EXAM 1 - Amenorrhea & Abnormal Uterine Bleeding

Can a imperforate hymen be surgically corrected?

Yes

How do you control an acute episode of dysfunctional bleeding?

Hemorrhage - COC at 3x the usual does for one week Consider continuing for several cycles at lower dose to raise hemoglobin levels

What are positive results from the progestin challenge test?

If bleeding follows (positive test), the ovaries are secreting estrogen and having effect on the endometrium

How can you help women achieve fertility, if desired, with secondary amenorrhea?

Induce ovulation

What can cause GnRH transport to not occur which leads to amenorrhea?

Injury to the arcuate nucleus • Trauma, radiation, tumors, infiltrative disorders (sarcoidosis, tuberculosis) • May destroy or prevent transport of hypothalamic hormones •

Would a person with Mullerian dysgenesis ovulate?

May ovulate and have normal 2° sex characteristics •

What is Premature ovarian failure?

Menopause before 40 years of age (more on this later)

What is Asherman's syndrome?

Most frequent anatomic cause of secondary dysmenorrhea caused by intrauterine synechiae/scarring from a vigerous Dilation & curettage (D&C)

What are Alteration of Genital Outflow tract (anatomic Issues) that cuase amenorrhea?

Müllerian dysgenesis, Vaginal agenesis, Transverse vaginal septum, Imperforate hymen, Asherman's syndrome*, 46,XY karyotype

What is the most common cause of ovarian dysfunction?

PCOS

What is the Most common cause of ovulatory dysfunction in reproductive-age women?

Polycystic Ovary Syndrome

What is PALM structural causes of abnormal uterine bleeding?

Polyp (AuB-A), Adenomyosis (AUB-A), Leiomyoma (AUB-Lsm) other myoma (AuB-Lo), Malignancy and hyperplasia

What is Sheehan syndrome?

Postpartum amenorrhea

How can you prevent future recurrences of dysfunctional bleeding?

Progestin alone to initiate withdrawal bleed - oral or IM Combined oral contraceptive Levonorgestrel IUD Surgery - D&C, endometrial ablations, hysterectomy

Is Asherman's syndrome a primary or secondary cause of amenorrhea?

Secondary

What is a Acquired pituitary dysfunction?

Sheehan syndrome

What is treatment for PALM?

Structural causes?

How do you administer the progestin challenge test?

Take Medroxyprogesterone acetate for 5-7 days and Progesterone IM x 1

What is the primary amenorrhea?

never menstruated by 13 years without secondary sexual development or by age 15 with secondary sexual development

What is secondary amenorrhea?

no menstruation for 3-6 months or for the duration of three typical menstrual cycles for the patient with oligomenorrhea

Contact bleeding

postcoital bleeding

Hypomenorrhea:

reduction in the number of days or the amount of menstrual flow, Light menstrual flow, sometimes only spotting

What labs can you do to work up AUB?

ß-HCG, CBC, coagulation studies, TSH, cervical cancer screening

What are Pituitary adenomas?

• Amenorrhea secondary to elevated prolactin levels • Pt may also have galactorrhea

How do you work through the differential diagnosis?

• Amount of menstrual flow • Length of menstrual cycle and menstrual period • How many bleeding episodes in 6 months? • Length and amount of episodes of intermenstrual bleeding • How many bleeding episodes in last six months? • Contact bleeding • Is the patient experiencing molimina? • Are there associated symptoms? • Is the patient taking any medications that may be contributory • Copper IUD, oral contraceptives, hormones, anticoagulants

Prevent complications of disease in those not desiring pregnancy

• Estrogen-progestin therapy to prevent osteoporosis

Correct underlying pathology, if possible

• Lifestyle changes • Surgery

What are the treatment goals for secondary amenorrhea?

• Offer prenatal care - if pregnancy is the cause • Correct underlying pathology, if possible, Help women achieve fertility, if desired, Prevent complications of disease in those not desiring pregnancy

What might cause Gonadal dysgenesis?

• Usually associated with sex chromosomal abnormalities • Also chemotherapy and radiation • Elevated gonadotropins and low estradiol

What is Heavy menstrual bleeding, menorrhagia?

• prolonged or excessive uterine bleeding that occurs at regular intervals • based on patient's perceptions • Gushing or open-faucet bleeding is always abnormal Intermenstrual bleeding (metrorrhagia)

Oligomenorrhea:

• reduction of the frequency of menses , cycle lengths of >40 days and <6 months • Bleeding is usually decreased in amount and associated with anovulation •

What are the top 4 causes of secondary amenorrhea?

1. Pregnancy** 2. Hypothalamic-pituitary dysfunction 3. Ovarian dysfunction 4. Alteration of genital outflow tract

How can you test for pregnancy?

Always exclude first!!! • Confirm or r/o with a ß-HCG (human chorionic gonadotropin) assay

What is the triad of the serious athlete?

Amenorrhea, eating disorder and osteopenia/osteoporosis

What is COEIN: nonstructural causes of abnormal uterine bleeding?

Coagulalophathy (AUB-C), Ovulatory dysfunction (AUB-O), Endometrial (AUB-E), Latrogenic (AUB-I), Not yet classified (AUB-N)

What is a Congenital pituitary dysfunction?

Congenital absence is rare and lethal, Surgical ablation or irradiation of pituitary as management of pituitary tumors • Iron deposition • Pituitary adenomas Drugs that produce hyperprolactinemia • Hypothyroidism

What is Mullerian dysgenesis?

Congenital absence of the uterus and upper 2/3 of vagina

What are two very rare pituitary defects?

Congenital pituitary dysfunction, Acquired pituitary dysfunction

What are the definitions of abnormal uterine bleeding?

Difference in frequency duration, and/or amount of menstrual bleeding.

What is abnormal uterine bleeding?

Difference in frequency, duration, and/or amount of menstrual bleeding

What might cause the functional or hypothalamic amenorrhea?

Eating disorders, physical or psychologic stress, weight loss, excessive exercise - Female athlete triad: amenorrhea, (eating disorder, and osteopenia/osteoporosis)

What is the defect with Ovarian resistance (Savage's syndrome)?

Elevated gonadotropins with ovaries that have primordial germ cells...defect in cell receptor mechanism

What could be causing hypothyroidism?

Elevated prolactin

What are other options?

Endometrial biopsy • Hysteroscopy - gold standard evaluation of pathology in the uterine cavity • Dilation & Curettage (D&C)

After having a positive progestin challenge test, what are the possible causes of the patient's secondary amenorrhea?

Essentially you have too much androgen and it may cause one of these specific things: Virilized, with or without ambiguous genitalia • Hirsute with polycystic ovaries, hyperthecosis, or mild maturity-onset adrenal hyperplasia • Non-hirsute with hypothalamic dysfunction • Amenorrheic secondary to systemic disease

What causes post-menopausal bleeding?

Exogenous hormones, but you should investigate other causes, treat endometrial hyperplasia Vaginal atropy and vaginal/vulvar lesions Tumor of the reproductive tract.

ALL POSTMENOPAUSAL BLEEDING IS ABNORMAL AND SHOULD BE WORKED UP

FOR ENDOMETRIAL CANCER

If a patient has unopposed estrogen, per the positive progestin challenge test, what could they develop?

Unopposed estrogen (positive progestin challenge test), is a risk for development of endometrial hyperplasia and carcinoma

What is amenorrhea?

Absence of menstruation - can be primary or secondary

What is the Karyotype of Mulerian dysgenesis?

46,XX karyotype

What is Kallmann's syndrome?

A condition characterized by delayed or absent puberty and an impaired sense of smell. This disorder is a form of hypogonadotropic hypogonadism, which is a condition resulting from a lack of production of certain hormones that direct sexual development

What are defects of GnRH pulse production?

Functional or hypothalamic amenorrhea caused by congenital GnRH deficiency or Idiopathic hypogonadotropic hypogonadism, Kallmann's syndrome (when associated with anosmia - lack of smell)

What are Steroid enzyme defects?

Genetic females with enzymatic defects and 46,XX karyotype cannot produce estrogen àno menses or breast development • Congenital lipoid adrenal hyperplasia

What is the treatment of dysfunctional bleeding?

Goal of anovulatory bleeding if for regular shedding of endometrium and consequent regulation of uterine bleeding. Or alternatively, suppression of endometrium with normal contraception.

What are some causes of amenorrhea having to do with ovarian dysfunction?

Gonadal dysgenesis, Premature ovarian failure, Steroid enzyme defects, Ovarian resistance (Savage's syndrome), Polycystic Ovary Syndrome*

Can a transverse vaginal septum be corrected?

Hard to correct sugically

Menometrorrhagia

Heavy and intermittent bleeding

What can you do with pelvic US?

Transvaginal - empty bladder. Greater details of the pelvic organs • Transabdominal - full bladder. Wider, but less discriminative exam of pelvis • Sonohysterography - injection of saline into uterus; increases sensitivity of transvaginal ultrasound.

What is treatment for COEIN?

Treat pathologic causes • Example: thyroid or adrenal abnormalities • Example: copper IUD

Polymenorrhea: •

bleeding that occurs more often than every 21 days • usually associated with anovulation but can be a luteal phase defect