Obgyn Amenorrhea And Abn Uterine Bleeding

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abnormal uterine bleeding

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difference in frequency, duration, and amount of menstrual bleeding- may be associated with ovulatory cycles or anovulatory causes

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primary amenorrhea

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if a women has never menstruated by age 13 without secondary sexual development or by age 15 with secondary sexual development

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secondary amenorrhea

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when a menstruating women has not menstruated for 3-6 months or the duration of three typical menstrual cycles for the patient with oligomenorrhea

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oligomenorrhea

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reduction in the frequency of menses, with cycle lengths of >35 days but <6 months

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hypomenorrhea

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reduction in the number of days or the amount of menstrual flow

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most common cause of amenorrhea

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pregnancy

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Categories of etiology of amenorrhea

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1. pregnancy
2. Hypothalamic Pituitary Axis Dyfunction
3. ovarian dysfunction
4. alteration of genital outflow tract

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most common causes of HPA dysfunction

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Functional causes
1. weight loss
2. excessive exercise
3. obesity

Drug-induced causes
1. marijuana
2. psychoactive drugs- including antidepressants

Neoplastic causes
1. prolactin secreting pituitary adenomas
2. cranipharyngioma
3. hypothalamic hamartoma

Psychogenic causes
1. chronic anxiety
2. pseudocyesis- false pregnancy
3. anorexia nervosa

Other causes
1. head injury
2. chronic medical illness

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Causes of ovarian failure

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Chromosomal Causes
1. Turner syndrome (X,O)
2. X chromosome long-arm deletion (46 XX q5)

Other causes
1. Gonadotropin resistent ovary syndrome (Savage syndrome)
2. Premature natural menopause
3. Autoimmune ovarian syndrome (Blizzard syndrome)

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most common congenital anomalies resulting in primary amenorrhea

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1. imperforate hymen
2. no uterus
3. no vagina

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most common anatomical cause of secondary amenorrhea

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Asherman syndrome- scarring of the uterine cavity often from D&Cs (esp if there was an infection present)

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Treatment and prevention of Asherman syndrome

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Tx- surgical lysis of adhesions by hysteroscopy and and D&C
prevention- estrogen therapy after D&C to promote endometrial regeneration, balloon or intrauterine device to keep uterine walls apart during healing

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challenge test for determining etiology of amenorrhea

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100 mg injection of progesterone or 5-14 day course of oral medroxyprogestone given to determine if there is progesterone withdrawal bleed a few days after completing drug course

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if positive progesterone challenge (withdrawal bleeding occurs), etiology is likely?

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anovulatory or oligo-ovulatory

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if negative progesterone challenge test (no bleeding), likely etiology of amenorrhea?

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hypoestrogenic estate or anatomic condition such as asherman syndrome

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polymenorrhea

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frequent menstrual bleeding (every 21 days or less)

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menorrhagia

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

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metorrhagia

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irregular menstrual bleeding or bleeding between periods

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menometorrhagia

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frequent menstrual bleeding that is excessive and irregular in amount and duration

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drugs for induction of ovulation

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1. clomiphene citrate-- for oligo or anovulatory women
2. human menopausal gonadotropins, pulsatile GnRH, or aromatase inhibitors

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anovulatory uterine bleeding

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irregular bleeding that is unrelated to anatomic lesions of the uterus. - women have constant, non-cyclic blood estrogen concentrations that stimulate growth and development of the endometrium. Progesterone induced endometrium changes do not occur.
- initially there is amenorrhea because of chronic constant estrogen levels, but then the endometrium outgrows its blood supply and sloughs leading to bleeding at irregular times and amounts

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most common causes of anovulatory uterine bleeding

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PCOS, exogenous obesity, adrenal hyperplasia

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luteal phase defect

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ovulation occurs but the corpus luteum is not fully developed to secrete progesterone to maintain the endometrium and thus also cannot maintain a pregnancy.
-menstrual cycle is shortened and menstruation occurs earlier than expected

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When should abnormal uterine bleeding be suspected?

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when vaginal bleeding is not regular, predictable and associated with premenstrual signs and symptoms

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premenstrual signs and symptoms

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breast fullness, abdominal bloating, mood changes, edema, weight gain, and uterine cramps

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anatomic causes of abnormal uterine bleeding

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must be ruled out before anovulatory uterine bleeding can be diagnosed!
- uterine myomas, polyps, endometrial carcinoma
- cervical neoplasia, polyps, cervicitis, cervical condyloma
- vaingal carcinoma, sarcoma, adenosis, laceration, infection, inflammation secondary to foreign body
- urethral caruncle
- infected urethral diverticulum
- gi bleeding
- labial lesion

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what would a uterine biopsy show in the case of abnormal uterine bleeding

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endometrial proliferation or hyperplasia due to chronic, unopposed estrogen stimulation-- increased risk for endometrial carcinoma

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what are women with abnormal uterine bleeding at risk for?

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endometrial carcinoma

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tx of abnormal uterine bleeding

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progesterone (medroxyprogesterone acetate)-- causing withdrawal bleeding or OCPs (creates anovulation-- but regular cycling of hormones and progesterone withdrawal)

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tx for menorrhagia/heavy bleeding
1. acute
2. chronic

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1. acute- high dose estrogen and progestin therapy (4 OCP pills/day)
2. chronic- intermittent progestin tx of OCPs.
- if unresponsive to medical tx-- then uterine ablation after endometrial cancer has been ruled out or hysterectomy