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GYN Endocrine

GYN Endocrine, AUB, DUB, Menstrual disorders

the 4 layers of endocrine control in the female reproductive system hypothalamus, pituitary, ovaries, endometrial lining (uterus)
hypothalamus secretes: GnRH
pituitary secretes: FSH and LH
ovaries secrete: estrogen (follicles), progesterone (corpus luteum), and testosterone
primary amenorrhea has never had a period, may be congenital
secondary amenorrhea has had at least one menstrual cycle
underlying conditions of amenorrhea pregnancy (95% of amenorrhea), hypothalamic dysfunction (thyroid, stress, exercise), pituitary dysfunction (adenomas), ovarian dysfunction (PCOS, menopause, chromosomal), outflow tract abnormalities (congenital)
metrorrhagia irregular and frequent bleeding
menorrhagia heavy and excessive bleeding
menometrorrhagia irregular, frequent, heavy, and excessive bleeding
oligomenorrhea infrequent menstrual flow
DUB (dysfunctional uterine bleeding) bleeding source is uterine/hormonal, abnormal bleeding, anovulatory or ovulatory (often anovulatory); abnormal bleeding caused by hormonal changes/shifts
postmenopausal bleeding after menopause, ALWAYS abnormal, cancer until proven otherwise
estrogen/progesterone preparations irregular bleeding commonly occurs during the first 3 months of treatment, initial breakthrough bleeding usually resolves spontaneously
AUB etiology may be due to too much or too little estrogen or progesterone
AUB common causes PCOS, OCPs, cancer, adolescent anovulatory cycles, thyroid dysfunction, prolactinomas, fibroids, onset of menopause
AUB empiric therapy < 35 y.o. = try progesterone withdrawal check TSH, FSH/LH, prolactin, (possibly testosterone); > 35 y.o. = r/o cancer, endometrial biopsy (perimenopausal or postmenopausal), sonohysterogram (postmenopausal)
Hirsutism/hypergonadism cause increased ovarian androgens
Hirsutism/hypergonadism treatment options OCPs, spironolactone
Anovulatory/infertility cause too much estrogen, not enough progesterone leads to immature uterine lining
Anovulatory/infertility treatments weight loss (decrease endogenous estrogen), clomiphene (blocks estrogen feedback), glucophage (metformin, insulin sensitizer)
Insulin resistance/diabetes cause obesity + possible other factors
Insulin resistance/diabetes treatments metformin
Obesity cause insulin resistance + possible other factors
Obesity treatments diet and exercise, metformin
Endometrial hyperplasia cause unopposed proliferative phase (again, endogenous estrogen)
Endometrial hyperplasia treatments combined OCPs, progesterone-only OCPs (intermittent or continuous), possibly metformin
PCOS key points excess estrogen, common cause of infertility and menorrhea, if endometrium is allowed to build up may cause endometrial hyperplasia, sometimes hyperplasia may turn atypical (precancerous), avoid atypical hyperplasia by progesterone cycling
Uterine cancer key points any postmenopausal bleeding is abnormal, AUB in perimenopause requires endometrial biopsy, FH plays a significant role, prolonged estrogen increases risk, evaluate the cervix as well as the uterus
Dysmenorrhea recurring pain that occurs consistently with the menstrual cycle
Primary dysmenorrhea pain resulting from the normal menstrual cycle, a diagnosis of exclusion, usually starts within first 2-4 years, s/s mediated by sloughing & PGs production & progesterone levels, tx with NSAIDs or OCPs or both
Secondary dysmenorrhea pain resulting from a pathologic menstrual process (pelvic adhesions, pelvic congestion, endometriosis, cervical stenosis, etc.)
Pelvic congestion diagnosis clinical, imaging (US, CT, arteriogram), laparoscopy
Pelvic congestion medical treatment progesterone
Pelvic congestion surgical treatment embolization, sclerotherapy
Pelvic congestion varicose veins
Hx of scant flow: cervical stenosis
Hx of worsening pain at night or when standing: pelvic congestion
Hx of accompanying dyspareunia: endometriosis, pelvic adhesions
Hx of infertility: pelvic adhesions
Hx of pain worsening with stress: somatization
Hx of mood swings: depression
Premenstrual s/s (dysphoric disorder and syndrome) bloating, fatigue, labile mood, increased appetite, headaches, mastalgia
Premenstrual incidence syndrome: 30%, dysphoric disorder: 5%
Premenstrual treatments SSRIs (continuous or luteal phase [symptomatic days have higher doses]), BZDs (alprazolam), spironolactone, calcium (600 mg bid), GnRH agonist therapy/oophorectomy (last resort)
Amenorrhea may result from: any disorder involving hypothalamus, pituitary, ovary, or outflow tract
Most common cause of secondary amenorrhea: pregnancy
DUB may result from: any abnormality in estrogen or progesterone levels
Uterine cancer must be suspected in: middle-aged women or older with unexpected vaginal bleeding
Dysmenorrhea usually improves with use of: NSAIDs or OCPs, regardless of cause
Premenstrual mood disorders usually respond to: medical therapy
Created by: Carrie D.