 2 diagnostics that can be used to Dx AUB?
1) a. Always rule out early pregnancy & its complications
b. Exclude anatomic causes
2) TVUS or endometrial biopsy
Define menorrhagia
Irregular episodes of uterine bleeding
Heavy menstrual bleeding (menorrhagia) may present as ___________ or ____________
acute or chronic
Acute AUB: ________________ is reserved for failure of medical therapy & bleeding which precludes medical therapy
Surgery
Acute AUB: What are 3 things you should do?
1) Assess for hemodynamic stability (vitals), anemia, & pregnancy
2) Obtain description
3) Complete Hx can help est categories for PALM-COEIN
Acute AUB: Hospitalization & transfusion usually recommended for severe anemia (Hgb ≤______g/dL) & hemodynamically unstable
7
NSAIDs can help Tx what cause of acute AUB?
Heavy bleeding episode (intermittent)
Give examples of surgeries for acute and chronic AUB
1) Hysteroscopy with D&C
2) Selective embolization of uterine vessels
3) Balloon tamponade
4) Endometrial ablation
5) Hysterectomy
1) How do you Tx AUB?
2) What is an alternative Tx?
1) Progestational agent x >10days (progesterone challenge test)
-Like medroxyprogesterone acetate (Depo-Provera)
2) OCPs
Hyperandrogenic disorders:
1) What is it?
2) What 2 things may indicate underlying androgen excess disorder?
1) Excess secretion of androgens
2) Hirsutism & virilization
Hirsutism: What 2 origins should you consider?
1) Familial origin (idiopathic)
2) Pathologic (PCOS most common)
Modified Ferriman-Gallwey scale:
1) What is it used to Dx?
2) What score warrants a Dx?
1) Hirsutism
2) >8 = hirsutism diagnosis
Virilization:
1) What is it assoc. with?
2) What phenotype does it lead to?
1) Marked increase in circulating testosterone
2) “Masculine” appearance
Hyperandrogenic disorders:
1) What causes them? (hint: it’s obvious)
2) What 2 things may indicate underlying androgen excess disorder?
1) Excess secretion of androgens
2) Hirsutism & virilization
CAH, Cushing syndrome, hyperprolactinemia are all DDxs for what?
PCOS
Hyperandrogenic disorders:
1) What controls adrenal androgen production?
2) What regulates ovarian androgen production?
3) Extraglandular testosterone production occurs in what?
1) Reciprocal feedback regulation through pituitary secretion of ACTH
2) LH secretion from the pituitary
3) Adipocytes secondary to the aromatase enzyme
In women with hirsutism and virilization, what 4 androgens may be measured?
1) DHEA (DHEA-sulfate)
2) +/- Androstenedione
3) Testosterone (total and free)
4) 17-hydroxyprogesterone level to exclude late-onset CAH
Starred:
What 3 things is PCOS the most common cause of?
1) Androgen excess and hirsutism in women
2) Most common endocrinopathy in women
3) Most common ovarian abnormality causing hyperandrogenism
1) What is defined by Defined by Rotterdam Criteria (at least 2 of the 3 criteria)?
2) Who should meet all 3 criteria?
1) PCOS
2) Adolescents
PCOS carries and increased risk of _____________ cancer
endometrial (endometrial hyperplasia caused by unopposed estrogen)
What aspect of PCOS causes AUB + endometrial hyperplasia?
Unopposed long-term elevated estrogen levels
PCOS:
1) When do Sx develop?
2) What is seen in 50% of patients?
3) What are 4 Sx?
4) What Sx is less likely in women who have used hormonal contraceptives for prolonged intervals
1) Typically develop at puberty
2) Obesity (50%)
3) Oligomenorrhea or amenorrhea, acne, hirsutism, infertility
4) Hirsutism
1) What can PCOS lead to in the ovaries?
2) Why?
1) Accumulation of follicles in ovaries [+follicular arrest]
2) Follicular growth disrupted
List the labs used for PCOS eval (3; don’t include the ones to rule out other causes)
1) Increased LH:FSH ratio (>3)
2) Estrone > estradiol
3) Androstenedione and testosterone upper limit of normal or increased
What 3 labs are used in PCOS eval to rule out other disorders?
1) Basal serum 17-hydroxyprogesterone level
2) Serum prolactin & TSH levels
3) 24-hour free urinary cortisolor overnight dexamethasone suppression test
What is the initial Tx for PCOS?
1) Combination oral contraceptive (COC) containing estrogen & progestin
2) Peripheral antiandrogen may be added (ex: spironole actone)
Local hair removal usually required to Tx what?
Hirsutism from PCOS
Insulin resistance in PCOS: What are 2 important aspects of Tx?
1) Counseling
2) Consider metformin
[to reduce insulin resistance & anovulation]
Hyperandrogenic insulin resistance & acanthosis nigricans (HAIR-AN):
1) What does it cause?
2) How may it present?
3) What is it often treated with?
1) Extremely high levels of circulating insulin
2) virilization & severe, rapidly progressing hirsutism
3) Metformin
True or false: Hyperandrogenic insulin resistance & acanthosis nigricans (HAIR-AN) often occurs with PCOS
True
1) Which version of CAH is more common?
2) Which is less common?
1) Nonclassic (milder)
2) Classic (most severe)
1) How is CAH diagnosed if nonclassic?
2) How is Dx confirmed?
1) If nonclassic, 17-OH early morning progesterone increased (significantly increased in classic)
2) ACTH stimulation test to confirm diagnosis
True or false: nonclassic CAH may not require Tx
True
Define:
1) Infertility
2) Subfertility
3) Sterility
4) Fecundity
1) Lack of fertility after 1yr of freq. attempts
2) A decrease, but not an absence, of fertility potential
3) Complete inability to achieve fertility
4) Probability of achieving a live birth in 1 menstrual cycle
Infertility:
1) >35yo = recommend workup after ________ of attempted conception.
2) Most infertility is ___________ & few couples are sterile
3) ______________ rate ~22% at age 24 & wanes to ~5% at age 40
1) 6mos
2) subfertility
3) Fecundity
Infertility factors:
1) Profuse, watery mucus produced by the cervix during few days before ovulation is called what?
2) Pt should be seen during immediate preovulatory phase (day __________ of 28-day cycle) to assess cervical quality
1) Spinnbarkeit
2) 12-14
Male infertility: Semen analysis may reveal what? (40% of male cases)
Abnormal spermatogenesis
1) What 2 types of genital tract infections can caus male infertility?
2) Give an example of a med that can cause it
1) Mumps + prostatitis
2) CCBs
1) Most common treatment for mild male infertility is what?
2) What is required for this?
1) Sperm washing with IUI
2) Must have >1mil motile sperm count
Further treatment for male coital factors includes IVF-ET with ________
ICSI
Insemination with donor sperm is effective when __________ factors refractory to treatment
male
1) Most common cause of ovulatory dysfunction in reproductive-aged women is what?
2) What is a common Tx option for ovulatory dysfunction?
1) PCOS
2) Clomiphene citrate (Clomid)
(can cause twins/ triplets/ etc)
List 3 Txs for ovulation factors
1) Fertility drugs (i.e., clomiphene (Clomid)- most commonly used)
2) U/S & carefully timed hCG administration if no ovulation with clomid
3) Induction of more frequent ovulation [for oligomenorrhea]
What is the most commonly used fertility drug?
Clomid
1) Main complication of ovulation induction is what?
2) What can this cause?
1) Ovarian hyperstimulation syndrome (OHSS)
2) Twins/ triplets/ etc
1) What is the most common location of tubal occlusion?
2) What is a common cause of tubal occlusion?
1) Fimbrial end (most common)
2) Prior salpingitis (PID)
1) Evaluation of uterine & tubal factors can include what?
2) What is a common finding with this?
1) Hysterosalpingography (HSG): checks patency of tubes
2) Hydrosalpinges
Treatment of tubal factors:
1) Overall, for women, if HSG normal or abnormal and further workup required, what are the next options?
2) What makes up >10% conceptions after repair of diseased tubes?
1) hysteroscopy and/or laparoscopy
2) Ectopic pregnancies
Peritoneal factors:
1) What is preferred to identify substantial adhesions or endometriosis? What is the most common finding?
2) What are other possible findings?
3) What is often preferred over surgery to Tx because of its high success rate?
1) Laparoscopy; Endometriosis
2) Pelvic inflammatory disease (PID), appendicitis, adhesions
3) IVF
