Menstruation-Related Disorders and Endometriosis Flashcards
(42 cards)
Amenorrhea
No menstrual bleeding in a 90-day period
Primary amenorrhea
- 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
Secondary amenorrhea
- 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
What are the three broad categories of amenorrhea etiology?
- Anatomical causes, including pregnancy and uterine structural abnormalities
- Anomalies of the hypothalamic-pituitary-ovarian (HPO) axis leading to chronic anovulation
- Ovarian insufficiency/failure
What is the first step in evaluating amenorrhea?
Urine pregnancy test
When should you take your home pregnancy test?
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
Diagnostic factors of amenorrhea
- 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
What do you measure for if you suspect hyperandrogenic state in amenorrhea?
- Free and total testosterone
- Dehydroepiandrosterone
- Fasting glucose
- Fasting lipid panel
What is the treatment of amenorrhea (primary or secondary)?
- 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
What is the treatment for amenorrhea related to hyperprolactinemia?
- Bromocriptine daily in two to three divided doses
- Cabergoline by mouth once weekly or in two divided doses
Polycystic Ovary Syndrome
- 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
What is the etiology and pathophysiology of PCOS?
- Hypothalamus-pituitary-ovarian abnormality
- Insulin resistance
Hypothalamus-pituitary-ovarian abnormality in PCOS
- Ovarian-induced increase in GnRH
- Increase in LH/FSH ratio with a resulting increase in ovarian testosterone production
Insulin resistance in PCOS
- 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
What are the symptoms of PCOS?
- Hyperandrogenism
- Ovulatory dysfunction
- Polycystic ovaries
- Intermenstrual bleeding
- Heavy Menstrual Bleeding (HMB)
- Exclusion of other diagnosis that could result in hyperadrogenism or ovulatory dysfunction
What are the signs of hyperandrogenism in PCOS?
- Excessive acne
- Male pattern hair loss
- Hirsutism
- Elevated serum levels of testosterone or metabolic intermediates
What are the signs of ovulatory dysfunction in PCOS?
- 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
What are the signs of polycystic ovaries in PCOS?
Ovary containing 12 or more follicles (2 to 9 mm diameter or greater than 10 mL) on ultrasound
What is the criteria for diagnosis of PCOS?
MUST have hyperandrogenism + oligomenorrhea or polycystic ovaries
What is a nonpharmacological therapy for PCOS?
Weight loss of 5-10%
* Improves menstrual irregularity and ovulatory function
* Reduces hirsutism
* Increases insulin sensitivity
* Improves response to fertility treatments
What is the first line treatment of anovulation and menstrual irregularity in PCOS?
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
What is the second line treatment of anovulation and menstrual irregularity in PCOS?
- Progestin-only contraceptive (such as Levnorgestrel-releasing intrauterine system)
- Metformin
What is the treatment for hirsutism for patients who had conceive?
Electrolysis and light-based therapy (effective for mild cases)
What is the first line treatment of hirsutism in PCOS?
Hormonal contraception with non-adrogenic progestin (norgestimate, desogestrel, drospirenone)
