OBGYN III: Menstrual Irregularities (1)
What is considered NORMAL volume of menstrual blood loss?
1. Change pad/tampons >3 hrs intervals. 2. Use <21 pads/tamps per cycle. 3. Seldom need to change the pad/tamp during the night. 4. Have clost <1in in diameter. 5. NOT ANEMIC!
What is the treatment for *chronic heavy menstrual bleeding*? What is the most effective treatment?
1. Normalize Prostaglandins 2. Antifibrinolytic Therapy 3. Coordinate Endometrial Sloughing 4. Endometrial Suppression (LNG-IUS is the most effective!)
Delayed Puberty is *lack of thelarche by* age _____?
12
If you choose to Rx COCPs for the management of *acute excessive uterine bleeding* -- what is the dosage and timeline?
35mcg EE + 1 mg Norethindrone (NETA) q 8h for 7 days THEN... 20mcg EE + 1 mg NETA q day for 21 days
What is menorrhagia or metrorrhagia (or polymenorrhea) currently termed?
Abnormal Uterine Bleeding (AUB) *regular, prolonged, heavy menses*
What is the most common gyn presenting complaint?
Abnormal Uterine Bleeding (AUB) 25% structural, ie PALM 75% non-structural, ie COIN
Pt presents with *secondary amenorrhea*, you perform a progesterone challenge test and the pt has *withdrawal bleeding* -- what is your dx?
Anovulatory Cycles (Functional Hypothalamic Amenorrhea, 2nd MC cause) or PCOS -- pt has a *estrogen-exposed endometrium*, so the progesterone exposure causes proliferation/bleeding
What is the indication for Tranexamic Acid?
Antifibrinolytic Therapy for the treatment of chronic heavy menstrual bleeding
What are the *uterine etiologies* of AUB?
Benign Growths Cancer Infection Ovulatory Dysfunction
What are the NON-structural etiologies of AUB?
COIN (75% of etiologies) C - coagulopathy O - ovulatory dysfunction I - iatrogenic (meds, procedures) N - NOT YET CLASSIFIED
Pt presents with *secondary amenorrhea*, you perform a progesterone challenge test and the pt *does NOT have withdrawal bleeding*, so you perform an *estrogen/progesterone challenge test*, and the patient has *withdrawal bleeding* -- what is the next step in dx?
Check FSH levels!!! *High FSH*: Ovarian Issue!! - Menopausal Ovarian Failure - Premature Ovarian Failure *Low FSH*: Hypothalamus Issue! - Stress (eating d/o, chronic illness) - CNS tumor/Cranial Radiation - Sheehan's Syndrome
Endometriosis is contributory to what other diagnoses?
Chronic pelvic pain (CPP) (69%) Dyspareunia (45%) Dysmenorrhea (79%) Infertility (26%)
What pt population commonly presents with endometriosis?
Common in women in their 30's Typical patient nulliparous, infertile
GnRH agonist used to treat endometriosis
Dep-Lupron
What is Pre-Menstrual Syndrome? How is it diagnosed?
Dx: - 2 widely used sets (DSM-V & UCSD). - Both utilize prospective documentation of S/S. - UCSD requires presence of physical sx.
<<What is the classic triad for endometriosis?>>
Dysmenorrhea Dyspareunia Dyschezia - pn with defecation
What is *Functional Hypothalamic Amenorrhea*?
Female is NOT OVULATING (having anovulatory cycles) d/t: - weight loss - nutritional deficiencies - low body fat (leptin deficiency) *2nd MC cause of secondary amenorrhea*
Pt presents with primary amenorrhea; pt has NO breast development... FSH levels are elevated -- what should you suspect?
Gonadal Failure!!! - Gonadal agenesis/dysgenesis - Ovarian resistance syndrome - Galactosemia - *Turner's Syndrome*
Pt presents with precocious puberty, you measure FSH/LH levels and note that they are at "pubertal levels". You give the pt a *GnRH agonst* and remeasure FSH/LH levels...which INCREASE -- what type of PP is this?
Gonadotropin-Dependent PP Tx: CONTINUOUS GnRH (non-pulsative), which will supress FSH/LH production!
Pt presents with precocious puberty, you measure FSH/LH levels and find that they are LOW. You give the pt a *GnRH agonst* and measure FSH/LH levels...which DO NOT CHANGE. What type of PP is this?
Gonadotropin-Independent PP (i.e. functional ovarian cyst) High amounts of estrogen are suppressing LH/FSH levels. Find the cause and fix it!
What is the initial treatment for *acute excessive uterine bleeding*?
High dose progesterone! Medroxyprogesterone Acetate (MPA or Provera) or COCPs
By mid-puberty, *positive feedback* mechanisms mature, causing...
Increased estradiol Decreased LH
Congenital GnRH deficiency
Kallman's if anosmic
DDX of AUG based on age: peri-menopausal years
May be due to declining ovarian function, or conditions more common for thi age group: - fibroids - polyps - endometrial CA
What is the treatment for PMDD?
Other "possibly" efficacious therapies for PMDD: -Continuous OCPs (esp with drospirenone) -Exercise and relaxation techniques -Agnus castus fruit extract (chasteberry tree) (not FDA regulated) -Calcium (1200 mg daily) -Vitamins D (1200 mg/day) and B6 (<100 mg/day) -Bright light therapy- may be placebo effect
What are the structural etiologies of AUB?
PALM (25% of etiologies) P - polyp A - adenomyosis L - leiomyoma (fibroids) M - malignancy & hyperplasia
What is the definition of *primary amenorrhea*? What is the definition of *secondary amenhorrhea*? What is the "modified" definition of amenorrhea?
PRIMARY: (1) No menses by *age 16* in the presence of normal secondary sexual characteristics (i.e. estrogen is present --> breasts). (2) No menses by *age 14* in the *ABSENCE* or normal secdonary sexual characteristics (i.e. NO estrogen present). (3) No menses *within 2 years of thelarche*! SECONDARY: - Absence of menses for *at least 6 months*, in women who were previously menstruating. MODIFIED DEFINITION: lack of menses EXCEPT when pre-pubertal, gravid, lactating, post-menopausal.
DDX of AUG based on age: post-menopausal years
RED FLAG! ABNORMAL, and requiring WORKUP!!! - R/O Endometrial Carcinoma
How do you describe *regularity of menses (cycle-tocycle variation over 12 months)*? - Regular - Irregular
Regular = variation +/- *2-20 days* Irregular = variation *>20 days*
Pt presents with *acute excessive uterine bleeding*, you Rx Medroxyprogesterone Acetate (20mg PO q 8 hrs), *it's been 12-24 hours* and the bleeding HASN'T STOPPED or reduced -- what is the next step in treatment?
SURGERY D&C (Dilation & Curettage) Balloon tamponade UA embolization Hysterectomy
Pt presents with *secondary amenorrhea*, you perform a progesterone challenge test and the pt *does NOT have withdrawal bleeding*, so you perform an *estrogen/progesterone challenge test*, and the patient *does NOT have withdrawal bleeding* -- dx?
Structural Abnormality! - Outflow Obstruciton - Asherman's Syndrome (intrauterine adhesions/scarring, an acquired uterine condition from previous uterine surgery i.e. D&C)
What causes anovulatory cycles?
*ETIOLOGY of AUB or amenorrhea* (most common etiology of secondary amenorrhea after preg is ruled out). Ovulation does NOT occur. There is lots of estrogen, but NO progesterone (no corpus luteum). = "unopposed estrogen". Most common at extremes of menses -- large & have "mixed" with anoulation/ovulation cycles.
How do you describe *frequency of menses*? - Frequent - Normal - Infrequent - Absent
- Frequent <24 days (between menses) - Normal 24-38 days - Infrequent >38 days - Absent
How do you describe *volume of monthly blood loss (mL)*? - heavy - normal - light
- heavy >80ml - normal 5-80mL - light <5mL
How do you describe *duration of flow (days)*? - prolonged - normal - short
- prolonged >8d - normal 4-5-8 d - short <4.5d
Pt presents with primary amenorrhea; pt has NO breast development... FSH levels are low/normal -- what should you suspect?
UPSTREAM ISSUE (with GnRH) which can be functional or structural (pituitary or hypothalamus). - *GnRH deficiency.* - Constitutional delay of puberty. - CNS neoplasms (mass). - *Stress*. - *Hyperprolactinemia*.
Incomplete PP
Usually a normal variant! KEY: is it isolated thelarche (normal variant) or precocious puberty? MONITOR BONE GROWTH q6mo, if >6cm/yr then estrogen is influencing...REFER!
What is the MC cause of Gonadotropin-Independent PP? (excess estrogen or androgens)
functional ovarian cyst
What is the primary reason that we address precocious puberty??
premature closure of growth plates (short stature)
Prolactinoma is a cause of ____ amenorrhea
primary OR secondary!!