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50 Cards in this Set
- Front
- Back
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What are the physical findings in pt w/ androgen insensitivity syndrome? (pt is XY)
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Neither wolffian duct nor mullerian system develops, so no uterus, little to no axillary or pubic hair
Usually have large breasts w/ immature nipples If incomplete, there could be some pubic and axillary hair plus phallic development Note: serum testosterone levels are in normal MALE range |
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What is another name for androgen insensitivity syndrome?
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Testicular feminization
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Treatment for androgen insensitivity syndrome?
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Allow to finish sexual maturity then remove gonads (to prevent dev't of gonadoblastoma or dysgerminoma
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What are the physical findings in pt w/ mullerian agenesis?
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Sexual hair + mature nipples
No uterus Note: serum testosterone levels are in FEMALE range |
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What other physical abnormality is associated with mullerian agenesis?
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Renal anomalies
Perform renal US or intrravenous pyelography on these pts |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does HIGH LH/FSH indicate?
What is next test to do? What additional studies? |
Gonadal failure.
Get karyotype Do CXR, IV pyelogram, thyroid fxn tests |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does LOW LH/FSH indicate?
What is next test to do? What additional studies? |
Unstimulated gonads
Head MRI/CT to r/o pituitary tumors thyroid fxn tests, GH, cortisol, PRL Consider pituitary stimulation tests |
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15 y/o w/o breasts, yes uterus, normal wt & diet/exercise. What does NORMAL LH/FSH plus negative progesterone challenge indicate?
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Pituitary-CNS failure – glycoprotein hormones are immunologically but not biologically active
W/u is similar to low LH/FSH w/u |
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What are pituitary causes of amenorrhea? (4)
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1) Cells are damaged 2/2 anorexia, thrombosis, hemorrhage (Sheehan's or Simmons)
2) Neoplasms: often PRL secretors 3) Acromegaly 4) Cushing's |
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What are hypothalamic causes of amenorrhea? (5)
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1) Congenital: Kallman's (anosmia + midline facial defects) or isolated Gn deficiency
2) CNS neoplasms 3) Infiltrating disease: TB or sarcoid 4) Stress 5) Eating disorder: anorexia or bulimia |
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Secondary amenorrhea plus high FSH in pt <40?
What are some causes of this? |
Premature ovarian failure
Autoimmune disease like Hashimoto's, Addison's, DM, or Hypoparathyroidism |
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What are symptoms of premature ovarian failure?
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Hypoestrogenism
High FSH Ovarian biopsy: Generalized sclerosis or only primordial follicles (no progression past antrum stage) |
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When to check karyotype in pt with premature ovarian failure? (4)
What else to check in these pts? |
1) Pt < 30y/o (46XX/XY mosaic → remove gonads to prevent malignancy)
2) Pt <63 inches tall (Turner's) 3) Gonadal failure = uterus, no breasts, high FSH 4) Androgen insensitivity = breast, no uterus, male testosterone levels Antithyroid antibodies, antinuclear antibodies, 24-hr cortisol |
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What are other, less common or rare causes of premature ovarian failure? (5)
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1) Chemo or rads
2) Lung cancer 3) Single gonadotropin deficiency 4) Resistant or insensitive ovaries (bad or absent receptors) 5) Galactosemia (rare AR galactose metabolism dz) |
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What is MC cause, overall, of amenorrhea?
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Pregnancy!
Always get UPT first |
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Which drugs can cause amenorrhea?
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Antipsychotics (phenothiazines, haloperidol, droperidol)
TCAs Antihypertensive (reserpine, methyldopa) Anti-anxiolytics (benzos) Metoclopramide Opiates Barbiturates Estrogens Any drug that stimulate PRL excretion |
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Initial eval of amenorrhea should include which tests?
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TSH
PRL Progesterone challenge |
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What is the mechanism behind athletic amenorrhea?
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High stress levels
Energy deficit Eating disorder The 1st 2 cause increase in catechol estrogens and beta endorphins → mess w/GnRH release and hence LH & FSH |
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Treatment for athletic amenorrhea?
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Encourage pt to improve diet, decrease stress, decrease strenuous exercise
Replace estrogen and progesterone if the other changes don't help |
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Which enzyme defect can cause cause amenorrhea?
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17-α-OHlase deficiency → effects both ovarian and adrenal gland production → no sex hormones or breast development
Pts do have uterus Also have xs mineralocorticoids → HyperNa, HypoK, HTN Decreased cortisol Tx: replace cortisol and sex hormones |
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What is major cause of anovulatory amenorrhea?
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PCOS
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What percentage of reproductive age women have PCOS?
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5%
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What are 2 other names for PCOS?
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Stein-Leventhal syndrome
Chronic ovarian hyperandrogenism |
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What systemic fxns are affected in PCOS?
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Ovulation
Glycemic control XOL metabolism |
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What are possible criteria for diagnosing PCOS?
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Menstrual dysfunction (anovulation or oligo-ovulation)
PCOS on US Hyperandrogenism (clinical or biochemical) Absence of other androgen disorders or hyperPRL |
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What other syndromes can present like PCOS?
What are tests to differentiate? |
Hyperprolactinemia
Late-onset adrenal hyperplasia Ovarian and adrenal hyperplasia Cushing's syndrome Tests to differentiate: Serum PRL 17-OH progesterone Serum testosterone DHEAS 1mg o/n dexamethasone suppression test & 24hr urine free cortisol |
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MC presenting symptoms of PCOS?
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Infertility (64%)
Hirsutism (69%) Amenorrhea (51%) Obesity (41%) Dysfunctional uterine bleeding (29%) |
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Which labs may be abnormally HIGH in PCOS pts?
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Testosterone and androstenedione
E1 DHEA and DHEAS LH (often 3:1 to FSH) Hyperinsulinemia(more frequent in obese PCOS pts) |
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Which labs may be abnormally LOW in PCOS pts?
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FSH (can be normal)
Sex hormone binding globulin E2 Decreased fasting glucose:insulin (<4.5:1) |
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What are clinical findings in PCOS?
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Hirsutism
Acanthosis nigricans (often associated w/ hyperinsulinemia = HAIR-AN) Anovulation Cardiovascular disease Abnormal glucose metabolism |
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What is the inheritance pattern of inherited PCOS?
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XLD or AR (other chapter says AD!)
Theoretical 50% inheritance but is more like 40% because of genetic and environmental factors |
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How to treat PCOS if desire fertility?(4)
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Clomiphene (80% ovulaton rate, 50-60% pregnancy rate)
Human menopausal gonadotropin is 2nd-line therapy (hMG) Wedge resection/ovarian drilling Metformin Wt loss IVF |
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Treat PCOS obesity? (3)
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Diet/exercise
Anti-obesity drugs Metformin |
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Treat PCOS dysfunctional uterine bleeding? (3)
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OCPs
Progestins Dilation and curretage |
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Treat PCOS hirsutism?
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OCPs
Vaniqa (eflornithine) Progestins Spironolactone (anti-androgen) Fluatmide (anti androgen) Finasteride (5α-reductase inhibitor) GnRH analog Metformin Cimetidine Electrolysis Laser vaporization Traditional acne treatments |
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Treat PCOS recurrent miscarriage?
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hCG
progesterone supplementation |
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Best treatment for PCOS?
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Likely insulin-lowering drugs
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Who gave PMS its name?
What year? |
Dalton
1953 |
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What is the definition of PMS?
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Constellation of symptoms that occurs in a cyclic pattern, always in the same phase of the menstrual cycle, interfering with work or lifestyle and followed by a period entirely free of symptoms
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What year was 1st published description of PMS symptoms?
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1931
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What symptoms are associated with PMS?
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1) Physical:
Wt gain, breast swelling and tenderness, pelvic pain Skin changes like acne Hot flashes Diarrhea or constipation H/a craving sweets 2) Emotional: Irritability Insomnia Depression Confusion or forgetfulness Anxiety Fatigue Feeling of being “out of control” |
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What are theories of PMS's cause?
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All related to hormonal alterations:
1) Ovarian hormones (estrogen and progesterone) 2) Fluids and electrolytes (PRL, Aldosterone, RAAS, Vasopressin) 3) Neurotransmitters (monoamines, acetylcholine) 4) Others: endorphins, androgens, glucocorticoids, melatonin, insulin 5) Serotonin (since SSRIs help!) |
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Does decrease in progesterone levels trigger depression and other emotional symptoms in PMS?
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Supplementing progesterone seems to INCREASE these symptoms, so likely not. Does seem to help a small number of pts, but this might be due to placebo effect.
Note: The theory was used by Dalton in England as defense in a murder trial. |
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What is the relationship between progesterone and monoamine oxidase in PMS?
During which phase? |
Progesterone increases MAO levels in plasma
Luteal phase |
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What is role of aldosterone antagonist in PMS?
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May be related to physical symptoms of fluid retention (wt gain and breast tenderness)
Some of the emotional symptoms may be related to renin/angiotensin and aldosterone increases So spironolactone is good treatment (has antiandrogenic fx) that offers relief to many people. |
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What is thought to be the mechanism behind carb and chocolate cravings in PMS?
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Falling serotonin levels
The body ingests carbs trying to raise serotonin and l-tryptophan levels). Normally, when serotonin levels are high enough, the body craves protein which lowers serotonin to begin a new cycle. In PMS, the pt only craves carbs and chocolate, and serotonin levels never get high enough to trigger protein cravings |
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What is best diet for reducing PMS symptoms?
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Low fat, salt, and sugar
Higher in proteins and complex carbs Maybe vitamins and minerals (no definitive results) |
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Do prostaglandins help PMS symptoms?
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PGE1 may be low in some women w/ PMS (who have symptoms related to altered carb metabolism)
This can also contribute to dysmenorrhea as well Both can benefit from NSAIDs, ibuprofen, others |
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Does sterilization reduce PMS?
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Nope (if tubal or ligasure)
In extreme circumstances, TAH and BSO can help with debilitating disease |
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What is role of psychogenic meds in treatment of PMS?
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Double-blind, placebo controlled studies have shown significant PMS symptom reduction with SSRI fluoxetine 20mg PO qday thruout cycle
Sertraline or alprazolam may also help |
