What does this describe?

Abnormal uterine bleeding-variation in frequency, duration or amount than usual (loses cyclic pattern)

•Abnormal uterine bleeding can be divided into two categories:*****

    A)abnormal bleeding with ovulatory cycles which usually have organic causes

   B) bleeding due to anovulatory causes, usually diagnosed by exclusion

         -anovulatory uterine bleeding is irregular bleeding          unrelated to anatomic lesions /no regular pattern (ie every week, every 3 mo

What is primary amenorrhea?

What is secondary amenorrhea?

•Primary amenorrhea- age 13 without  secondary sex characteristics or 15 with secondary sex characteristics who has never menstruated

•Secondary amenorrhea- if a menstruating woman has not menstruated for 3-6 months or for the duration of three typical menstrual cycles

What is this called:

reduction of frequency of menses with frequency of menses being greater than 35 days but less than 6 months

What is this called:

reduction in the number of days or amount of flow

1. Disruption along the hypothalamic-pituitary-axis

2. Ovarian dysfunction

3. Abnormality along the genital outflow tract

4. Pregnancy

pregnancy

Most common cause of amenorrhea

•Must be ruled to allay patient’s anxiety and avoid unnecessary testing

•Rule out ectopic pregnancy which can present as amenorrhea or abnormal bleeding

What does it mean to have hypothalamic pituitary dysfunction?

ie. what is disrupted in terms of secretions?

What could you be lacking?

Most hypothalamic pituitary amenorrhea is due to what? How is it corrected?

Most hypothalamic pituitary amenorrhea is due to what? How is it corrected?

1. Polymenorrhea-frequent menstrual bleeding (frequency 21 days or less)

2. Menorrhagia-prolonged or excessive uterine bleeding that occurs at regular intervals (>80mL or > 7 days)

3. Metorrhagia-irregular menstrual bleeding or bleeding between periods

4. Menometrorrhagia-frequent menstrual bleeding that is excessive and irregular in amount and duration

Frequent menstrual bleeding (frequency 21 days or less)

ANEMIA!!

get blood count

Functional: weight loss, excessive exercise, obesity

Psychogenic: chronic anxiety, pseudocyesis, anorexia nervosa

Drug induced: marijuana, psychoactive drugs, including anti-depressants

Neoplastic Causes: prolactin-secreting pituitary adenomas, craiopharyngioma, hypothalamic hamartoma

What lab values would you expect to see for someone with hypothalamic pituitary dysfunction? (ie. high, low, normal, etc)

FSH

LH

Prolactin

FSH and LH below normal

What would you expect levels to be in ovarian dysfunction?

FSH

LH

•Most outflow obstruction results from __________in the development and canalization of the __________

•Most outflow obstruction results from congenital abnormalities in the development and canalization of the mullerian ducts

What are the two most common anomalies that cause primary amenorrhea?

What is the most common cause of secondary amenorrhea?

•

Imperforate hymen and absent uterus or vagina are the most common anomalies that cause primary amenorrhea

•Asherman’s syndrome is the most common cause of secondary amenorrhea/scarring of the lining of the uterus-can’t grow in response to estrogen “pt states had regular periods but they stopped- provider ask: did u have any surgeries? D&C Any discharge after? Take any abx?”

What is the progesterone "challenge test?" 

What three things are tested?

if you still don't get a response, what do you need to evaluate?

•Progesterone “Challenge Test” determines adequate estrogen, competent endometrium and patent outflow tract

•If withdrawal bleeding does not occur repeat “Challenge Test” after first treating with estrogen

•If still no response in the presence of a uterus evaluate endometrial canal

Challenge test:

if prog causes period what does that mean?

if give progesterone to someone who doesn’t menstruate, but give progesterone and now has period-what does that mean?

normal outflow tract, normal uterus, normal endometrium, normal uterus-what does that mean?

if prog causes period: adequate estrogen has been produced; -

if give progesterone to someone who doesn’t menstruate, but give progesterone and now has period-what does that mean?TELLS YOU SHE HAD ESTROGEN PRODUCTION-

normal outflow tract, normal uterus, normal endometrium, normal uterus- probably hypothalamic pituitary function making estrogen

•Turner syndrome (45,X gonadal dysgenesis)

•X chromosome long-arm deletion (46, XXq5)

Other causes

•Gonadotropin-resistant ovarian syndrome (Savage syndrome)

•Premature natural menopause= ovary stops working before 40

•Autoimmune ovarian failure (Blizzard syndrome)- causes ovaries to stop working

•80% of pituitary tumors secrete _____ causing ______

•80% of pituitary tumors secrete prolactin causing galactorrhea

•Low serum thyroxine (T4) eliminates negative feedback to the hypothalamic-pituitary axis

•Thyrotropin-releasing hormones levels increase in the absence of negative feedback

•Positive feedback that stimulates dopamine secretion is also absent, causing a decrease in dopamine levels

•Elevated TRH stimulates release of prolactin from the pituitary gland.

•Reduced dopamine secretion results in elevated levels of TSH and prolactin

Induction of ovulation

•Oligo-ovulatory or anovulation -Clomiphene citrate

•Polycystic ovary syndrome-clomiphene citrate

•Hypogonadotropic hypogonadism-human menopausal gonadotropins or Pulsatile GnRH

•Menstruation will never be established if the uterus is absent

True or False:

Amenorrhea and abnormal bleeding can exist in the same patient.

How do you diagnose abnormal uterine bleeding?

What two things should you rule out?

What do you suspect?

What studies do you do?

•Suspect when bleeding is irregular, not predictable, not associated with premenstrual signs and symptoms

•Rule out pregnancy

•Rule out anatomic and neoplastic etiologies

•Pelvic ultrasound

•Basal body temperature chart

•Endometrial biopsy  to rule out endometrial lesions

Establish ovulation

•Progestational agent minimum 10-14 days/month. (medroxyprogesterone acetate)

•Oral contraceptives

Anatomic Causes of Abnormal Uterine Bleeding

Uterine Lesions (3)

Cervical Lesions (4)

Vaginal Lesions (4)

Bleeding from other sites (4)

Uterine Lesions

•Myomas

•Polyps

•Endometrial carcinoma

Cervical Lesions

•Neoplasia

•Polyps

•Cervicitis

•Cervical condyloma

Vaginal Lesions

•Carcinoma, sarcoma, or adenosis

•Laceration or trauma

•Infections

•Inflammation  or ulceration secondary to foreign bodies

Bleeding from Other Sites

•Urethral caruncle

•Infected urethral diverticulum

•Gastrointestinal bleeding