GYN- AUB & Menstruation

How is normal menses defined?

regular cyclical shedding secondary to successful ovulation

normal cycle length 21-35; normal menses duration 2-7 days

What are the key plays in the menstrual cycle?

Hypothalamus - GnRH

Post pit- FSH/LH

Ovaries- estrogen & progesterone

Endometrium

What causes AUB in neonates?

Estrogen withdrawal after birth

What is frequent bleeding where the internal between periods are < 24 days?

Polymenorrhea

What is infrequent bleeding where the interval between periods are > 38 days (< 12 / yr)?

Oligomenorrhea

What is an absence of uterine bleeding?

Amenorrhea

what is considered irregular bleeding from menarche to 25 y/o and 42 y/o to menopause?

> 9 days difference between cycle lengths

What is considered irregular bleeding in ages 26-41?

>7 days difference between cycle lengths

What is prolonged menstrual bleeding?

Menses lasting > 8 days

What is considered a heavy menstrual volume?

> 80 mL or volume that interferes with quality of life

What is considered a light menstrual volume?

< 5 mL

What is abnormal genital bleeding?

Generic term used when source of bleeding is not yet identified

What organs are involved in bleeds from the lower genital tract?

Cervix, vagina, vulva

What organs are involved in upper genital tract bleeding?

Uterus, ovary, fallopian tube

What can cause ovarian bleeding?

Ovarian cancer, ovarian cyst

What can cause fallopian tube bleeding?

Salpingitis w/ PID, fallopian tube cancer, hysteroscopic sterilization

What is abnormal uterine bleeding (AUB)?

Indicated uterine source but not yet classified as anatomic, hormonal, systemic dz or cancer

What is excessive non cyclic endometrial bleeding unrelated to anatomical lesions of the uterus or systemic dz (dx of exclusion; outdated term)?

Dysfunctional uterine bleeding (DUB)

What is anovulation that may be related to a disease state vs other factors that effect the HPG-A; irregular menses from no ovulation (newer definition for DUB)?

Anovulatory bleeding

What is the MC type of AUB?

Anovulatory

Who is anovulatory AUB MC in?

extremes of age

What is the pathophys of anovulatory AUB?

Disruption of HPG-A → ovulation failure → lack of CLC formation → failure of normal progesterone secretion → unopposed estrogen causes endometrium to outgrow blood supply → necrosis & abnormal bleeding

what does Anovulatory AUB increase the risk for?

Hyperplasia w/ atypia or or dysplasia which can lead to malignancy

What is heavy and/or prolonged bleeding at normal intervals (cyclic, ovulatory)?

Menorrhagia

What causes menorrhagia?

Hormonal imbalance (estrogen > progesterone [MC] or progesterone + PG > estrogen)

structural (PALM- polyps, adenomyosis, leiomyoma, malformations)

liver dz, pregnancy comp, VWD, IUDs, meds

What meds can cause menorrhagia?

Anticoagulants & steroids

What are tx options for menorrhagia?

Cyclical NSAIDs, Tranexamic acid, surgery for structural abnormalities, hormonal contraceptives

what is bleeding that occurs bt menses aka intermenstrual bleeding?

Metrorrhagia

What is heavy bleeding and intermenstrual bleeding/spotting?

Menometrorrhagia

What is bleeding that occurs after contact with cervix or vaginal walls, commonly after sex (post coital)?

Contact bleeding

What should contact bleeding be considered until proven otherwise?

Cervical cancer

What is the workup for contact bleeding?

Pap smear, colposcopy +/- bx, vaginal/culture to r/o infx

What is the term for light periods?

Hypomenorrhea / cryptomenorrhea

What condition is the development of intrauterine adhesions after endometrial injury caused by previous pregnancy, D&C, surgery, or infx; confirmed by HSG or hysterectomy?

Uterine synechia / Asherman’s syndrome

What is the absence of menses?

Amenorrhea

Primary or secondary amenorrhea?

• failure of onset of menarche

• by age 13 if no secondary sex characteristics

• by age 15 if characteristics are present

Primary

Primary or secondary amenorrhea?

• New absence of menses but has menstruated for atleast 6 mos prior to

• > 3 mos if regular before onset

• > 6 mos if oligomenorrhea or irregular before onset

Secondary

What are causes of primary amenorrhea if the breast and uterus are absent?

Mullerian agenesis, androgen insensitivity (genetically male but resistant androgen effects - presents like prepubertal female)

What are causes of primary amenorrhea if breasts are absent and uterus is present with high FSH/LH?

Ovarian problems - premature ovarian failure, gonadal dysgenesis (Turney’s syndrome MC)

What are causes of primary amenorrhea if breasts are absent and uterus is present with normal to low FSH or LH?

Hypothalamic pituitary failure, pubertal delay (athletes, illness, anorexia(

What are causes of primary amenorrhea with breasts and uterus present?

Outflow obstruction - transverse vaginal septum, imperforate hymen

What are causes of primary amenorrhea if breasts are present and uterus is absent?

Defect in testosterone synthesis, presents like adolescent female but has intra-abdominal tests

What is the MCC of secondary amenorrhea?

Pregnancy

What are causes of secondary amenorrhea?

Pregnancy, Hypothalamic dysfunction, pituitary dysfunction, ovarian disorders (MC PCOS), uterine disorder, uterine outflow tract problem

What is bleeding occurring after confirmed menopause (1 full year w/o bleeding)?

Postmenopausal AUB

What is postmenopausal AUB considered until proven otherwise?

Endometrial cancer

What are causes of postmenopausal AUB?

Endometrial cancer, unopposed estrogen, obesity, cervical dysplasia/pathology, atrophic vaginitis, infx

Does the following correlate with ovulatory AUB or anovulatory AUB?

• regular cycles days 21-35

• PMS- bloating, breast pain, irritability

• Dysmenorrhea (1st/2nd day)

• Basal body temp (BBT) inc when ovulating

• cervical mucus changes to clear & stretchy

Ovulatory

What should always be done first when evaluating a patient presenting with AUB?

Pregnancy test

What should be included in the PE for an AUB patient?

Speculum & bimanual exam, general exam to look for systemic signs

What diagnostic testing should be considered for AUB?

Pregnancy test, Pap/cervical cultures, endometrial sampling (esp if risk for endometrial hyperplasia), U/S, MRI ± contrast, hysterosalpingogram, progesterone challenge

What labs should be considered for AUB?

CBC, CMP, TFTs, Testosterone, Insulin, Prolactin, 17hydrogyprogesterone, FSH/LH/Estradiol/Progesterone

What is a normal endometrial thickness if premenopausal females?

10-14mm

What endometrial thickness is considered thickened in premenopausal females?

≥ 15 mm

What endometrial thickness is normal in postmenopausal females?

≤ 4 mm

What endometrial thickness is considered thickened in postmenopausal females?

≥ 5 mm

What can confirm if AUB is due to anovulation?

Progesterone challenge- one time use of oral progestin x 10 days to see if it induces withdrawal bleeding

When should combo hormonal therapy NOT be used for AUB treatment?

Suspicion of estrogen sensitive lesions if not r/o by bx (endometrial hyperplasia, malignancy, PM bleeding)

How does combo hormonal therapy work to treat AUB?

Suppresses GnRH and pituitary FSH/LH → suppression of ovarian folliculogenesis & mid cycle LH surge → prevention of ovulation

How does progestin based therapy work to treat AUB?

Allows for steady state of reproductive hormones → less endometrial proliferation and secretion → decrease menstrual flow, thicken cervical mucus, & impair normal tubal motility & pregnancy

What AUB treatment option should be considered in those with refractory heavy bleeding after failure of OCPs, progestin therapies, or tranexamic acid?

GnRH agonists/antagonists

What is the MCC of infertility in the US and one of the MC endocrine disorders in women of reproductive age?

PCOS

What is a disorder resulting in spectrum of symptoms characterized by hyperandrogegism, ovulatory dysfunction and polycystic ovaries that has metabolic consequences?

Polycystic ovarian syndrome (PCOS)

What are RF for PCOS?

Genetics, obesity, impaired glucose tolerance/DM, fhx DM, metabolic syndrome, epilepsy / anti epileptic drugs

What is the pathophysiology of PCOS?

GnRH causes pituitary to secrete unequal LH > FSH d/t inc LH responsiveness to GnRH, pulse frequency, & amplitude → no ovulation → no CLC → reduced progesterone & no secretory phase → unopposed estrogen effect → endometrial hyperplasia → inc risk endometrial CA

No ovulation → collection of underdeveloped follicles remain in ovary → polycystic appearance

How is insulin involved in PCOS?

Insulin resistance → inc serum insulin →

inc lipogenesis → wt gain

inc LH secretion → inc androgens & cyst formation

inc hepatic secretion SHBG → hyperandrogegism

What are the sx associated with PCOS?

Menstrual irregularities, infertility, hyperandrogegism, obesity, DM, metabolic syndrome

What is the MC presenting menstrual irregularity seen in PCOS?

Oligomenorrhea

What hyperandrogenic symptoms are seen in PCOS?

Hirsutism, scalp ahir loss / androgenic alopecia, change in fat distribution (inc central obesity), inc muscle mass of arms and chest, acne, deep voice, clitoromegaly, inc body odor

What are signs of insulin resistance that can be seen in PCOS?

Skin tags, acanthosis nigricans

What metabolic syndromes are seen in PCOS?

Central obesity, dyslipidemia, HTN, pro-inflammatory state

What criteria is used to diagnosis PCOS?

Rotterdam criteria

What is the Rotterdam criteria?

*need 2/3 for PCOS dx

Irregular periods (oligo and/or anovulation),

Clinical and/or biochemical signs of hyperandrogegism,

Polycystic ovaries on US (12+ follicles or inc ovarian volume, MC B/L)

What is seen on U/S in PCOS?

string of pearl’s sign

What is the diagnostic workup for PCOS?

Labs: inc LH:FSH ratio, testosterone & DHEA (inc or normal), SHBG (dec or normal), fasting glucose (inc), lipid panel (inc TG, LDL & TC, dec HDL), r/o other causes

Transvaginal U/S

Progesterone challenge

What are nonrx treatment options for PCOS?

Diet, supplements (Vitamin D, omega 3s/fish oil, myo and D Chiro inositol), exercise

In the treatment of PCOS, who should statins be considered in?

women that are not trying to conceive

What are treatment options for metabolic derangements in PCOS?

Metform, GLP-1 agonists (semaglutide, tirzepatide)

What hormonal BC options can treat PCOS?

Combo is preferred (pill, patch, ring), progestin w/ low androgenic profile (drospirenone, norgestimate), cyclic progestin if trying to conceive or opposed to use of BC

What are non hormonal treatment options for PCOS?

Spironolactone (help w/ acne, hirsutism, hair loss)

Eflornithine hydrochloride cream 13.9% (slow facial hair growth)

what are surgical treatment options for PCOS?

Ovarian wedge resection, laparoscopic surgery

How can infertility associated with PCOS be treated?

Clomid or Letrozole