Amenorrhea & DUB

Question 1

What is the definition of AUB?

Answer 1

Abnormal Uterine Bleeding

• bleeding o/side of norm physiologic menstruation
• includes both DUB [absence of organic dz] and structural bleeding
  
  • 15-20% of menstruating women

Question 2

What is normal for menses?

duration

amount

cycle length

other

Answer 2

• duration: 2-7 days
• amt: <80 ml [2.5 oz]
• length: 24-35 days

other:

• —Change pad/tampon >3 hours
• —Use fewer than 21 pads/tampons per cycle
• —Seldom need to change pad/tampon overnight
• —Clots less than 1 inch in diameter

Question 3

on what days of the menstrual cycle does the following fall on?

menses

proliferative phase/follicular

secretory phase/luteal

ovulation

Answer 3

menses: day 0-8

proliferative phase/follicular: day 8-14

• E>P

secretory phase/luteal: 14-28

• ovulation triggers P prodxn

ovulation: on day 14, or 14 days before menses start

Question 4

after the LH surge, what happens?

Answer 4

ovulation w/in 48 hrs

Question 5

Define the following terms:

menorrhagia

metrorrhagia

menometrorrhagia

oligomenorrhea

polymenorrhea

Answer 5

¢Menorrhagia –Normal intervals, but prolonged (>7d) or excessive (>80 ml/cycle)
¢Metrorrhagia –irregular and more frequent intervals, amount is variable
¢Menometrorrhagia –prolonged or variable amounts occurring irregularly and more frequently than normal
¢Oligomenorrhea-menses at interval greater than 35 days
¢Polymenorrhea- —menses at interval less than 21 days

Question 6

define:

intermenstrual bleeding

midcycle spotting

postmenopausal bleeding

amenorrhea

Answer 6

¢Intermenstrual bleeding –—bleeding between regular periods
¢Midcycle spotting –—just prior to ovulation, from declining estrogen
¢Postmenopausal bleeding-—bleeding in a woman at least 1 year after cessation of cycles
¢Amenorrhea –—Lack of bleeding for 6 months or longer

Question 7

1’ vs 2’ amenorrhea

Answer 7

¢Primary amenorrhea: no spontaneous uterine bleeding by age 14 in the absence of secondary sexual characteristics –OR- by age 16 with otherwise normal development [—prevalence is 0.3%]

¢Secondary amenorrhea: the absence of menstrual bleeding for six months in a woman with prior regular menses or for 12 months in a woman with previous oligomenorrhea

• —Ovary – 40%, Hypothalamus – 35 %, Pituitary – 19 %, Uterus – 5 %, Other – 1%
• —prevalence is 1.3%, higher in certain subgroups such as competitive atheletes.

Question 8

What are compartment I causes of amenorrhea?

Answer 8

DO’s of o/Q tract

• —Imperforate hymen
• —Ashermans Syndrome–destruction of endometrium. Scarring preventing bleeding – due to D&C, ablation, severe infection–> scraped too far down and taken away stratum basalis
• —Mullerian Anomolies-absent uterus, no vaginal orifice
• —Testicular Feminization (Androgen Insensitivity) -46 XY – resistent to testosterone- fail to develop normal male features, but testes still present and secreting mullarian inhibiting substance

Question 9

What are compartment II causes of amenorrhea?

Answer 9

DO’s of ovary

¢Turners Syndrome 46XO –follicles undergo apoptosis –resulting in high FSH, low estrogen

• Mosaicism

¢Gonadal agenesis/dysgenesis
¢Resistant ovary syndrome (rare)
¢Prematureovarian failure ** (before age 40)** **menopause)

¢Radiation/chemotherapy

17 alpha-hydroxylase deficiency

Question 10

what are compartment III causes of amenorrhea?

Answer 10

DOs of anterior pituitary

• —Pituitary Adenoma –(hyperprolactinemia) –prolactin inhibits GnRH (so decrease LH/FSH)
• Empty Sella Syndrome –(elevated prolactin)
• Sheehans Syndrome –-necrosis of pituitary –post partum or trauma
• Hypopituitarism
• Hypothyroid– increase TSH suppresses GnRH
• Infiltrative (Sarcoidosis/hemochromostosis)
• (medications) –opiates and phenothiazines can increase prolactin

Question 11

what are compartment IV causes of amenorrhea?

Answer 11

DO’s of CNS or hypothalamus
¢Tumors
¢Craniopharyngioma, harmartoma
¢Stress – Increases cortisol- decreases FSH/LH
¢Hypothalamic amenorrhea- High corticotropin –releasing hormone –inhibits GnRH
— Eating disorder, weight loss (or gain), exercise
— Kallmanns Syndrome –congenital GnRH deficiency
— Disease-JRA,syphillis, TB
— Psychosocial stress

Question 12

What should be part of your evaluationof amenorrhea?

Answer 12

HISTORY

• menstrual Hx, reproductive hx, gneral medical Hx, famHx, social Hx

PE: complete

• anatomy, genital development, BMI, hair distribution, galactorrhea etc

LABS

• hCG to rule out preg, PRL, FSH, LH [if hypoGonad sx’s do test., 17hydro, & DHEA]
• P w/drawal bleed
• CT/MRI

Question 13

What is necessary to Tx amenorrhea?

Answer 13

need a clear Dx!!!

—Hypothyroid– thyroid replacement
—Ovarian Failure– estrogen replacement
—Pituitary Tumor–medication or surgery
—Hypothalamic Amenorrhea–change lifestyle, cyclical hormones

Question 14

what are some major causes of abnormal bleeding?

Answer 14

• pregnancy: ectopic, miscarriage, placenta previa, moles
• medications: steroid, thyroid, H’s, anticoagulatns, SSRIs, herbs
• benign genital tract path: myoma, endoM, polyp, PID, infxn, trauma
• malignant GTP: carcinoma
• systemic dz: ovulatory or anovulatory
• iatrogenic: IUD, implant

Question 15

What is the condition that is MC to affect ovulation?

Answer 15

PCOS!!!

about 6% of women

Question 16

what is anovulatory bleeding?

Answer 16

unpredictable, variable flow & duration

• distrubance of normal HPO axis
• P is low and E dominant
• MC in extremes of reproductive yrs
  
  • also in athletic young female who previously had normal periods??? kaplan

no ovulation, there4 no CL ==> decreased P, prolonged E, excessive prolif of endoM & it becomes unstable, erratic bleeding

Question 17

Who should we evaluate for irregular periods??

hell, we are all irregular pracitcally

Answer 17

¢Adolescents

• —Consistently more than 3 months between cycles
• —Irregular cycles for more than 3 years

¢Adult Women: —Suspected recurrent anovulatory cycles

¢Perimenopausal

• —Increased volume or duration of bleeding over baseline
• Periods more often than every 21 days
• Intermenstrual spotting
• Postcoital bleeding

Question 18

What are some risks for enoM cancer?

Answer 18

¢Obesity
¢Nuliparity
¢Previous tamoxifen therapy
¢Unopposed estrogen therapy
¢diabetes
¢Increased with age

• —Age 19-39 – 10 cases per 100,000
• Age 40-49 – 36 cases per 100,000
• Age 50-70 – 1000 cases per 100,000

Question 19

Who should we do an endometrial Bx on?

Answer 19

¢Adolescents: Obese with 2-3 years of untreated anovulatory bleeding
¢W_omen <35 years old with risk factors: _—Chronic anovulation, —Diabetes, Family history of colon cancer, —Infertility, —Nulliparity, —Obesity, —Tamoxifen use
¢Women >35 with suspected anovulatory bleeding
¢Women with bleeding not responsive to medical tx

Question 20

How good is a endoM Bx?

Answer 20

high sensitivity for carcinoma

low for atyp. hyperplasia

can miss: 18% of focal lesions, & miss fibroids & polyps

Question 21

how good is an endoM US?

Answer 21

• show leiomyoma, endoM thickening & focal masses
  
  • misses: polyps & fibroids
• sensitivty: 96% for endoM cancer
  
  • 92% for endoM abnormality

Question 22

What is the goal of Tx for uterine bleeding>?

Answer 22

¢Goal of treatment is to control bleeding, prevent recurrence, and preserve fertility (if desired)

Question 23

What is important to determine in a pt with acute, heavy bleeding?

how do we Tx accordingly?

Answer 23

are they hemodynamically stable?????

NO: high dose IV E [regorws endoM], IV fluids, blood products if needed, consider D&C, follow w/ P w/drawal bleed

YES:

• medications: OCP, NSAIDS, P, GnRH agonist, antifibrolytic
• observation

Question 24

other more radical Tx options for uterine bleeding?

Answer 24

¢IUD (Mirena)
¢Hysteroscopy
¢Endometrial ablation
¢Uterine artery embolization
¢hysterectomy