Chapter 39: Amenorrhea and Abnormal Uterine Bleeding

Question 1

Amenorrhea

Answer 1

Absence of menstruation

Question 2

Definition of abnormal uterine bleeding

Answer 2

Abnormal uterine bleeding: Difference in frequency, duration and amount of menstrual bleeding. Usually separated into two categories of abnormal bleeding associated with ovulatory cycles (usually organic) and bleeding due to anovulatory cycles.

Question 3

Oligomenorrhea

Answer 3

Oligomenorrhea: Reduction of frequency of menses with cycle length over 40 days but less than 6 months

Question 4

Hypomenorrhea

Answer 4

Hypomenorrhea: Reduction in the number of days or the amount of menstrual flow

Question 5

Polymenorrhea

Answer 5

Polymenorrhea – Frequent menstrual bleeding (21 days or less in a cycle)

Question 6

Menorrhagia

Answer 6

Menorrhagia – Prolonged excessive uterine bleeding that occurs at regular intervals (loss of 80 mL or more of blood that lasts for more than 7 days)

Question 7

Metorrhagia

Answer 7

Metorrhagia: Irregular menstrual bleeding or bleeding between periods

Question 8

Menometorrhagia

Answer 8

Menometorrhagia – Frequent menstrual bleeding that is excessive and irregular in
amount and duration

Question 9

Primary vs secondary amenorrhea

Answer 9

Age 13 without menstruation without sexual characteristics or age 15 who hasn’t menstruated but has sexual characteristics

vs.

Menstruating woman who has not menstruated for 3 to 6 months or for the duration of three typical menstrual cycles for the patient with oligomenorrhea

Question 10

General pathway cause of amenorrhea

Answer 10

Menstruation ceases when: Endocrine function along the hypothalamic-pituitary- ovarian axis is disrupted or an abnormality develops in the genital outflow tract (obstruction of the uterus, cervix, or vagina or scarring of the endometrium).

Question 11

Most common cause of amenorrhea

Answer 11

Pregnancy

Question 12

Functional causes of hypothalamic pituitary dysfunction

Answer 12

Weight loss, excessive exercise and obesity

Question 13

Drugs that can cause amenorrhea due to hypothalamic pituitary dysfunction

Answer 13

Marijuanna, psychoactive drugs, and antidepressants

Question 14

Neoplastic causes of amenorrhea due to hypothalamic pituitary dysfunction

Answer 14

Neoplastic: Prolactin secreting pituitary adenomas, craniopharyngioma, hypothalamic hamartoma

Question 15

Psychogenic causes of amenorrhea due to hypothalamic pituitary dysfunction

Answer 15

Psychogenic causes: Chronic anxiety, pseudocyesis, anorexia nervosa

Question 16

In hypothalamic pituitary dysfunction, what labs will we see?

Answer 16

Definitive method is to measure LH, FSH, and Prolactin levels in the blood. In these conditions, FSH and LH are in the low range. Prolactin
normal unless prolactin-secreting pituitary adenomas.

Question 17

What labs will we see if there is an ovarian failure?

Answer 17

In ovarian failure, the ovarian follicles are either exhausted or are resistant to stimulation by FSH and LH. As the ovaries cease functioning, blood concentrations of FSH and LH rise in an attempt to wake em up.

Pts will show signs of estrogen deficieny.

Question 18

Causes of ovarian failure

Answer 18

• Chomosomal (Turner-45X gonadal dysgenesis, X Chromosome, long arm deletion 46XXq5)
• Gonadotropin-resistant ovary syndrome (Savage syndrome)
• premature natural menopause
• Autoimmune ovarian failure (Blizzard syndrome)

Question 19

How do we treat Asherman syndrome (rough dilation and curretage effect)

Answer 19

Tx: Lyse adhesions, but usually not much to help here. Estrogen to restore denuded areas of the endometrium.

Some cases, place a balloon or intrauterine device to keep the walls apart and stop the webbing from coming back

Question 20

First step in treating amenorrhea

Answer 20

Progesterone challenge test: 10-14 day course of oral medroxyprogesterone acetate –> induces progesterone –> withdrawal –> bleeding within a week = anovulatory, no bleeding = hypoestrogenic or anatomic condition

Question 21

How does hyperprolactinemia present? How do we treat it?

Answer 21

Hyperprolactinemia from prolactinoma in pituitary: Usually presents also with galactorrhea. Treat with bromocriptine dopamine agonist (dopamine inhibits prolactin).

5% of patients have hyperprolactinemia and galactorrhea = hypothyroidism

Question 22

What do we do with patients who have amenorrhea but want kids?

Answer 22

Ovulation can be induced through clomiphene citrate, human menopausal gonadotropins, pulsatile GnRH, or aromatase inhibitors.

1. In patients who are oligo-ovulatory or anovulatory like with PCOS, ovulation can be induced with clomiphene citrate.
2. In patients who have hypogonadotropic hypogonadism, ovulation can be induced with pulsatile GnRH or human menopausal gonadotropins

Question 23

What do we do about premature menstruation?

Answer 23

Premature menopause = Need estrogen supplementation

Question 24

When we see bleeding without ovulation, what do we need to suspect?

Answer 24

Unlike hypothalamic amenorrhea who have low estrogen and thus never stimulate the endometrium or ovulation, those with oligoovulation or anovulation with abnormal uterine bleeding have constant non-cyclic blood estrogen concentrations that are high enough to to stimulate growth and development of the endometrium. Without ovulation though, progesterone changes never occur at the uterus, and the growing uterine layer just sloughs off unpredictably as parts of it run out of blood supply.

Question 25

Chronic low stimulation vs chronic high stimulation of estrogen

Answer 25

i. Chronic low stimulation = light and infrequent bleeding

ii. Chronic high stimulation = heavy and frequent

Question 26

What is a luteal phase defect and what do we see?

Answer 26

Luteal Phase Defect: Ovulation occurs but corpus luteum is not fully developed so you don’t get the protecting progesterone for the uterus, and even if conception occurs, the pregnancy won’t last.

We see a shortened menstrual cycle pattern

Question 27

Treating anovulatory uterine bleeding

Answer 27

1. Progesterone Test
2. Give OCPs
3. Test for endometrial cancer before endometrial ablation or hysterectomy.