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MED: Women’s Health/Reproductive System > Amenorrhea > Flashcards

Amenorrhea Flashcards

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1
Q

What is the menstrual cycle controlled by?

A

Menstrual cycle controlled by hormones produced by the hypothalamus, pituitary, and ovary.
Hypothalamus produces gonadotropin releasing hormone (GnRH)
Pituitary gland produces FSH and LH
Stimulates ovary to produce estrogen
After ovulation, ovary primarily produces progesterone

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2
Q

what is primary amenorrhea?

A

No menarche by age 16 with signs of pubertal development (breasts/pubic hair)
No onset on pubertal development by 14 yo

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3
Q

What is secondary amenorrhea?

A

Secondary Amenorrhea:
Absence of menstruation for 3 months or more in a previously menstruating woman of reproductive age
Absence of menstruation for 9 or more months in a woman with previous oligomenorrhea

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4
Q

What are common causes of primary amenorrhea?

A 
Chromosomal abnormalities
Hypothalamus abnormalities
Pituitary problems
Reproductive organ abnormalities
Structural abnormalities
Pregnancy (uncommon)
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5
Q

what is are the common causes of secondary amenorrhea? what is the most common?

A 
pregnancy is most common. other causes: 
Thyroid abnormalities
Pituitary abnormalities
Medications (inc. contraceptives)
Breast-feeding
Stress
Illness
Excessive exercise/low body weight
Polycystic Ovarian Syndrome (PCOS)
Premature menopause
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6
Q

Why should you eval a patient who has amenorrhea?

A 
Inability to conceive - anovulation
Lack of estrogen - osteoporosis
excess exercise
Eating disorders - life threatening
Pregnancy - early care, statutory rape
Pituitary tumors - life and sight threat
Adrenal or ovarian tumors
Psychosocial issues - related to body and menses
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7
Q

What info is important to gather from the patient’s history?

A 
Menarche and menstrual history
Sexual history
Medications or illicit drug use
Exercise - Weight Loss - Nutrition
Stress
Illness (chemo treatment)
Genetic defects
Infertility
Menarche history of mother and sisters
Growth delays
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8
Q

What labs are important for amenorrhea?

A 
Labs:
-Pregnancy test  (urine/serum)
-LH, FSH, Prolactin, TSH, T4, testosterone, progesterone, estrogen, DHEAS and Serum 17-hydroxyprogesterone (adrenal hyperplasia, Cushing's syndrome, PCOS/masculinizing ovarian tumors)
Diagnostics:
-Pelvic U/S (include transvaginal)
-MRI - head
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9
Q

What is Turner’s Syndrome?

A

Turner’s Syndrome: Genetic condition occurs only in females

  • 45 XO karyotype
  • Neck webbing, short stature
  • Congenital heart defects
  • No development of ovaries
  • Absence of secondary sexual characteristics - breast buds possible
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10
Q

How should you eval for Turner’s syndrome?

A

Pelvic exam
LH and FSH both HIGH
Karyotyping–> 45 XO karyotype
Pelvic U/S - reproductive organs and kidneys (see no development of ovaries)
EKG and echocardiogram (heart defects common)

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11
Q

What are the complications of Turner’s syndrome?

A

Complications:

  • Heart defects – coarctation, aortic valve disease, aortic dissection
  • Kidney abnormalities – horseshoe kidney
  • HTN / CVD
  • Obesity
  • Diabetes
  • Cataracts
  • Arthritis
  • Scoliosis
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12
Q

How do you treat Turner’s Syndrome?

A

Exogenous Estrogen

Human Growth Hormone

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13
Q

Describe delayed puberty:

A 
Common - 20%
Under stature and delayed bone age (wrist joint xray)
Positive family history
Diagnosis by exclusion and follow-up
Good prognosis - late developer
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14
Q

Is delayed puberty a primary or secondary cause of amenorrhea?

A

primary

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15
Q

What is a good way to use diagnostic imaging to check on delayed puberty? How about history questions to ask?

A

can use wrist joint X-ray to examine hand
could ask about a family history
THIS IS A DIAGNOSIS OF EXCLUSION

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16
Q

Describe Congenital Adrenal Hyperplasia:

A

-Inherited disorder
-Decreased cortisol and aldosterone production due to lack of enzyme needed
-Increased androgen production (male characteristics)
—>Puberty - voice deepens, facial hair
Ovaries, uterus, fallopian tubes present
–>possibly ambiguous genitalia
If severe type, can be fatal in newborn

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17
Q

What will you see on lab results that is suggestive of Congential Adrenal hyperplasia?

A
  1. Aldosterone and cortisol levels (LOW)
  2. High urinary 17-ketosteroids
  3. Electrolyte panel (“salt wasting” - low Na+, high K+)
  4. Karyotyping
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18
Q

How do you treat Congenital Adrenal Hyperplasia?

A
  1. Cortisol
  2. Reconstructive surgery of genitals (1-3 mo)
  3. Education and side effects of long-term steroid therapy
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19
Q

What is a Mullerian Defect?

A

Malformation of genital tract

absent hormone in embryonic development

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20
Q

What do you normally see with a Mullerian Defect?

A 
Normal breasts, pubic hair, normal external genitalia
Normal female range testosterone level
Absent vagina - normal ovaries
Karyotype 46-XX
15-30% skeletal and middle ear anomalies
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21
Q

What is the treatment for Mullerian Defect?

A

Treatment: Create vagina

***You may need to be aware of the skeletal and middle ear problems, could cause hearing issues or easily broken bones.

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22
Q

Is Mullerian Defect a Primary or Secondary amenorrhea?

A

primary

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23
Q

What is Outflow Tract Obstruction?

A

There are 2 types:

  1. Primary:
    Imperforate hymen
2. Secondary:
Secondary to curettage from surgery, to control heavy bleeding after delivery or abortion – “Asherman’s Syndrome”
walls of uterus become adherent
Cervical Stenosis
Fibroids
Polyps
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24
Q

How can Hyperprolactinemia cause amenorrhea?

Study These Flashcards
A

It is a secondary cause. Causes include:

  1. Pituitary tumor (prolactinoma)
  2. Hypothyroidism
  3. Medications - antidepressants, antipsychotics, opiates, oral contraceptives
  4. Stress
25
What are the signs and symptoms of hyperprolactinemia?
Galactorrhea, infertility, amenorrhea
26
What labs are needed to diagnose hyperprolactinemia? | What is the treatment?
Prolactin level, TSH, MRI of pituitary gland | Treatment: Medical (dopamine agonists), surgical, radiation
27
Describe Hypothyroidism:
``` Signs/Sxs: -Dry skin, fatigue, coarse hair, goiter, weight gain, "cold", memory problems, amenorrhea, constipation Evaluation: -TSH, free T4 Treatment: -Levothyroxine ```
28
What is Cushing's syndrome?
Glucocorticoid excess: 1. Endogenous: secreted by the adrenal cortex or 2. Exogenous: long-term steroids
29
What are the signs and symptoms of Cushing's?
Truncal obesity, moon facies, buffalo hump, amenorrhea, osteoporosis, hirsutism, acne, abdominal striae, HTN
30
How do you evaluate for Cushing's?
Corticotropin Releasing Hormone stimulation test Dexamethasone suppression test 24-hour urine free cortisol level
31
What is the treatment for Cushing's?
- Surgery if pituitary adenoma or adrenal tumor discovered | - Decrease steroid use if possible (if not, treat effects aggressively)
32
What labs will be elevated in Premature Ovarian Failure? | what other signs/symptoms are present?
FSH AND LH LEVELS HIGH!! Hot flashes, menopausal sxs, and increased risk of osteoporosis (so may have breaks). (check TSH, glucose, and cortisol levels to help rule out other diseases)
33
What is the treatment for Premature Ovarian Failure?
Oral contraceptives may help
34
What is often the first sign of an eating disorder?
amenorrhea
35
How do you want to evaluate for an eating disorder? | What is the treatment?
CBC, Electrolytes, TSH, free T4, FSH, LH tx: Increase body weight Not easy, intensive therapy and counseling Family needs to be involved
36
What is the female athlete triad?
Weight loss, Amenorrhea, Osteoporosis Treatment: Oral contraceptives Ca+ and Vit D intake Exercise moderation
37
Describe PCOS
a common hormonal disorder among women of reproductive age. The name of the condition comes from the appearance of the ovaries in most, but not all, women with the disorder — enlarged and containing numerous small cysts located along the outer edge of each ovary (polycystic appearance)
38
How do patients with PCOS present?
``` Amenorrhea or oligomenorrhea most common Obesity Masculine body type Hirsutism, acne Glucose intolerance ```
39
Describe what causes PCOS:
Underlying defect not well understood - prime underlying abnormality most likely pituitary Increased GnRH secretion resulting in increased LH and LSH/FH ratio Increased ovarian androgen production Lack of ovulation, leads to endometrium with unopposed estrogen Hyperinsulinemia is an independent contributory factor, association between POS and DM
40
What is the workup for PCOS?
Exam: Possibly enlarged ovaries Evaluation: Labs: lipids, fasting glucose, LH and LH/FSH ratio (3:1 - high probability), testosterone level, prolactin Pelvic U/S: multiple ovarian follicles - "Pearl Necklace"
41
What is the treatment for PCOS?
Treatment: -Oral contraceptives or progestin-only -Spironolactone (off-label) - androgen receptor antagonist -Metformin - oral antidiabetic agent reduces insulin resistance, may help with fertility -GnRH analogs - Lupron -Referral to Endocrinologist
42
What is the first thing you should do for amenorrhea?
PREGNANCY TEST!! | if negative, then progesterone challenge
43
What is the progesterone challenge?
10mg of progesterone for 10 days If bleed... 1. amenorrhea due to anovulation (consider PCOS, idiopathic--> may benefit from OCs) If NO bleed... 1. add estrogen to P by way of oral contraceptives. - --> if bleed= patient lacks sufficient estrogen, think ovarian failure or hypothalamic dysfunction 2. if still no bleed --> then get LH, FSH, TSH, and prolactin level.
44
In secondary amenorrhea, and no bleeding after progesterone challenge or estrogen being added...then what can you do?
-LH/FSH ratio > 3 = PCOS -FSH >40 = premature ovarian failure, menopause -Increased prolactin level = MRI, r/o pituitary tumor -Increased TSH = Hypothyroidism -Decreased FSH and LH = hypothalamic or thyroid malfunction -Stress, weight loss, excessive exercise, eating disorder (Treatment based on underlying disorder)
45
What is dysfunctional uterine bleeding?
abnormal uterine bleeding in terms of quantity, frequency, duration, or regularity in the ABSENCE of pelvic disease, pregnancy, or medical illness.
46
When is DUB most common? What is the most common cause?
Most common at menarche and peri-menopause >90% due to anovulatory cycle Patient usually presents with irregular and/or heavy flow affecting their lifestyle DIAGNOSIS OF EXCLUSION
47
What kind of diagnosis is DUB?
diagnosis of exclusion
48
What is hypermenorrhea?
cycles regular and normal duration, blood loss excessive
49
what is menorrhagia?
interval normal, excessive duration and flow
50
what is metrorrhagia?
interval irregular, duration and flow excessive
51
What is menometrorrhagia?
interval irregulation, duration and flow excessive and intermenstrual bleeding
52
oligomenorrhea:
interval is >35 days
53
polymenorrhea:
interval is <21 days
54
hypomennorrhea:
cycles regular, blood loss abnormally decreased
55
What are the two most common causes of DUB?
Anovulatory – estrogen breakthrough bleeding - Estrogen production unaccompanied by cyclic leutinizing hormone production leads to unopposed estrogen - Peri-menopause – gradual ovarian failure Ovulatory - Persistent progesterone production - Prematurely decreased progesterone - Mid-cycle spotting due to decreased estrogen following ovulation
56
What are some contributing factors to DUB?
Anxiety and stress Body habitus (Obesity, anorexia) Somatization Smoking (Heavier periods)
57
How do you treat DUB?
``` Combination oral contraceptives Cyclical progesterone (21-day cycle) D&C Endometrial Ablation Hysterectomy ```
58
In what patient population is OC considered high risk?
smokers older than 35
59
Post-menopausal bleeding needs...
endometrial biopsy and U/S

MED: Women’s Health/Reproductive System (14 decks)

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