AIM ob gyn

what is the first step in the evaluation of secondary amenorrhea

rule out pregnancy

after ruling out pregnancy, what lab helps stratify secondary amenorrhea

FSH level

low or normal FSH in secondary amenorrhea suggests pathology at what level

hypothalamic-pituitary-ovarian axis dysfunction

elevated FSH in secondary amenorrhea suggests what diagnosis category

ovarian failure (premature ovarian failure or menopause)

what diagnoses are associated with elevated FSH in secondary amenorrhea

premature ovarian failure, menopause

bleeding after a progestin challenge with low/normal FSH suggests what diagnosis

polycystic ovarian syndrome

what diagnosis is suggested by hyperprolactinemia in secondary amenorrhea

hyperprolactinemia

high prolactin levels in secondary amenorrhea indicate dysfunction at what level

hypothalamic-pituitary axis

what causes fall under organic hypothalamic-pituitary causes of secondary amenorrhea

congenital GnRH deficiency, infiltrative or inflammatory lesions, tumors, infarction, empty sella syndrome, apoplexy

failure to bleed after a progestin challenge suggests what broad diagnosis category

functional hypothalamic amenorrhea or outlet obstruction

what are causes of functional hypothalamic amenorrhea

weight loss, eating disorders, excessive exercise, stress, prolonged illness

what structural problems can cause failed progestin challenge bleeding

outlet obstruction (cervical stenosis, uterine synechiae)

bleeding after a progestin challenge can be seen in which endocrine disorders besides PCOS

hypothyroidism, hyperthyroidism, diabetes mellitus

exogenous androgen use can lead to what progestin challenge result in secondary amenorrhea

bleeding after progestin challenge

congenital abnormalities associated with secondary amenorrhea fall under which branch of the algorithm

bleed with progestin challenge

what diagnosis must always be ruled out first in secondary amenorrhea

pregnancy

amenorrhea with irregular barrier contraception and sexual activity supports what diagnosis

pregnancy

what test helps confirm or rule out pregnancy in secondary amenorrhea

urine hCG

amenorrhea with acne supports what endocrine diagnosis

polycystic ovarian syndrome

previously regular periods and no hirsutism argue against which diagnosis

polycystic ovarian syndrome

what labs help evaluate suspected PCOS

testosterone, DHEA-S

what imaging helps further evaluate suspected PCOS

transvaginal pelvic ultrasound

amenorrhea with fatigue and constipation supports what diagnosis

hypothyroidism

absence of weight changes, thyroid symptoms, or thyromegaly argues against what diagnosis

hypothyroidism

what test helps evaluate hypothyroidism in amenorrhea

TSH

amenorrhea with a history of eating disorder supports what diagnosis

functional hypothalamic amenorrhea

lack of weight changes argues against which cause of amenorrhea

functional hypothalamic amenorrhea

what history helps further evaluate functional hypothalamic amenorrhea

dietary and exercise history

amenorrhea with headache supports what diagnosis

hyperprolactinemia

absence of nipple discharge or visual disturbances argues against what diagnosis

hyperprolactinemia

what lab test helps evaluate hyperprolactinemia in amenorrhea

prolactin

what is the first diagnosis that must always be ruled out in abnormal uterine bleeding

pregnancy

what framework is used to classify causes of abnormal uterine bleeding

PALM-COEIN

what does PALM stand for in abnormal uterine bleeding

polyp, adenomyosis, leiomyoma, malignancy/hyperplasia

what does COEIN stand for in abnormal uterine bleeding

coagulation defect, ovulatory dysfunction, endometrial, iatrogenic, not otherwise specified

what type of causes does PALM represent in abnormal uterine bleeding

structural causes

what type of causes does COEIN represent in abnormal uterine bleeding

non-structural causes

endometrial or cervical polyp falls under which abnormal uterine bleeding category

polyp (PALM)

adenomyosis is classified as what type of abnormal uterine bleeding cause

structural (PALM)

leiomyoma is classified under which abnormal uterine bleeding category

structural (PALM)

malignancy or hyperplasia is most commonly from what tissue in abnormal uterine bleeding

endometrial

cervical malignancy is how common as a cause of abnormal uterine bleeding

rare

vaginal malignancy is how common as a cause of abnormal uterine bleeding

extremely rare

coagulation defects causing abnormal uterine bleeding are intrinsic to what

the patient

ovulatory dysfunction causing abnormal uterine bleeding falls under which category

non-structural (COEIN)

endometrial causes of abnormal uterine bleeding fall under which category

non-structural (COEIN)

iatrogenic causes of abnormal uterine bleeding fall under which category

non-structural (COEIN)

abnormal uterine bleeding with no identifiable cause is classified as what

not otherwise specified (COEIN)

sexually active with sperm exposure, inconsistent contraception, and enlarged uterus supports what diagnosis

pregnancy

what finding argues against pregnancy in abnormal uterine bleeding

regular bleeding 10 days ago

what test helps confirm pregnancy in abnormal uterine bleeding

pregnancy test

enlarged uterus without uterine tenderness supports what diagnosis

leiomyoma

what imaging test helps evaluate suspected leiomyoma

transvaginal pelvic ultrasound

age over 40 with testosterone therapy supports what cause of abnormal uterine bleeding

ovulatory dysfunction

regular bleeding argues against which cause of abnormal uterine bleeding

ovulatory dysfunction

what tests help evaluate ovulatory dysfunction causing abnormal uterine bleeding

TSH, prolactin, endometrial biopsy

enlarged uterus with dysmenorrhea supports what diagnosis

adenomyosis

what exam finding argues against adenomyosis

nontender uterus on exam

what imaging test helps evaluate suspected adenomyosis

transvaginal pelvic ultrasound

age over 40 and obesity support what diagnosis in abnormal uterine bleeding

endometrial hyperplasia

testosterone therapy and regular bleeding argue against which diagnosis

endometrial hyperplasia

what test helps evaluate suspected endometrial hyperplasia

endometrial biopsy

postmenopausal bleeding should raise concern for what broad diagnosis category first

malignancy

what is the most common malignancy causing postmenopausal bleeding

endometrial cancer

cervical and vaginal malignancies rank how commonly as causes of postmenopausal bleeding

cervical less common, vaginal least likely

what benign endometrial process can cause postmenopausal bleeding

endometrial hyperplasia

atrophy of which tissues can cause postmenopausal bleeding

vaginal epithelium and endometrial epithelium

postmenopausal bleeding due to estrogen deficiency is most consistent with what diagnosis

atrophy

what inflammatory conditions can cause postmenopausal bleeding

cervicitis or vaginitis

what urethral lesion can present as postmenopausal bleeding

urethral caruncle

what medications can contribute to postmenopausal bleeding

anticoagulants and hormones (e.g., tamoxifen)

what structural growths can cause postmenopausal bleeding

endometrial or cervical polyps

bleeding mistaken for vaginal bleeding in postmenopausal patients may come from what non-gynecologic sources

UTI, hemorrhoids

what external cause should be considered in postmenopausal bleeding

trauma

atrophic labia and cervix with pale vaginal mucosa and dyspareunia support what diagnosis

genital atrophy

low estrogen–related postmenopausal bleeding is most consistent with what diagnosis

genital atrophy

what tests can help evaluate suspected genital atrophy

serum estradiol, therapeutic trial of estrogen

a lesion visualized on exam with blood noted on wiping supports what diagnosis

urethral caruncle

bladder tenderness with dysuria supports what diagnosis

acute cystitis (UTI)

absence of urinary frequency or urgency argues against which diagnosis

acute cystitis (UTI)

what tests help evaluate suspected acute cystitis in postmenopausal bleeding

urinalysis and urine culture

vaginal petechiae with dyspareunia support what diagnosis

vaginitis

absence of vaginal discharge argues against which diagnosis

vaginitis

what tests help evaluate suspected vaginitis

vaginitis panel, GC/CT testing

presence of postmenopausal bleeding supports what uterine pathology

endometrial hyperplasia or polyp

what imaging test helps evaluate suspected endometrial hyperplasia or polyp

transvaginal pelvic ultrasound

how is vaginal bleeding in pregnancy first categorized by gestational age

early pregnancy vs late pregnancy

vaginal bleeding before 20 weeks falls under what category

early pregnancy

what causes of vaginal bleeding occur in early pregnancy

physiologic implantation bleeding, spontaneous abortion, ectopic pregnancy, molar pregnancy

implantation bleeding in early pregnancy is considered what type of process

physiologic

pregnancy-related bleeding due to pregnancy loss before 20 weeks is called what

spontaneous abortion

pregnancy implanted outside the uterus causing early bleeding is called what

ectopic pregnancy

abnormal trophoblastic proliferation causing early pregnancy bleeding is called what

molar pregnancy

what causes of vaginal bleeding can occur at any gestational age

cervicitis or vaginitis, trauma or intercourse

in pregnancy, bleeding caused by infection or inflammation of the cervix or vagina is due to what

cervicitis or vaginitis

vaginal bleeding after intercourse or injury in pregnancy is due to what cause

trauma or intercourse

vaginal bleeding at or after 20 weeks gestation falls under what category

late pregnancy

what placental separation disorder causes late pregnancy bleeding

placental abruption

what placental implantation abnormality causes late pregnancy bleeding

placenta previa

what fetal vessel abnormality causes late pregnancy bleeding

vasa previa