Repro Exam 2: Aliff: Bleeding Irregularities

Front 1

Objectives for this lecture

:)

Back 1

Define common gynecological bleeding problems

differentiate anatomic vs organic bleeding

know common available diagnostic and treatment modalities

Front 2

Oh shit: My periods are irregular :(

Back 2

Be sure to ask the pt the following:

- What does irregular mean to the patient?
- How long is the menstrual cycle?
- Is it truly irregular?
- Is the amount of bleeding irregular?
- Are they skipping menstruation?
- Get specific – calendars help

Front 3

What do most women consider as abnl irregular period?

Back 3

The length of the menstrual cycle is inconsistent

Front 4

What is considered Day 1 of the menstrual cycle?

Back 4

Day 1 = 1st day of bright red bleeding

Front 5

What is the length of the avg period?

Back 5

28 days

Front 6

What is considered still a nl period range in days?

Back 6

21-35 days

Front 7

***EXAM

What is oligomenorrhea?

Back 7

>35 day cycle

Front 8

****EXAM

What is Hypermenorrhea?

Back 8

<21 day cycle

Front 9

What are some causes of oligomenorrhea?

Back 9

Oligomenorrhea >35 days cycle

- Aunovulation
- extremes in age***** think really young or really old (teens & preimenopausal)
- oral contraceptions
- cyclic progestins
- SKIP periods and eventual heavy bleeding
- out of synch shedding causes bleeding bet ovulatory cycles

Front 10

How is estrogen linked to ovulation?

Back 10

increased estrogen PREVENTS ovulation

- remember when you withdraw ESTROGEN and PROGESTERONE you have a period

- thus we can pharmacologically mimic periods

Front 11

If a women has Out of synch shedding causes bleeding between ovulatory cycles
What can we do?

Back 11

Reset

so 1 big progestin withdraw

Front 12

What is major pathological dz to be concered of with oligomenorrhea?

Back 12

Polycystic Ovarian Syndrome

secretes high levels of estrogen

Front 13

More reasons linked to oligomenorrhea are?

Back 13

-Hypothyroidism
- Prolactinoma
-Obesity******
-Polycystic Ovarian Syndrome
-Anorexia

Front 14

How is HYPOthyroidism Dx?

Back 14

Look at TSH levels

elevated TSH and LOW free T4

Front 15

What are the symptoms of HYPOthyroidism?

Back 15

Cold intolerance
fatigue
constipation

Front 16

What is autoimmune disease that can cause Hypothyroidism?

Back 16

Hashimoto's thyroiditis

Front 17

If you give a women Thyroid Hormone due to hypothyroidism because she complained of oligomenorrhea (period >35days), how long will it take for a clinical repsonse?

Back 17

6-8 weeks

Front 18

What will prolactin levels be with hypothyroidism and oligomenorrohea?

Back 18

Prolactin levels may be high

Front 19

If a women has Hyperthyroidism will she present with oligomenorrhea or hypermenorrhea?

Back 19

Either

Front 20

What autoimmune disease causes Hyperthyroidism?

Back 20

Graves's disease

Front 21

How will a person present with Hyperthroidism?

Back 21

Heat intolerance
agitation
exophalmos
brisk reflexes

Front 22

A women presents with:
Amenorrhea
Galactorrhea
Bitemporal hemianopsia
What could this be?

Back 22

Prolactinoma

Front 23

What test should you order if you suspecet a prolactinoma?

Back 23

MRI of Sella Tursica

Front 24

If on exam you find a prolactinoma.
How will you treat if prolactin levels are increased?

Back 24

Bromocriptine

*****EXAM
Treat with bromocriptine if isolated increase prolactin

Front 25

If on exam you find a prolactinoma and hypothyroidism what should you treat?

Back 25

treat hypothyroidism if TSH is elevated
******EXAM

Front 26

What does prolactinoma cause again?

Back 26

Oligomenorrhea
>35days

Front 27

You think a women might be anorexic.
What tests and symptoms will tell you this?

Back 27

Anorexic:

- HYPOgonadotropic HYPOgonadism
- Central suppression
- LOW FSH, LH, TSH
- Poor enamel on teeth*****
- Marks on nail beds and cuticles*****

causes oligomenorrhea

Front 28

Why would obesity cause oligomenorrhea?

Back 28

Peripheral conversion of testosterone to estrogens

High baseline estrogen negatively feedbacks and decreases GnRH

Front 29

What can also be seen with obseity and the uterus?

Back 29

high chance to cause endometrial cancer

thick lining biopsy

again you have increased estrogen which eliminate pregnancies

Front 30

What is Polycystic ovarian syndrome?

Back 30

- Ovaries are making increased levels of estrogens
- lots of stored estrogen
- causes oligomenorrhea****
- chronic anovulation****

Front 31

What are symptoms of Polycystic Ovarian Syndrome?

Back 31

Obesity
acne
hirsuitism
oligomenorrhea
infertility
Insulin resistance
acthanosis nigricans

Front 32

What can hyperinsulinemia of PCOS cause to androgens and estrogen levels?

Back 32

Increase androgens

increased estrogens

increased insulin like growth factor

Front 33

What is the pathogenesis of PCOS?

Back 33

Ovaries produce excess androgen (testosterone) and insulin like growth factor

Front 34

A women presents with hair on her back and a beard.
You run labs and they come back nl
What is her diagnosis

Back 34

PCOS - CLINICAL DIAGNOSIS*****

*****EXAM

does not matter about labs
again clinical diagnosis

Front 35

why do we see increased estrogen in women with PCOS?

Back 35

Elevated Testosterone********EXAM

Increased appetite – weight gain – more conversion to estrogen in peripherary

Front 36

How can you Dx PCOS.....ok a lab value that is very helpful

Back 36

Decreased SHBG – more free (active) testosterone and estrogen

Front 37

Again what are symptoms of PCOS?

Back 37

Acne
Hirsuitism
Male pattern balding

Front 38

If a women has PCOS why should I check her pelvis?

Back 38

PCOS
- increased estorgen will Stimulate endometrial proliferation
- May lead to endometrial cancer*****

Front 39

What will the LH and FSH be in a women with PCOS?

Back 39

Elevated LH
Suppressed FSH - again due to increased estrogen

(LH:FSH) (2:1)

Front 40

WOo exam:

If you see:
Rosary Bead appearance on ultrasound what is this?

Back 40

Follicles become arrested at the ovarian surface – rosary bead appearance on ultrasound

PCOS

Front 41

What is the result of PCOS?

Back 41

Anovulation

thickened ovaries -- follicles cannot get through
**see string of rosary beads

Front 42

What is Insulin Like Growth Factor?

Back 42

The insulin-like growth factors (IGFs) are proteins with high sequence similarity to insulin

Insulin-like growth factor 1 (IGF-1) is mainly secreted by the liver as a result of stimulation by growth hormone (GH). IGF-1 is important for both the regulation of normal physiology, as well as a number of pathological states, including cancer

Front 43

What happens with insulin resistence and PCOS?

Back 43

Insulin like growth factor abnormally stimulates an already overestrogenized endometrium – furthers endometrial cancer risk

Front 44

What does increased insulin levels do?

Back 44

Increase insulin levels – further increases testosterone levels

Which are converted into estrogens and cause oligomenorrhea and endometriosis

Front 45

What are symptoms of PCOS insulin resistence?

Back 45

- Acanthosis nigricans
- Increases appetite
-HTN
-HYperlipidemia
- CAD

AT increased risk of developing metabolic syndrome

Front 46

What are several NON_PHARM tx options for PCOS?

Back 46

- Education – present and future risks
- Diet
- Exercise

- Weight loss – even a 10% weight loss increases ovulation******EXAM

Front 47

What is a PHARM option for a women with PCOS and what does it do?

Back 47

- Oral contraceptives****

- Increase SHBG – decrease free testosterone

Improves acne, hair growth, male pattern balding

Empties uterus monthly – may reduce long term risk of endometrial cancer

Front 48

What is another option for PCOS?

Back 48

Metformin******

Decreases hepatic gluconeogenesis
Increases insulin sensitivity
Decreases insulin levels
Decreases LH levels
Decreases testosterone levels
May aid in weight loss – also due to GI side effects
Often results in spontaneous ovulation

Front 49

Can HYPERthyroidism cause hyper or hypo - menorrhea?

Back 49

Hypermenorrhea

Front 50

What is Hypermenorrhea usually due to?

Back 50

Usually due to an anatomical abnormality, not a physiologic dysfunction

Front 51

What may Hypermenorrhea be associated with?

Back 51

May be associated with anovulation – areas of endometrium out of synch and shed when they outgrow their blood supply

Front 52

***EXAM

What is the difference between:
Dysfunction vs Abnl Uterine Bleeding?????

Back 52

-Dysfuncitonal: PHYSIOLOGICAL-anovulation

- Abnormal: ANATOMICAL abnormality

Front 53

What is the most common cause of abnormal uterine bleeding?

Back 53

Fibroids

Front 54

What is the most common cause for hysterectomies?

Back 54

fibroids

Front 55

What is the most common uterine pathology?

Back 55

Adenomyosis

Front 56

What does this describe:

- uterus is big and boggy

Back 56

Adenomyosis

Front 57

Is endometrial hyperplasia cancer?

Back 57

NO
precancerous though

Front 58

When do you see endometrial cancer?

Back 58

postmenopausal bleeding******

EXAM

Front 59

When do you think cervical cancer?

Back 59

postcoidal bleeding

aftern sex

Front 60

What 2 examples of infection of the uterus?

Back 60

Cervicitis
Endometritis

Front 61

Give me a list of abnormal uterine bleeding causes.

Back 61

-Fibroids
-Adenomyosis
-Endometrial Hyperplasia – precancerous
-Endometrial Cancer – postmenopausal bleeding
-Cervical Cancer – postcoital bleeding
-Infection – cervicitis, endometritis
-Endometrial polyps

Front 62

What are 3 things you can see abnormal uterine bleeding with endometrial atrophy*****

Back 62

menopause,
Depo provera,
long term progesterone

Front 63

Abnormal Uterine Bleeding due to Foreign body

Back 63

IUD

Front 64

Abnormal Uterine Bleeding due to drugs

Back 64

Unopposed estrogen,
&
tamoxifen

Front 65

More causes of abnormal uterine bleeding

Back 65

- Endometrial atrophy - menopause, Depo provera, long term progesterone
- Foreign body – IUD
- Bleeding disorders – Von Willebrand’s
- Aspirin, anticoagulants
- Pregnancy
- Unopposed estrogen, tamoxifen

Front 66

What is the Workup of AUB and DUB

Back 66

History and Physical

Pelvic exam – pap, GC/Chl cultures, endometrial biopsy over age 35, CBC, TSH, Prolactin, pelvic ultrasound, HCG, hysterosonogram, hysteroscopy

Front 67

At what age should you so a endometrial Bx?

Back 67

After age 35*****

Front 68

What will this test tell you
pap

Back 68

cervical cancer

Front 69

What will this test tell you
CBC

Back 69

Hypermennorhea

Front 70

What will this test tell you
Pelvic US

Back 70

PCOS

Front 71

What will this test tell you
HCG

Back 71

prego

Front 72

What will this test tell you
hysterosonogram

Back 72

may see polyps - very painful if so

Front 73

What are Tx options for abnl uterine bleeding?

Back 73

OCP’s

Cyclic progestins

Continuous progestins – includes Depo Provera, Mirena IUD

Front 74

What if the abnl bleeding will NOT stop?

****EXAM

Back 74

****If the bleeding is due to an anatomical cause, it won’t respond.

Front 75

What is Dilation and Curettage?

Back 75

Scrape endometrium

Tx for abnl uterine bleeding

Front 76

What is Asherman's Syndrome?

Back 76

Results from scaring of the endometrial wall on ablation

Asherman’s Syndrome – amenorrhea, uterine synechiae, infertility

Front 77

Is dilation and dilation and curettage effective?

Back 77

Rarely

Front 78

If a women keeps on bleeding and you add endometrial ablation what & will it decrease?

Back 78

Add endometrial ablation – 80% reduction in flow