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Endocrinology > Menstruation-Related Disorders and Endometriosis > Flashcards

Menstruation-Related Disorders and Endometriosis Flashcards

1
Q

Amenorrhea

A

No menstrual bleeding in a 90-day period

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2
Q

Primary amenorrhea

A
  • Absence of menses by age 16 in the presence of normal secondary development
  • Absence of menses by age 14 in the absence of normal secondary development
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3
Q

Secondary amenorrhea

A
  • Absence of menses for 6 months AFTER menses has begun
  • Occurs more in people < 25 years w/ history of menstrual irregularities
  • Occurs more in competitive athletics
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4
Q

What are the three broad categories of amenorrhea etiology?

A
  • Anatomical causes, including pregnancy and uterine structural abnormalities
  • Anomalies of the hypothalamic-pituitary-ovarian (HPO) axis leading to chronic anovulation
  • Ovarian insufficiency/failure
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5
Q

What is the first step in evaluating amenorrhea?

A

Urine pregnancy test

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6
Q

When should you take your home pregnancy test?

A

If testing earlier than 10 days after period was expected to start, then use first morning urine to maximize the chances of picking up the smaller levels of hCG

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7
Q

Diagnostic factors of amenorrhea

A
  • Pregnancy test
  • Serum FSH and LH
  • Thyroid-stimulating hormone
  • Prolactin
  • Progesterone challenge to confirm functional anatomy and adequate estrogenization
  • Pelvic ultrasound to evaluate for polycystic ovaries, presence/absence of uterus, and/or structural abnormalities
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8
Q

What do you measure for if you suspect hyperandrogenic state in amenorrhea?

A
  • Free and total testosterone
  • Dehydroepiandrosterone
  • Fasting glucose
  • Fasting lipid panel
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9
Q

What is the treatment of amenorrhea (primary or secondary)?

A
  • CEE by mouth daily on days 1-25 of the cycle
  • Ethinyl estradiol patch every day
  • CHC
  • Oral MPA by mouth on days 14-25 of the cycle
  • Progesterone vaginal gel intravaginally every other day for 6 doses
  • Norethindrone by mouth daily for 7-10 days
  • Micronized progesterone by mouth daily for 7 to 10 days
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10
Q

What is the treatment for amenorrhea related to hyperprolactinemia?

A
  • Bromocriptine daily in two to three divided doses
  • Cabergoline by mouth once weekly or in two divided doses
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11
Q

Polycystic Ovary Syndrome

A
  • Abnormal uterine bleeding due to chronic unopposed estrogen on the endometrium
  • Ovulatory dysfunction
  • Disorder of androgen excess accompanied by ovulatory dysfunction and/or polycystic ovarian morphology
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12
Q

What is the etiology and pathophysiology of PCOS?

A
  • Hypothalamus-pituitary-ovarian abnormality
  • Insulin resistance
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13
Q

Hypothalamus-pituitary-ovarian abnormality in PCOS

A
  • Ovarian-induced increase in GnRH
  • Increase in LH/FSH ratio with a resulting increase in ovarian testosterone production
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14
Q

Insulin resistance in PCOS

A
  • Increase in endogenous insulin concentration caused by insulin resistance in muscle and adipose tissues results in excessive androgen production by the ovaries
  • Excessive insulin decreases hepatic synthesis of sex hormones binding globulin (binds free testosterone)–leading to hirsutism
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15
Q

What are the symptoms of PCOS?

A
  • Hyperandrogenism
  • Ovulatory dysfunction
  • Polycystic ovaries
  • Intermenstrual bleeding
  • Heavy Menstrual Bleeding (HMB)
  • Exclusion of other diagnosis that could result in hyperadrogenism or ovulatory dysfunction
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16
Q

What are the signs of hyperandrogenism in PCOS?

A
  • Excessive acne
  • Male pattern hair loss
  • Hirsutism
  • Elevated serum levels of testosterone or metabolic intermediates
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17
Q

What are the signs of ovulatory dysfunction in PCOS?

A
  • Oligomenorrhea–cycles more than 35 days apart but less than 6 months apart
  • Amenorrhea–absence of menstruation for 6 or more months after a cyclic pattern has been established
18
Q

What are the signs of polycystic ovaries in PCOS?

A

Ovary containing 12 or more follicles (2 to 9 mm diameter or greater than 10 mL) on ultrasound

19
Q

What is the criteria for diagnosis of PCOS?

A

MUST have hyperandrogenism + oligomenorrhea or polycystic ovaries

20
Q

What is a nonpharmacological therapy for PCOS?

A

Weight loss of 5-10%
* Improves menstrual irregularity and ovulatory function
* Reduces hirsutism
* Increases insulin sensitivity
* Improves response to fertility treatments

21
Q

What is the first line treatment of anovulation and menstrual irregularity in PCOS?

A

CHCs
* w/ 35 mcg of ethinyl estradiol and a progesterone that exhibits minimal androgenic side effects (e.g. norgestimate and desogestrel) or with antiandrogenic effects (e.g. drospirenone) is desirable

22
Q

What is the second line treatment of anovulation and menstrual irregularity in PCOS?

A
  • Progestin-only contraceptive (such as Levnorgestrel-releasing intrauterine system)
  • Metformin
23
Q

What is the treatment for hirsutism for patients who had conceive?

A

Electrolysis and light-based therapy (effective for mild cases)

24
Q

What is the first line treatment of hirsutism in PCOS?

A

Hormonal contraception with non-adrogenic progestin (norgestimate, desogestrel, drospirenone)

25
Q

What is the first line treatment of hirsutism in PCOS?

A

Hormonal contraception with non-androgenic progestin (norgestimate, desogestrel, and drospirenone)
* CHC increase sex hormone-binding globulin which binds androgen and reduces their circulating free concentration

26
Q

What is the second line treatment of hirsutism in PCOS?

A

Spironolactone 100 mg daily (monotherapy or synergistic therapy)
* Eflornithine (Vanqua)
* Flutamide (non-steroid antiandrogen)

27
Q

What is the third line treatment of hirsutism in PCOS?

A

Metformin
* Improves insulin sensitivity and can reduce androgen
* Can reduce ovulation

28
Q

What is the treatment of acne in PCOS patients who want to conceive?

A
  • Topical creams (e.g., antibiotic, benzoyl peroxide)
29
Q

What is the first line treatment of acne in PCOS?

A

Hormonal contraceptives, topical cream, including benzoyl peroxide, trentinoin (Retin-A), adapalene (Differin) or antibiotic cream

30
Q

What is the second line treatment of acne in PCOS?

A

Spironolactone and antiandrogen

31
Q

```

What is the first line treatment of anovulation and infertility in PCOS?

A

Letrozole (Aromatase inhibitor)
* dosed at 2.5-7.5 mg daily for 5 days beginning on cycle day 3 after induced withdrawal bleedig with a progesterone such as MPA 10 mg daily or orrally for 10 days

32
Q

What is the second line treatment of anovulation and infertility in PCOS?

A

Clomiphene (estrogen antagonist)
* dosed at 50-150 mg daily for 5 days beginning on cycle day 3 after induced withdrawal bleeding with a progesterone such as MPA 10 mg daily orally for 10 days

33
Q

What is the third line treatment of anovulation and infertility in PCOS?

A

Gonadotropins

34
Q

Endometriosis

A

Chronic, reoccurring disease that is defined by the presence of endometrial tissue outside of the uterus

35
Q

What are the principle manifestations of endometriosis?

A
  • Pelvic pain: structural or inflammatory causes (period pains)
  • Infertility: inability for implantation
  • No symptoms
36
Q

What is the pathophysiology of endometriosis?

A
  • Retrograde menstrual flow leads to endometrial deposits in various areas of the genitourinary tract including the bladder, ureter, and ovaries in addition to the gastrointestinal tract
37
Q

What are the clinical presentation of endometriosis?

A
  • Pelvic pain–often correlated to the menstrual cycle (may be asymptomatic for years)
  • Dysmenorrhea, dyspareunia, infertility, epigastric or bowel symptoms
38
Q

How do you diagnose endometriosis?

A
  • Often difficult
  • Definitive diagnosis can only be made by histological examination of lesions
  • Imaging, ultrasound, pelvic exam
39
Q

What is the first line treatment of endometriosis?

A

NSAIDs
* May decrease size of implants due to prostaglandins response within implants
* Does NOT improve fertility rate or cure disease
* Dose “round the clock” for best effect

40
Q

What are some 2nd line treatment of endometriosis?

A
  • Combined hormonal contraceptives
    • More effective at reducing dysmenorrhea associate dwith endometriosis
    • Decrease pain, flow, and implant size
  • Depo-Provera
    • Decrease pain, flow, and implant size
  • May use NSAID and hormonal therapy
41
Q

What are the third line treatment of endometriosis?

A

GnRH agonist
* Inhibit FSH/LH which leads to decrease in estrogen production
* Use up to 6 months
* Use limited by vasomotor symptoms and decrease in bone mineral density

42
Q

What are some non-pharmacological treatment for endometriosis?

A

Diet
* Decrease foods with high glycemic index
* Eliminate caffeine and high tyramine containing foods
* Increase omega-3 fatty acids

Surgery
* Laparoscopic ablation and excision removal of endometrial implants
* Hysterectomy-oophorectomy

Endocrinology (10 decks)

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