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TN Gyneco > 4. Disorders of Menstruation > Flashcards

4. Disorders of Menstruation Flashcards

1
Q

Name DDX of primary amenorrhea with: Normal breast and pelvic (4)

A
  • Hypothyroidism
  • Hyperprolactinemia
  • PCOS
  • Hypothalamic dysfunction
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2
Q

Name DDX of amenorrhea with: Normal breast, abnormal uterine development (4)

A
  • Androgen insensitivity
  • Anatomic abnormalities
    • Müllerian agenesis
    • uterovaginal septum
    • imperforate hymen
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3
Q

Name DDX of primary amenorrhea with: High FSH (hypergonadotropic hypogonadism) (2)

A
  • Gonadal dysgenesis
    • Abnormal sex chromosome (Turner’s XO)
    • Normal sex chromosome (46XX, 46XY)
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4
Q

Name DDX of primary amenorrhea with: Low FSH (hypogonadotropic hypogonadism) (8)

A
  • Constitutional delay (rare in girls)
  • Congenital abnormalities Isolated
  • GnRH deficiency
  • Pituitary failure (Kallman syndrome, head injury, pituitary adenoma, etc.)
  • Acquired endocrine disorders (type 1 DM)
  • Pituitary tumours
  • Systemic disorders (IBD, JRA, chronic infections, etc.)
  • Functional hypothalamic amenorrhea
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5
Q

Name: Most Common Causes of Primary Amenorrhea (3)

A
  1. Müllerian agenesis
  2. Abnormal sex chromosomes (Turner’s syndrome)
  3. Functional hypothalamic amenorrhea
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6
Q

Name the most common cause of secondary amenorrhea

A

Functional hypothalamic amenorrhea

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7
Q

Name ddx secondary amenorrhea: With Hyperandrogenism (4)

A
  • PCOS
  • Autonomous hyperandrogenism (androgen secretion independent of the HPO axis)
  • Ovarian: tumour, hyperthecosis Adrenal androgen-secreting tumour
  • Late onset or mild congenital adrenal hyperplasia (rare)
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8
Q

Name DDX secondary amenorrhea: Without Hyperandrogenism (5)

A
  • Hypergonadotropic hypogonadism (i.e. primary ovarian insufficiency: high FSH, low estradiol)
    • Idiopathic
    • Autoimmune: type 1 DM, autoimmune thyroid disease, Addison’s disease
    • Iatrogenic: cyclophosphamide drugs, radiation
  • Hyperprolactinemia
  • Endocrinopathies: most commonly hyper or hypothyroidism
  • Hypogonadotropic hypogonadism (low FSH):
    • Pituitary compression or destruction: pituitary adenoma, craniopharyngioma, lymphocytic hypophysitis, infiltration (sarcoidosis), head injury, Sheehan’s syndrome
  • Functional hypothalamic amenorrhea (often related to stress excessive exercise and/or anorexia)
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9
Q

Describe diagnostic approach to amenorrhea (figure)

A
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10
Q

Describe investigation: Amenorrhea (4)

A
  • β-hCG, hormonal workup (TSH, prolactin, FSH, LH, androgens, estradiol)
  • progesterone challenge to assess estrogen status
    • medroxyprogesterone acetate (Provera®) 10 mg PO OD for 10-14 d
    • any uterine bleed within 2-7 d after completion of Provera® is considered to be a positive test/ withdrawal bleed
      • withdrawal bleed suggests presence of adequate estrogen to thicken the endometrium; thus withdrawal of progesterone results in bleeding
      • if no bleeding occurs, this may be secondary to inadequate estrogen (hypoestrogenism), excessive androgens, or progesterones (decidualization) or pregnancy
  • karyotype: indicated if primary ovarian insufficiency or absent puberty
  • U/S to confirm normal anatomy, identify PCOS
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11
Q

Describe management of Primary Amenorrhea: Androgen insensitivity syndrome (3)

A
  • Gonadal resection after puberty
  • Psychological counselling
  • Creation of neo-vagina with dilation
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12
Q

Describe management of Primary Amenorrhea: Müllerian dysgenesis (MRKH syndrome) (3)

A
  • Psychological counselling
  • Creation of neo-vagina with dilation
  • Diagnostic study to confirm normal urinary system and spine
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13
Q

Describe management of Primary Amenorrhea:

A
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14
Q

Describe management of Primary Amenorrhea:

Anatomical

  • Imperforate hymen
  • Transverse vaginal septum
  • Cervical agenesis
A
  • Imperforate hymen: Surgical management
  • Transverse vaginal septum: Surgical management
  • Cervical agenesis: Suppression and ultimately hysterectomy
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15
Q

Describe management of Secondary Amenorrhea: HP-axis dysfunction (2)

A
  • Identify modifiable underlying cause
  • Combined OCP to decrease risk of osteoporosis, maintain normal vaginal and breast development (NOT proven to work)
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16
Q

Describe management of Secondary Amenorrhea: Hyperprolactinemia (3)

A
  • MRI/CT head to rule out lesion
  • If no demonstrable lesions by MRI
    • Bromocriptine, cabergoline if fertility desired
    • Combined OCPs if no fertility desired
  • Demonstrable lesions by MRI: surgical management
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17
Q

Describe management of Secondary Amenorrhea: Premature ovarian failure (2)

A
  • Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
  • Hormonal therapy with estrogen + progestin to decrease risk of osteoporosis; can use OCP after induction of puberty
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18
Q

Describe management of Secondary Amenorrhea: Uterine defect, Asherman’s syndrome (2)

A
  • Evaluation with hysterosalpingography or sonohysterography
  • Hysteroscopy: excision of synechiae
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19
Q

Describe: Diagnostic approach to abnormal uterine bleeding (figure)

A
20
Q

Describe approach to abnormal uterine bleeding (5)

A
  • menstrual bleeding should be evaluated by ascertaining: frequency/regularity of menses, duration, volume of flow, impact on quality of life, and timing (inter or premenstrual or breakthrough)
  • is it regular?
    • regular: cycle to cycle variability of <20 d – “Can you predict your menses within 20 days?”
    • irregular: cycle to cycle variability of ≥20 d
  • is it heavy?
    • ≥80 cc of blood loss per cycle or
    • ≥8 d of bleeding per cycle or
    • bleeding that significantly affects quality of life
  • is it structural?
    • PALM
  • is it non-structural?
    • COEIN
21
Q

Name STRUCTURAL etiologies of Abnormal Uterine Bleeding (4)

A
  • Polyps (AUB-P)
  • Adenomyosis (AUB-A)
  • Leiomyoma (AUB-L)

Submucosal (AUB-Lsm)

Other (AUB-Lo)

  • Malignancy and Hyperplasia (AUB-M)
22
Q

Name NON-STRUCTURAL etiologies of Abnormal Uterine Bleeding (5)

A
  • Coagulopathy (AUB-C)
  • Ovulatory dysfunction (AUB-O)
  • Endometrial (AUB-E)
  • Iatrogenic (AUB-I)
  • Not yet classified (AUB-N)
23
Q

Describe investigations and management: Polyps (AUB-P) (2)

A
  • Investigations:
    • Transvaginal sonography
    • Saline infusion sonohysterography
  • Management: Polypectomy (triage based on symptoms,polyp size, histopathology and patient age)
24
Q

Describe investigations and management: Adenomyosis (AUB-A) (2)

A
  • Investigations:
    • Transvaginal sonography
    • MRI
  • Management: See Adenomyosis, GY13
25
Q

Describe investigations and management:

Leiomyoma (AUB-L)

Submucosal (AUB-Lsm)

Other (AUB-Lo)

A
  • Investigations:
    • Transvaginal sonography
    • Saline infusion sonohysterography
    • Diagnostic hysteroscopy
  • Management: See Fibroids (Leiomyomata), GY13
26
Q

Describe investigations and management: Malignancy and Hyperplasia (AUB-M) (3)

A
  • Investigations:
    • Transvaginal sonography
    • Endometrial biopsy for all women >40 yr with AUB, for women <40 yr with persistent AUB or endometrial cancer risk factors
  • Management: Dependent on diagnosis
27
Q

Describe investigations and management: Coagulopathy (AUB-C) (2)

A
  • Investigations: CBC, coagulation profile (especially in adolescents),

vWF, Ristocetin cofactor, factor VIII

  • Management: Dependent on diagnosis (hormonal modulation (e.g. OCP), Mirena IUS, endometrial ablation)
28
Q

Describe investigations and management: Ovulatory dysfunction (AUB-O) (2)

A
  • Investigations:
    • Bloodwork: β-hCG, ferritin, prolactin, FSH, LH, serum androgens (free testosterone, DHEA), progesterone, 17-hydroxy progesterone, TSH, free T4
    • pelvic ultrasound
  • Management: See Infertility, GY22
29
Q

Describe investigations and management: Endometrial (AUB-E) (5)

A
  • Investigations: Endometrial biopsy
  • Management:
    • Tranexamic acid
    • Hormonal modulation (e.g. OCP)
    • Mirena IUS
    • Endometrial ablation
30
Q

Describe investigations and management: Iatrogenic (AUB-I) (4)

A
  • Investigations:
    • Transvaginal sonography (rule out forgotten IUD)
    • Review OCP/HRT use
    • Review meds (especially neuroleptic use)
  • Management: Remove offending agent
31
Q

Describe tx: Abnormal Uterine Bleeding (4)

A
  • resuscitate patient if hemodynamically unstable
  • treat underlying disorders
    • if anatomic lesions and systemic disease have been ruled out, consider AUB
  • medical: mild vs acute,severe
  • surgical
32
Q

Describe medical tx: MILD Abnormal Uterine Bleeding (6)

A
  • NSAIDs
  • anti-fibrinolytic (e.g. Cyklokapron®) at time of menses
  • combined hormonal contraceptive
  • progestins (Provera®) on first 10-14 d of each month or every 3 mo if AUB-O
  • Mirena® IUD
  • correct anemia - iron
33
Q

Describe medical tx: ACUTE, SEVERE Abnormal Uterine Bleeding (4)

A

– replace fluid losses, consider admission

  1. estrogen (Premarin®) 25 mg IV q4h x 24 h with Gravol® 50 mg IV/PO q4h or anti-fibrinolytic (e.g. Cyklokapron®) 10 mg/kg IV q8h (rarely used)
  2. tapering OCP regimen, 35 µg pill tid x7d then taper to 1 pill/d for 3wk with Gravol® 50 mg IV/ PO q4h

– or taper to 1 tab tid x 2 d s bid x 2 d s OD (more commonly used)

  • after (a) or (b), maintain patient on monophasic OCP for next several months or consider alternative medical treatment
    • medical (can also consider):
      • high dose progestins
      • danazol (Danocrine®)
      • GnRH agnosits (e.g. Lupron ®) with add-back if taken for >6 mo
      • ulipristal acetate
34
Q

Describe surgical tx: Abnormal Uterine Bleeding (2)

A
  • endometrial ablation
    • if finished childbearing
    • repeat procedure may be required if symptom recur, especially if <40 yr
  • hysterectomy: definitive treatment
35
Q

Define: Primary Dysmenorrhea (1)

A

Recurrent crampy lower abdominal pain during menses in the absence of demonstrable disease

36
Q

Define: Secondary Dysmenorrhea (1)

A

Pain during menses that can be attributed to an underlying disorder (endometriosis, adenomyosis, fibroids)

37
Q

Name etiologies of secondary Dysmenorrhea (12)

A
  • endometriosis
  • adenomyosis
  • uterine polyps
  • uterine anomalies (e.g. non-communicating uterine horn)
  • leiomyoma
  • intrauterine synechiae
  • ovarian cysts
  • cervical stenosis
  • imperforate hymen, transverse vaginal septum
  • pelvic inflammatory disease
  • IUD (copper)
  • foreign body
38
Q

Describe features: Primary Dysmenorrhea (3)

A
  • Recurrent, crampy lower abdominal pain
  • that occurs during menses
  • in the absence of demonstrable disease
39
Q

Describe features: Secondary Dysmenorrhea (2)

A
  • Similar features as primary dysmenorrhea
  • but with an underlying disorder that can account for the symptoms, such as endometriosis, adenomyosis or uterine fibroids
40
Q

Name signs and symptoms: Primary Dysmenorrhea (4)

A
  • Colicky pain in abdomen
  • radiating to the lower back, labia, and inner thighs beginning hours
  • before onset of bleeding and persisting for hours or days (48-72 h)
  • Associated symptoms: N/V, altered bowel habits, headaches, fatigue (prostaglandin-associated)
41
Q

Name signs and symptoms: Secondary Dysmenorrhea (3)

A

Associated

  • dyspareunia
  • abnormal bleeding
  • infertility
42
Q

Describe diagnosis: Primary Dysmenorrhea (3)

A
  • Assess for associated dyspareunia, abnormal bleeding, infertility (signs of 2º dysmenorrhea)
  • Rule out underlying pelvic pathology and confirm cyclic nature of pain
  • Pelvic examination not required; indicated for patients not responding to therapy or with signs of organic pathology
43
Q

Describe diagnosis: Secondary Dysmenorrhea (3)

A
  • Bimanual exam: uterine or adnexal tenderness, fixed uterine retroflexion, uterosacral nodularity, pelvic mass, or enlarged irregular uterus (findings are rare in women <20 yr)
  • U/S, laparoscopy and hysteroscopy may be necessary to establish the diagnosis
  • Vaginal and cervical cultures may be required
44
Q

Describe treatment: Primary Dysmenorrhea (3)

A
  • Regular exercise, local heat
  • NSAIDs: should be started before onset of pain
  • Combined hormonal contraceptives with continuous or extended use: suppress ovulation/ reduce menstrual flow
45
Q

Describe treatment: Secondary Dysmenorrhea (1)

A

Treat underlying cause

TN Gyneco (20 decks)

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