Week 2 pt 2

Question 1

1) ___% or less of all women during menstrual lives (not caused by pregnancy) have amenorrhea
2) What are the 2 kinds of amenorrhea?

Answer 1

1) 5%
2) Primary and Secondary

Question 2

1) Define secondary amenorrhea
2) Define oligomenorrhea

Answer 2

1) Menstruating women without menstruation for 3 months in individuals with hx of regular cycles or for 6 months in those with irregular cycles.
2) Bleeding occurring less frequently than every 35 days (>35days)

Question 3

Menstruation ceases due to one of what 2 things?

Answer 3

1) Disrupted endocrine function along HPO axis or
2) Abnormality in genital outflow tract

Question 4

What are 4 causes of amenorrhea?

Answer 4

1) Pregnancy (most common)
2) HP dysfunction
3) Ovarian dysfunction
4) Alteration in genital outflow tract

Question 5

What are some Sx of pregnancy?

Answer 5

Breast fullness, weight gain, nausea, absent menses

Question 6

1) Define Hypothalamic-pituitary (HP) dysfunction
2) What occurs with this?
3) What does this ultimately lead to?

Answer 6

1) Disruption or alteration of pulsatile GnRH secretion
2) Anterior pituitary gland not stimulated to secrete LH & FSH > Lack of folliculogenesis, no ovulation, & no corpus luteum
3) Leads to lack of increased sex hormone production & minimal endometrial proliferation > no menstruation

Question 7

Hypothalamic-pituitary (HP) dysfunction: What are the causes of this?

Answer 7

1) Altered catecholamine (dop, epi, norepi) secretion & sex steroid hormone feedback
2) OR alteration of blood flow through HP portal plexus (i.e., tumor)

Question 8

1) Define Primary ovarian insufficiency
2) What are some causes of this?

Answer 8

1) Follicles are exhausted or low in number
2) Chromosomal causes: Turner syndrome, X chromosome long arm deletion
Other causes: Savage syndrome, premature menopause, autoimmune ovarian failure

Question 9

How can alteration of the genital outflow tract cause amenorrhea?

Answer 9

Obstruction prevents menstrual bleeding (if ovulation occurs)

Question 10

Asherman syndrome:
1) What is it? What can it cause?
2) How do you Tx it?

Answer 10

1) Scarring of uterine cavity; amenorrhea
2) Most cases corrected with surgical lysis of adhesions
-Severe cases often refractory & require estrogen postoperatively to stimulate endometrial regeneration
-Balloon or IUD for some cases to prevent further adhesions (keeps the uterine walls separated)

Question 11

What medical Hx should you take for amenorrhea?

Answer 11

Past illnesses
FHx of delayed puberty
LMP
h/o amenorrhea
Exercise amount (per day & week)
Dietary (restrictions, special diets)
Eating disorders
Medications
Illicit drug use
Psychiatric Hx
Other conditions

Question 12

What should amenorrhea PE include?

Answer 12

-Tanner staging
-Breast development or no?
-Other stages of puberty met?
-Genital tract anatomy
-Uterus present?
-Hirsutism or acne (or both)
-BMI measurement
-Careful genital exam

Question 13

1) What imaging can be done for amenorrhea?
2) What lab studies can be done for it?

Answer 13

1) Imaging with US, MRI, CT
2) Pregnancy (hCG), TSH, PRL, Estradiol, FSH

Question 14

How do you Tx amenorrhea? Give examples

Answer 14

Correct the underlying pathology (if possible)
-Ex. Treat pituitary adenoma: hyperprolactinemia causing amenorrhea & galactorrhea
-Ex. Treat underlying cause of hypothyroidism with thyroxine replacement
-Ex. Oligo-ovulatory/anovulatory with PCOS: clomid (clomiphene citrate) to induce ovulation
-Ex. Hypogonadotrophic hypogonadism, induce ovulation with pulsatile GnRH

Question 15

What are the goals of amenorrhea Tx? Give an example

Answer 15

Help the woman to achieve fertility (if desired)
Prevent of complications of the disease process
-Ex. estrogen replacement to prevent osteoporosis

Question 16

Abnormal Uterine Bleeding (AUB):
1) Define Abnormal Uterine Bleeding (AUB)
2) Define Anovulatory Uterine Bleeding (AUB)
3) Give examples of Anovulatory Uterine Bleeding (AUB)

Answer 16

1) Abnormal uterine bleeding: vaginal bleeding not regular, not predictable, and not associated with premenstrual signs and symptoms that usually accompany ovulatory cycles.
2) Irregular bleeding that is associated with anovulation and unrelated to anatomic lesions of the uterus
3) PCOS, exogenous obesity, or adrenal hyperplasia

Question 17

List and describe 2 etiologies of AUB (abnormal uterine bleeding)

Answer 17

1) Amenorrhea due to HP dysfunction with no genital tract obstruction: estrogen deficiency > no bleeding
2) Oligo-ovulation and anovulation with AUB: constant, noncyclic blood estrogen concentrations slowly stimulate the growth and development of endometrium
-Progesterone-induced changes do not occur > amenorrhea leads to intermittent sloughing over time

Question 18

List and define 3 causes of abnormal uterine bleeding (AUB)

Answer 18

1) Ovulatory dysfunction (most common cause overall):
Relative estrogen deficiency due to HP dysfunction if no genital tract obstruction
2) Other nonstructural causes: Coagulopathy, endometrial factors (i.e. endometriosis), iatrogenic (breakthrough bleeding on hormonal contraceptives)
3) Structural Causes: Cervical or endometrial polyps,
Adenomyosis, Leiomyoma (uterine fibroid), Uterine or cervical cancer

Question 19

How do you Dx AUB?

Answer 19

1. Always rule out early pregnancy & its complications
2. Exclude anatomic causes
   Pelvic exam (including speculum) +/- pelvic u/s to eliminate other sources

Question 20

What labs can you use in the Dx of AUB?

Answer 20

1) hCG testing, CBC, TSH, cervical cancer screening, +/- STI testing (if high risk)
2) Basal body temperature chart or ovulation predictor kit also options

Question 21

List and describe 2 diagnostics for AUB

Answer 21

1) TVUS: Can evaluate endometrial stripe (thickness) to evaluate for endometrial proliferation (can lead to endometrial cancer)
Normal: during menstruation 2-4mm
2) Endometrial biopsy: Do if anovulatory with abnormal bleeding; concern regarding endometrial hyperplasia

Question 22

Define the following AUB terms:
1) Polymenorrhea
2) Menorrhagia
3) Metrorrhagia
4) Menometrorrhagia
5) Dysfunctional uterine bleeding

Answer 22

1) Abnormally freq. menses at intervals of less than 24 days
2) Aka hypermenorrhea; excessive and/ or prolonged menses (>80mL + >7 days) occurring at normal intervals
3) Irregular episodes of uterine bleeding
4) Heavy and irregular uterine bleeding
5) Bleeding caused by ovulatory dysfunction

Question 23

Heavy menstrual bleeding (menorrhagia):
1) How common is it in healthy women of reproductive age?
2) It’s the reason for up to ____% outpatient clinic visits by women

Answer 23

1) Occurs in up to 14%
2) 20%

Question 24

Acute AUB: How do you assess this?

Answer 24

1) Assess for hemodynamic stability (vitals), anemia, & pregnancy
2) Obtain description of current bleeding episode and recent & usual bleeding patterns
3) Complete history can help suggest PALM-COEIN categories
4) Rule out obvious causes requiring immediate surgery (trauma, lacerations, etc.)
5) Prompt control and organic pathology ruled out
6) Imaging usually delayed until bleeding controlled & patient is hemodynamically stable
-May need sooner for other symptoms (i.e., significant pain)

Question 25

1) What are the initial labs for AUB? 2) What are the other labs?

Answer 25

1) HCG, CBC, coagulation tests (PT, PTT, INR), iron, ferritin, T&S 2) Thyroid, liver, creatinine, BUN

Question 26

How do you Tx acute AUB?

Answer 26

1) Acute/Emergent: IVF, PRBCs 2) Heavy bleeding episode (intermittent): High-dose estrogen and progestin therapy; combo OCPs advocated for in the acute phase -NSAIDs to normalize prostaglandins 3) Surgery

Question 27

When should you use surgery for acute AUB?

Answer 27

1) For failure of medical therapy & bleeding which precludes medical therapy 2) Failure of initial therapy (within 12-24 hours)

Question 28

Describe when to use the 5 different surgeries for acute and chronic AUB

Answer 28

1) Hysteroscopy with D&C to remove remaining endometrium Selective embolization of uterine vessels (interventional radiology) Balloon tamponade if emergent treatment required to stop bleeding Endometrial ablation only if other treatments unsuccessful, the pt has no plans for future childbearing, and endometrial/uterine cancer r/o as cause of AUB Hysterectomy (rarely) as last resort, for endometrial cancer/hyperplasia

Question 29

Chronic AUB: 1) What is the goal of Tx? 2) What is the main Tx? 3) What is an alternative Tx? 4) What if there's no response to Tx?

Answer 29

1) Ensure regular shedding of endometrium and regulation of uterine bleeding 2) Progestational agent x >10days (progesterone challenge test) -Most common: medroxyprogesterone acetate (Depo-Provera); when stopped, uterine withdrawal bleeding expected with 7-10days 3) Alternative: oral contraceptives (OCs) Suppress the endometrium and establish regular, predictable withdrawal cycles 4) If no response to treatment, likely requires specialty (surgical) care.

Question 30

Hyperandrogenic disorders: What should you initially look into with these?

Answer 30

Use/abuse of androgenic drugs (anabolic steroids)

Question 31

Hirsutism: 1) Define it 2) What are the 2 origins you should consider?

Answer 31

1) Excess terminal hair (dark, thick, coarse) in a male pattern of distribution 2) Consider familial origin vs pathologic a) Idiopathic: often familial; most common cause of non-pathologic b) PCOC: most common cause of pathologic

Question 32

What does Hirsutism originate?

Answer 32

Starts on lower abdomen & around nipples, then chin & upper lip, then between breasts & lower back +/- acne

Question 33

Hirsutism: What can you use to Dx it? Describe

Answer 33

Modified Ferriman-Gallwey scale: Score of 1-4 for 9 areas (next slide) a) Normal: < 8 b) Mild: 8-15 >8 = hirsutism diagnosis c) Moderate-severe: > 15

Question 34

Virilization: Where does it start? Where does it spread?

Answer 34

1) Starts with enlargement of the clitoris 2) Then temporal balding, deepening of voice, involution of the breasts, remodeling of limb-shoulder girdle, & hirsutism

Question 35

What are 4 causes of excess androgen production?

Answer 35

1) PCOS 2) Testosterone-secreting tumors 3) Adrenal disorders 4) Iatrogenic and idiopathic causes

Question 36

How do you define PCOS in a patient? Explain

Answer 36

Defined by Rotterdam Criteria (at least 2 of the 3 criteria): Clinical or biochemical hyperandrogenism Oligo-ovulation or anovulation (irregular menstrual cycles or oligomenorrhea) Polycystic ovaries (ultrasound) *Adolescent girls should meet all 3 criteria

Question 37

What must you rule out when diagnosing PCOS?

Answer 37

Other endocrine disorders that mimic PCOS: CAH, Cushing syndrome, hyperprolactinemia

Question 38

What approach should you use for PCOS evaluation?

Answer 38

Obtain history (hirsutism, acne, alopecia) Identify underlying serious medical conditions in need of treatment Assess emotional impact of hirsutism Plan personalized approach

Question 39

What should PCOS eval PE include?

Answer 39

Assess degree of hirsutism, acne, androgenic alopecia Thyroid Breasts Cushing syndrome (truncal weight gain, round face, limb muscle wasting) Acanthosis nigricans Bimanual pelvic exam

Question 40

List and describe the 3 labs used in PCOS Dx to rule out other disorders

Answer 40

Basal serum 17-hydroxyprogesterone level to exclude late-onset CAH due to 21-hydroxylase deficiency Serum prolactin & TSH levels to exclude hyperprolactinemia (with or without thyroid dysfunction) and hypothyroidism 24-hour free urinary cortisol or overnight dexamethasone suppression test to exclude Cushing syndrome

Question 41

PCOS Evaluation: 1) What imaging and why? 2) What types of metabolic eval?(patients with classic PCOS and/or HAIR-AN) Why?

Answer 41

1) Pelvic ultrasound to exclude significant ovarian pathology CT or MRI to detect androgen-secreting tumors of adrenals 2) 2-hour oral glucose tolerance test to exclude DM (or HbA1C) Fasting serum lipid levels (checking for metabolic syndrome)

Question 42

1) What does PCOS Tx depend on? 2) What does initial therapy include? How long can it take to see improvement?

Answer 42

1) Patient presentation & desires 2) Combination oral contraceptive (COC) containing estrogen & progestin Peripheral antiandrogen may be added to oral contraceptive to treat hirsutism (i.e., spironolactone – most common in U.S.) May take 6 months to see improvement (maximum effect up to 2 years)

Question 43

81

Answer 43

Local hair removal usually required (cosmetic results) Shaving, depilatory creams, electrolysis, laser therapy, and/or intense pulsed light Plucking hairs discouraged (discomfort, scarring, folliculitis)

Question 44

Describe Tx of insulin resistance in PCOS

Answer 44

1) Occurs in up to 70% (95% of obese women) 2) T2DM risk 3) CVD risk 4) OSA risk 5) Counseling for weight loss, nutrition, exercise, & other lifestyle changes to reduce risk of DM & CVD 6) Consider metformin for some patients to reduce insulin resistance & anovulation

Question 45

Hyperandrogenic insulin resistance & acanthosis nigricans (HAIR-AN): 1) What is it? What does it cause? 2) What does it put you at increased risk for?

Answer 45

1) Inherited hyperandrogenic disorder; extremely high levels of circulating insulin 2) Increased risk of dyslipidemia, T2DM, HTN, & CVD

Question 46

Congenital Adrenal Hypertrophy (CAH): 1) What is it? 2) What is the most severe/ classic form? 3) Describe the milder (nonclassic) forms

Answer 46

Increased adrenal androgen production most commonly caused by 21-hydroxylase deficiency Most severe form (Classic): virilization of female infant (ambiguous genitalia) or virilization + life-threatening salt wasting Milder forms (Nonclassic) more common and may appear later in life S/Sx: terminal body hair, acne, subtle alterations in menstrual cycles, and infertility, may also have polycystic ovaries on u/s

Question 47

1) How do you Tx nonclassic CAH? 2) What about classic?

Answer 47

1) Nonclassic CAH: may not require tx or may need supplementing glucocorticoids (prednisone) Classic (dx in childhood): hormone replacement therapy (hydrocortisone/cortisol; aldosterone replacement)

Question 48

Infertility: 1) ____% fertile couples conceive after 1 year of frequent attempts 2) _________% couples in U.S. infertile (15% unexplained)

Answer 48

1) 85% 2) 10-15%

Question 49

1) Define primary infertility and give an example 2) Define secondary infertility

Answer 49

1) Occurs without any prior pregnancy -Ex: azoospermia (absence of sperm), endometriosis, tubal occlusion 2) Occurs following previous conception

Question 50

Successful conception requires what 6 things?

Answer 50

1) Ovulation of a competent oocyte 2) Production of competent sperm 3) Subsequent fertilization 4) Generation of a viable embryo 5) Transport of the embryo into the uterine cavity 6) 1Successful implantation of the embryo into the endometrium

Question 51

Describe the cervical factors of infertility

Answer 51

1) Spinnbarkeit: Profuse, watery mucus produced by the cervix during few days before ovulation 2) Patient seen during immediate preovulatory phase (day 12-14 of 28-day cycle) to assess quality 3) Amount & clarity recorded 4) Should stretch to at least 6.5 cm 5) pH should be > 6.5

Question 52

Male infertility (20-40%): 1) What should Hx include? 2) What about exam? 3) What initial lab?

Answer 52

1) coitus frequency, pregnancies sired, genital tract infections (mumps, prostatitis), genital/inguinal surgery or trauma, exposures, excessive alcohol/cigarettes, environmental heat, meds (ex CCBs) Exam: location of urethral meatus, testicular size estimated, assess for varicocele Labs: Semen analysis after 2-4 days of abstinence Sperm production and development: ~70 days Abnormal spermatogenesis 40% of male fertility causes

Question 53

Describe further testing for male infertility (depending on DDX)

Answer 53

Genetic evaluation (if azoospermia or very low #) FSH, LH, testosterone levels (primary vs secondary hypogonadism) Prolactin level Epididymal sperm aspiration Testicular biopsy

Question 54

Describe Tx for male coital factors

Answer 54

1) “Scheduled intercourse” every 1-2 days during periovulatory period (days 12-16 of 28-day cycle) 2) Avoid lubricants toxic to sperm 3) Reduce (or cease) use of alcohol & smoking 4) Discourage use of saunas, hot tubs, & tight underwear

Question 55

IVF-ET with ICSI (effective for male factor) requires what?

Answer 55

1 motile sperm for each egg

Question 56

List and describe 3 treatments for ovulation factors

Answer 56

1) **Fertility drugs**: correct luteal insufficiency in unexplained infertility -clomiphene (Clomid) most commonly used 2) **U/S & carefully timed hCG administration**: if no ovulation with clomid 3) Induction of more frequent ovulation for oligomenorrhea (menses > 35 days): Technique depends on diagnosis (i.e., thyroid disease, hyperprolactinemia, PCOS, etc.)

Question 57

Describe the main complication of ovulation induction

Answer 57

1) Excessive stimulation of ovaries ovarian hyperstimulation syndrome (OHSS) 2) Multiple pregnancy (8-10%) may occur with ovulation induction treatment (clomiphene)

Question 58

1) Describe uterine factors if infertility 2) What do all the tubal factors of infertility have in common?

Answer 58

1) Seldom the cause; ex fibroids or endometrial polyps 2) Occlusion

Answer 59

Fimbrial end (most common) Mid-section – postoperative or TB infection Isthmus-cornual – congenital, mucus plugs, endometriosis, tubal adenomyosis, or prior infection

Question 60

Evaluation of uterine & tubal factors: 100

Answer 60

Hysterosalpingography (HSG) or laparoscopy to diagnose tubal abnormalities (click me) Helps check patency of fallopian tubes Hydrosalpinges (singular = hydrosalpinx) Damage & blockage of end of fallopian tubes (fluid-filled & edematous)

Question 61

Treatment of tubal factors

Answer 61

May require surgical treatment >10% conceptions after repair of diseased tubes = ectopic pregnancies *Overall, for women, if HSG normal or abnormal and further workup required, hysteroscopy and/or laparoscopy are the next options. 102

Question 62

103

Answer 62

Laparoscopy identifies unsuspected pathologic conditions in ~30% unexplained fertility Preferred for substantial adhesions or endometriosis Endometriosis most common finding Other possible causes/findings: pelvic inflammatory disease (PID), appendicitis, adhesions Often IVF preferred over surgery (because of high success