AUB + Pelvic Pain Flashcards by Kristin Godsey

REALLY study the menstrual cycle

back to Mod 1

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smooth, deep, fragile, bright red polyps that often bleed after sex

endocervical polyps

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connective, glandular or muscular tissue polyps that are usually asymptomatic and rarely cancerous

endometrial polyps

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small areas of endometrium within the myometrium that occur in multiparous women over age 40 usually with a history of miscarriage, curettage, resection, C/S, Tamoxifen use

adenomyosis

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submucosal (usually bleed) or fibroids (usually asymptomatic) that are benign tumors of the endometrium that is the leading cause for hysterectomy most common benign pelvic tumor

Leiomyoma

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rare in reproductive age women w/o PCOS and normal BMI

malignancy or hyperplasia

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consider this when AUB occurs in African American women or PCOS

malignancy or hyperplasia

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most common symptom of endometrial malignancy/hyperplasia

AUB/ postmenopausal bleeding

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hormone imbalance that causes anovulatory bleeding, amenorrhea, or oligomenorrhea

ovulatory dysfunction

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Causes of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:
PCOS
pituitary tumors (prolactinomas)
thyroid dx
associated w/ excessive exercise
minimal body fat

ovulatory dysfunction

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Categories of ___________:
Amenorrhea
Anovulatory
Ovulatory

ovulatory dysfunction

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type of AUB that is typically predictable cyclical w/ heavy bleeding but may involve intermenstrual or prolonged bleeding

endometrial

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diagnosis of exclusion in which ovulation still occurs, there are no coagulopathies, no structural reasons for AUB, and no medications being taken that would cause AUB

endometrial

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type of AUB caused by medications of LNG-IUDs

Iatrogenic

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reasons why aldolescents and perimenopausal women have AUB which is considered normal

irregular ovulation

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menstrual periods with abnormally heavy or prolonged bleeding

menorrhagia

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\_\_\_\_\_\_\_\_\_ AUB Causes:
Endocrine disruption:
thyroid, pituitary
Ovulatory Dysfunction:
Progestin contraceptives/IUDs
2 years post-menarche
Perimenopause
Chlamydia
Gonorrhea
Endometritis
PCOS
Polyps (post-coital)
Adnexal mass

Irregular

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_________ AUB Causes:

Ovulatory: Fibroids, Polyps, Adenomyosis

Regular

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_________/__________ AUB Causes:
Ovulatory Dysfunction
Fibroids (heavy, clots, pelvicfullness)

Irregular/Regular

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new, heavy, irregular bleeding is suspicious for:

endometrial cancer

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To Rule Out __________:
prolactin
FSH
LH

Endocrine causes of AUB

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To Rule Out __________:
adrenal studies
testosterone

Adrenal causes

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Treatment for ____________:
Estrogen (concomitant use of antiemetics d/t nausea)
COCs
Progestogen-only
LNG-IUD
GnRH agonists - short term while waiting for surgical tx
Nonhormonal - NSAIDs (ovulatory-idiopathic)
Tranexamic acid - Lysteda
Surgical - D&C, endometrial ablation

Acute Non-life Threatening Heavy AUB

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Treatment for \_\_\_\_\_\_\_\_\_\_\_:
Provera
Norethindrone
Prometrium
Depo-provera
LNG-IUD

Chronic Anovulation

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painless, spontaneous, heavy, intermenstrual bleeding is indicative of:

endometrial hyperplasia

``` ALWAYS order ___________ if: postmenopausal vaginal bleeding Older women - risk increases with age women >/= 45 30-45 w/ negative pregnancy test and med management of AUB fails ```

endometrial biopsy

``` Risk Factors for ___________: >/= 40 anovulation PCOS fam history new onset heavy irregular bleeding especially postmenopausal nulliparity overweight unopposed estrogen stimulation of endometrium tamoxifen tx infertility DM Type II ```

endometrial cancer

Need to Know for ___________: Contraindicated in: Hx of DVT/VTE + coagulopathies Family Hx of idiopathic VTE Give antiemetic for nausea Give progesterone afterwards

Estrogen

Need to know for ______________: | If flow does not stop w/in 48 hours - return for further evaluation

monophasic COC's

Need to know for ______________: for chronic anovulation Cyclic repeat endometrial biopsy w/in 3-6 months after initiated Take at night due to possible fatigue Caution w/ peanut allergies Contraindicated: pregnancy - even if she thinks she is but test is negative

Progesterone

Need to know for ______________: Give when awaiting surgery for heavy bleeding Side effects r/t estrogen deficiency Caution in anemic patiets

GnRH

Need to know for __________: | Contraindicated: ulcers, bronchospastic lung disease

NSAIDs

Need to know for __________: Second line for those who cannot or do not wish to use hormonal options s/e: VTE, arterial and venous retinal occlusions, rarely nausea and leg cramps Contraindicated: hx or risk of thrombosis

TXA

When ________ can be used for AUB: Chronic anovulation Long-term/chronic management Heavy menstrual bleeding caused by fibroids that do not distort uterine cavity and uterus is less than 12 wks gestation in size

LNG-IUD

``` Other options for __________: Surgical - medical therapy fails D&C Endometrial ablation Uterine artery embolization Hysterectomy ```

AUB-E

most common causes of ____________: pregnancy hypothalamus PCOS

amenorrhea

Evaluate for ______________ if: No menses by 14 in absence of growth or development of secondary sexual characteristics No menses by 16 regardless of the presence of normal growth of development of secondary sex characteristics Women who have menstruated previously, no menses for an interval of time equivalent to a total of at least 3 previous cycles or 6 months

amenorrhea

failure to begin menses by age 16

primary amenorrhea

3 months w/o menses when menses has been established

secondary amenorrhea

``` Categories of __________: Disorders of the genital outflow tract Disorders of the ovary Disorders of the anterior pituitary Disorders of the hypothalamus or CNS ```

Amenorrhea

``` Physiological Disorders for ____________: anatomic defects ovarian failure chronic anovulation anterior pituitary disorders CNS disorders ```

Amenorrhea

most common cause of amenorrhea

ovarian function abnormalities

absence of menses due to suppression of HPOA with no anatomic or organic disease

Functional Hypothalamic Amenorrhea

____________ > 40 = functioning ovaries | Low value may be ovarian failure or hypothalamic amenorrhea

serum estradiol

low level of ___________ = normal ovulatory function

serum FSH

If these diagnostic labs for amenorrhea (estrogen, serum estradiol, progestogen challenge, endometrial thickness, serum FSH, serum prolactin) are normal = ovaries are producing estrogen and FSH normal = diagnosis is:

chronic anovulation

antidepressants, opiates, CCBs, and estrogens can cause:

hyperprolactinemia

If hyperprolacteinemia present with amenorrhea - more evaluation needed to rule out:

pituitary tumors and hypothalamic mass lesions

treatment of choice for hyperprolactinemia

dopamine agonist

If progestogen challenge test is positive and no galactorrhea and prolactin level normal, midwife can rule out:

pituitary tumor

If progestogen challenge test is positive and no galactorrhea and prolactin level normal, diagnosis is:

anovulation

Treatment for _________: Progestogen for first 10 days each month to induce menses CHC **Evaluate for PCOS

Anovulation

management is necessary for ____________ because if not treated it can cause endometrial cancer regardless of age

Anovulation

Anovulation Treatment: Medroxyprogesterone 5-10mg QD for first ___-___ cycle days

12-14

still possible during progesterone anovulation treatment

pregnancy

diagnosed when estrogen production is low while serum FSH is high

ovarian failure

Treatment for ____________: Karyotype Test for women < age 30 (possible genetic cause) Test for Anti-Adrenal Antibodies (possible autoimmune- Addison’s disease)

Ovarian Failure

test to perform when no clear explanation for hypogonadism or hyperprolactinemia in amenorrhea

MRI

No lesions on MRI means no need for further pituitary testing and diagnosis is:

functional hypothalamic amenorrhea

PCT is positive if this occurs

withdrawl bleeding 7-10 days after progesterone is stopped

withdrawl bleed after progesterone is discontinued means there is plenty of __________ and _________ are functioning:

estrogen | ovaries

________ PCT means: Minimal/No estrogen → no endometrium → no flow ***Physician consult

Negative (Not Positive)

Galactorrhea + No withdrawal bleed + High Prolactin | means ______ estrogen

Low

Prolactinemia + No withdrawal bleed + High Prolactin | means ______ estrogen

Inhibited

If patient has PCOS, PCT will result:

positive (withdrawal bleed)

Excess adipose tissue + Withdrawal bleed | means estrogen is:

produced in part by adipose tissue

No withdrawal bleed means ovaries not producing:

estrogen

``` Clinical Manifestations of _____________: Irregular menses - HALLMARK FEATURE Hirsutism Acne Alopecia Virilization Clitoral hypertrophy Voice deepening Increased muscle mass Breast atrophy Male pattern baldness Adrenal or ovarian tumor Congenital adrenal hyperplasia Hyperthecosis Severe Hyperinsulinemia Menstrual dysfunction Infertility Anovulation Oligomenorrhea (cycles last 35-199 days) Amenorrhea cycle > 199 days --Significant endocrinopathies --More severe hyperandrogenemia --Increased serum LH and cortisol levels --Increased incidence of hyperinsulinemia Polycystic ovaries Chronic anovulation (not required for dx) Obesity (often abdominal) Insulin resistance (Risk of impaired glucose tolerance and T2DM) Dyslipidemia Metabolic syndrome Cardiovascular disease markers Depression Anxiety Binge eating Less sexual satisfaction and overall quality of life Cancer risks ```

Hyperandrogenism

Consequences of _____________: HTN Impaired glucose tolerance-- Type 2 DM Mood disorders Infertility/Subfertility Psychological impact **3x risk for Endometrial Cancer Estrogen-Dependent tumors Dyslipidemia (Low HDL, High LDL and triglycerides) Metabolic syndrome (Risk for cardiovascular disease and DM) Systemic inflammation-- endothelial vascular dysfunction and coronary artery calcification

Hyperandrogenism

``` Conditions that cause ____________: PCOS **most common Congnital adrenal hyperplasia Hyperthecosis Nonclassical adrenal hyperplasia Androgen producing tumors Adrenal or ovarian tumor ```

Hyperandrogenism

hallmark feature of PCOS

menstrual irregularity

results from more significant endocrinopathies including more severe hyperandrogenemia High serum LH, cortisol, and incidence of hyperinsulinemia

amenorrhea

menstrual cycle dysfunction that rarely occurs with hyperandrogenism

polymenorrhea (cycle length < 21 days)

regular menses can occur with ______-anovulation

oligo

``` History Questions for _______________: Age at onset of: Thelarche - breast development Adrenarche - pubic hair Menarche Menstrual pattern Pregnancy history/ miscarriages Obesity Hirsutism Seborrhea Acne Alopecia Complete medication hx --Testosterone, anabolic steroids, danazol, certain progestins, glucocorticoids, valproic acid Virilization (suspicion for androgen-producing tumor) Libido Muscle bulk Voice deepening Breast atrophy Clitoromegaly Polydipsia/ Polyuria (glucose intolerance) Galactorrhea Visual disturbance Headache Thyroid dysfunction → hot/cold intolerance, weight loss/gain Cushing syndrome - striae, mood changes, easy bruising, or weight gain Cardiovascular and metabolic risk factors Smoking Hx of HTN, dyslipidemia, DM, CVD Family Hx - hirsutism, acne, infertility, DM, CVD - esp first-degree relatives w/ premature CVD before 55 in men and 65 in women, obesity, or dyslipidemia ```

Hyperandrogenic Disorders

Physical Exam for ______________: - Establish severity and related symptoms - Height, weight, BMI - BP - Skin - hirsutism, acne, alopecia - Consider racial, familial, genetic and hormonal influences - Acanthosis nigricans - velvety, warty, hyperpigmented on axillae, neck, under breasts (insulin resistance) - Thyroid - Breast - Galactorrhea - Cushing - mone facies, dorsocervical fat pad - buffalo hump, and abdominal striae - Pelvic - clitoris for hypertrophy and bimanual for uterine size, ovaries, and mass presence

Hyperandrogenic Disorders

Diagnostic Labs for _____________: Prolactin TSH Fasting lipid 2-hour oral GTT Progesterone days 20-24 of menstrual cycle Free testosterone (more sensitive than total count) Total testosterone (if tumor suspected) Serum 17-OHP (rules out congenital adrenal hyperplasia) Anti-mullerian hormone (AMH) (> 4.5 = PCOS) Cushings Test (dexamethasone suppression test) **only if sx present Pelvic ultrasonography (polycystic ovary morphology and endometrial hyperplasia for oligo and amenorrheics) TVUS (w/ machines used for follicle numbering and morphology) TVUS of ovaries (if virilizing tumor suspected--adrenal CT if not identified w/ US) Endometrial biopsy (for longstanding anovulation due to carcinoma risk- consider unopposed estrogen exposure over age ) **Avoid routine adrenal imaging

Hyperandrogenic Disorders

If Luteal phase < 3 days x 2 cycles, midwife can diagnose:

oligo-anovulatory/ PCOS

PCOS is diagnosed by:

exclusion

``` Diagnosis of ____________: (2 of 3) 1. oligo or anovulation 2. clinical/biochemical signs of hyperandrogenism 3. polycystic ovaries ```

PCOS

First line treatment for PCOS

COCs

``` Effects of __________ for PCOS: Inhibits LH and LH-dependent ovarian androgen production Increases SHBG to bind free testosterone Cosmetic relief of hirsutism and acne --Acne - effect w/in 2 months --Hair growth - effect w/in 9-12 months Regular menstrual cycle Endometrial cancer protective ```

COCs

Safety Concerns of _______ for PCOS: May increase insulin resistance VTE Risk 2x for PCOS with this VTE Risk 1.5x for PCOS without this

COCs

PCOS treatments for those who don't want COCs or have contraindications to COCs

**First Line** Antiadrogens (spironolactone, finasteride, flutamide) Progestogens (LNG-IUDs, POPs, depo, nexplanon)

Alone will not treat hirsutism

Progestogens (LNG-IUDs, POPs, depo, nexplanon)

PCOS treatments that are endometrial cancer protectives

Progestogens (LNG-IUDs, POPs, depo, nexplanon) and COCs

Considerations for ___________ PCOS Treatments: Teratogen (always use w/ effective contraception w/ sexually active) Hirsutism and androgenic alopecia

Antiadrogens (spironolactone, finasteride, flutamide)

Other treatments for _______: Insulin-sensitizing agents - metformin, TZDs Topical - eflornithine for facial hirsutism GnRH analogs - leuprolide to tx hirsutism

PCOS

Reasons for Immediate ___________ in PCOS woman: Sudden onset or rapid progression of virilization Endocrinopathies - CAH, HAIR-AN syndrome, Cushing's, hyperprolactinemia, or androgen-producing tumors Refractory to treatment Infertility

Referral

Chronic mucocutaneous w/ inflammation, epithelial thinning, and depigmentation, and dermal change of the vulva -Agglutination of labia minora -Progressive or Remittive -Sometimes seen in other body areas - trunk, neck, forearm, axillae, under breasts, trauma induced -Early s/s - Dull, nonspecific vulvar irritation Progressive = severe pruritus, burning, dyspareunia

Lichen Schlerosis

Goals for _____________: s/s relief Reversal of agglutination Prevention of further architectural distortion w/ loss of function Prevention of potential malignant changes

Lichen Schlerosis

First Line Treatment for _____________: | high or very high potency topical steroid ointment - clobetasol propionate 0.05%; 3 month tapered dosing common

Lichen Schlerosis

-May be asymptomatic (incidental on imaging) -Pain mild to moderate and self-limiting UNLESS d/t hemorrhagic corpus luteum cyst which can cause significant blood loss -Sudden -Midcycle -Most prone to rupture = mimic ectopic -Hypovolemia only if there is hemoperitoneum -Abdominal tenderness (often rebound tenderness d/t peritoneal irritation) -May be able to palpate mass w/ bimanual if not entirely ruptured -Functional - resolve w/in 3 months

Ovarian Cysts

Treatment for __________: | Hormonal contraceptives - control repeated episodes but unlikely to resolve

Ovarian Cysts

GOLD standard for endometriosis diagnosis

laparoscopy w/ histology of biopsy

``` Symptoms of ____________: Can be asymptomatic Dysmenorrhea Deep dyspareunia Sacral backache during menses ```

Endometriosis

endometriosis treatment that removes focal areas, endometriomas, distorting adhesions Also effective for pain mgmt

Laprascopic Conservative

definitive diagnostic surgery for endometriosis that allows for elective ovarian preservation to benefit bone and CV effects but has increased risk of recurrent symptoms greatly

complete hysterectomy and bilateral salpingo-oophorectomy

``` Disease that causes: Infertility Late miscarriage Preterm birth FGR Antepartum hemorrhage Progesterone resistance Subclinical atherosclerosis ```

Endometriosis

variant of endometriosis where endometrial cells are located w/in the myometrium

Adenomyosis

variant of endometriosis where endometrial cells are located w/in the myometrium

Adenomyosis

``` Symptoms of ______________: May be asymptomatic Menorrhagia Dysmenorrhea Dyspareunia Pelvic pain Diffusely enlarged, boggy, and/or tender uterus that is asymmetrical w/o firm nodularity of fibroids ```

Adenomyosis

Adenomyosis is diagnosed by:

TVUS, definitively by histology by surgical biopsy

Treatment: | May choose hysterectomy w/ ovarian preservation (curative)

Adenomyosis

``` Symptoms of _____________: May be asymptomatic Uterine bleeding Pelvic pain or pressure Dyspareunia Torsion or rupture = acute pain Palpation of abdomen reveals mass(es) arising from uterus May be tender to palpation May have increased temp and WBCs **May be confused with subacute salpingo-oophoritis ```

Fibroids

``` Treatment for _____________: -Decisions based on number, size, location, s/s type and severity, distance to menopause, childbearing plans, preference for uterine preservation --Medical options Progestens GnRH agonists SERMs Aromatase Inhibitors COCs NSAIDs Surgical - myomectomy and hysterectomy ```

Fibroids

Risk Factors for _____________: **Unopposed estrogen → endometrial hyperplasia** Exogenous - Estrogen therapy, tamoxifen Endogenous - Early menarche, late menopause, hx of infertility, nulliparity, obesity, chronic anovulation, diabetes, high-fat diet, ovarian cancer Obesity Physical inactivity White race (for incidence) Black women (for higher grade + aggressive histology) Genetic predisposition Lynch syndrome Cowden disease Older age Smoking Sedentary lifestyle History of pelvic radiation to treat other cancer Endometrial hyperplasia

Endometrial Cancer

Risk Factors for ___________: Advancing age (increasing at menopause and into 80s) Family history in 1st degree relative Gene mutations (assoc w/ family Hx of ovarian or breast cancer before age 50) Northern european or ashkenazi jewish descent BRCA1 or BRCA2 Lynch syndrome Cyclic hormonal stimulation by estrogen Short or irregular menstrual cycles and late age at menopause Obesity talcum powder use Smoking BMI>30 Smoking (mucinous type) Fertility drug use (Decreased Risk = hysterectomy, tubal ligation, or previous salpingectomy)

Ovarian Cancer

Most likely to develop _____________: Unopposed Estrogen Not Ovulating PCOS

Endometrial/Ovarian Cancer

Type II Endometrial cancer rarely presents with enodmetrial lining < ___ mm

In office procedure to directly visualize uterine cavity Visualize and biopsy Recommended to do w/ D&C → best opportunity to examine endometriumn and confirm premalignant endometrial lesions

Saline-infusion Sono-Hysterography

Highest mortality GYN cancer

ovarian

Gold standard diagnostic for endometrial cancer

D+C

AUB + Pelvic Pain Flashcards

(114 cards)