Abnormal Uterine Bleeding Definitions Oligomenorrhea 35 day cycle

• Abnormal Uterine Bleeding Definitions • • Oligomenorrhea: >35 day cycle Polymenorrhea: <21 day cycle Metrorrhagia: Irregular intervals, excessive flow Menorrhagia: Regular intervals, excessive flow Amenorrhea: No flow for 6 months Dysmenorrhea: Uncomfortable menses (Goljan says its due to prostaglandins causing cramps). DDx • • Fibroids Polyps Endometrial Hyperplasia/Carcinoma (esp. post-menopausal) Anovulatory Cycles Adenomyosis Endometriosis Pregnancy Coagulopathy • Take a complete gynecologic history, medications, signs of virilization, DM, and sexual history. Physical exam should look for virilization, endocrine dysfunction, body habitus, etc. • Anovulatory Cycles Too much unopposed E 2 causing endometrial hyperplasia and bleeding. Since there is no ovulation, progesterone never shifts phases in the endometrium. Eventually the tissue outgrows its vascular supply and sheds causing bleeding. • • • Physiologic (“first and last” cycles) PCOS Congenital Adrenal Hyperplasia Increased Androgens (DHEA, Androstenedione, Testosterone) Hypothalamic-Pituitary dysfunction Hypothyroidism • Ovulatory Cycles Short luteal phase or dysfunctional progesterone secretion result in early shedding of the endometrium and bleeding • Amenorrhea Primary refers to no menses by age 14 without secondary sexual characteristics or 16 with sexual characteristics. Secondary refers to absence of menses for 6 months. It can be thought of as a hypothalamic-pituitary issue, an ovarian issue or an anatomic issue. Levels of FSH and LH will help determine where the issue is (e. g. it will be high in ovarian failure and low in hypopituitarism). NEVER RULE OUT PREGNANCY. • • Hypothalamic-Pituitary: Prolactinoma, Hypopituitary (Sheehan’s, Empty Sella, Craniopharyngioma, trauma) Ovarian: Sertoli-Leydig Tumors, PCOS, XO, Savage Syndrome (Gn resistance), autoimmune (Blizzard Syndrome), Chemotherapy Anatomic: Asherman’s Syndrome (fibrosis of the endometrium secondary to D&C), Cervical Stenosis, Imperforate Hymen All of these obstruct outflow of menses. Physio up in this bitch: Hypothyroidism causes amenorrhea due to the fact that TRH promotes synthesis of prolactin. Low levels of thyroxins increase TRH and therefore lead to production of prolactin which inhibit Gn. RH secretion.