ppt2

1. OBSTETRICS & GYNECOLOGY GYNECOLOGICAL MEDICAL PROBLEMS Pascale Gehy-Andre PA-C

2. COMMON PROBLEMS DYSMENORRHEA AMENORRHEA MENOPAUSE DYSFUNCTIONAL UTERINE BLEEDING POST MENOPSAUAL BLEEDING PREMENSTRUAL SYNDROME LEIOMYOMA ENDOMETRIOSIS GYNECOLOGICAL ABDOMINAL PAIN

3. Frequent Terms Hypermenorrhea- Heavy or prolonged bleeding & regular Menorrhagia- Heavy bleeding Metrorrhagia- Bleeding in between periods Polymenorrhea- Menses < 21 days, frequent period Menometrorrhagia- Prolonged flow with intermenstrual bleeding Oligomenorrhea- infrequent periods Amenorrhea- Absent periods Dyspareunia- Pain during intercourse Dysmenorrhea- Painful menstruation Mittelschmerz- Mid-cycle lower abdominal pains associated with ovulation

13. AMENORRHEA - Defined as failure of menarche by age 16 regardless of development or the absence of menstruation for 3-6 months after menarche. - Typically menstruation start by age 12 with about 98% by age 16 & last from 24-38 days - Mean development by age 14 getting earlier recently ? etiology - Two different types primary & secondary

14. AMENORRHEA REMEMBER : R/O PREGNANCY

15. AMENORRHEA PRIMARY - Failure of development by 14 years of age - Failure of menses by 16 years of age regardless of development - Secondary to chromosomal (Turners 45,XO) genital agenesis/congenital abnormalities (absent vagina or imperforated Hymen) , failure of pituitary-ovarian axis

20. AMENORRHEA ETIOLOGY Reproductive Outflow Disorders * Mullerian agenesis- absence of either vagina or uterus * Imperforated Hymen * Androgen Insensitive * Cervical stenosis * Intra uterine adhesions(Asherman’s syndrome naturally or surgical etiology)

21. AMENORRHEA ETIOLOGY Ovarian Disorders * Chronic anovulation * Resistant ovary * Gonadal dysgenesis * Premature ovarian failure

22. AMENORRHEA ETIOLOGY Pituitary Disorders * Hyperprolactinemia * Various tumors * Pituitary insufficiency

23. AMENORRHEA ETIOLOGY Hypothalamic Disorders * Functional- Exercise, stress anorexia S/P * OBC pill, obesity * Drugs TCA, tranquilizers * Neoplastic lesions * Nonfunctional- Space occupying lesions * Kallman’s Syndrome is LHRH hypogonadism

24. AMENORRHEA DIAGNOSTIC APPROACH - History: is extremely important in these cases detailing the physical sexual developmental, nutritional, medical, and psychological history. - Details of possible endocrine symptoms i.e.: (virilization, hypothyroid and diabetes) - Exercise & weight loss (Body fat index) - History anorexic or bulimia (menstruational anomalies are often the presenting symptom in adolescent females) - Emotional stress extremely important

31. Polycystic ovarian syndrome PCOS - AKA Stein-Leventhal Syndrome - Is most common cause of chronic anovulation - Can cause either amenorrhea or irregularity due to estrogen breakthrough - Triad: obesity-hirsutism-amenorrhea - Also may include anovulation and infertility - Thought to be X-linked - HX of insulin resistance may be present

32. Polycystic ovarian syndrome PCOS - Etiology: Increased adrenal androgens with obesity related increased extra-ovarian estrogens. - This leads to inappropriate follicular development with thecal layer over-activity producing increased levels of androgens. - Both leading to elevated LH and decreased FSH - Thus failure of conversion of progesterone to estrogen by depressed granulosa cells. - This leads to premature but slow regression of the follicle leading to multiple cystic formation.

40. Polycystic ovarian syndrome PCOS Treatment - Intermittent progesterone interruption with OBCP - Weight reduction ideal & often only issue needed - If pregnancy is a non issue periodic MPA withdrawal is indicated 3-4x/year - For Pregnancy use Clomiphene or gonadotropins - Hirsutism with spironolactone

41. MENOPAUSE - Cessation of menses may be perimenopausal - Median age 50 - Not related to age of menarche - smoking and family history - Chronic estrogen deficiency - Ovarian atresia with follicular failure

42. MENOPAUSE SYMPTOMS - Vasomotor disturbances 75% with hot flashes - Urogenital atrophy - Osteoporosis 1-3% bone loss/year increase Fx. - Cardiovascular change with increase LDL to male levels with slight decrease in HDL - Neuro/Psychiatric: increase depression, mood changes, decrease sexual desire & other subtle metal status changes. Estrogen reversible

44. SIGNS & SYPMTOMS of ESTROGEN DEFICIENCY Symptoms: Hot flashes, Mood changes, sleep disturbances, Vaginal dryness, Dyspareunia Signs: Vaginal atrophy, thinning of skin & hair, Hot flashes

49. ABNORMAL UTERINE BLEEDING - Defined as alteration of normal flow - Dysfunctional uterine bleeding DUB is most common cause of abnormal uterine bleeding prior to menopause - Heavy, prolonged or inter-menstrual - Normal is for 3-7 day & 60-80 ml blood loss - DUB increase to 7-18 day & 100-200 ml - May have chronic Fe loss & anemia - About 15% have regular ovulation but lack adequate corpus function

50. ABNORMAL UTERINE BLEEDING REMEMBER : R/O PREGNANCY

51. ABNORMAL UTERINE BLEEDING REMEMBER : R/O PREGNANCY

52. ABNORMAL UTERINE BLEEDING ETIOLOGY - Organic: Coagulopathies, liver/renal disease, drugs (steroids, chemo & Coumadin) Obesity and endocrine abnormalities (thyroid, diabetes & adrenal). - Uterine: included Leiomyomas, polyps, endometrial hyperplasia, PID, IUD, pregnancy, cancers & endocrine active tumors. - Non organic: Persistent ovulatory failure, the most common cause is the continuous acyclic estrogen production leading to anovulation and endometrial proliferation. DUB is the most common cause of bleeding in adolescent & young adults.

53. ANATOMIC CAUSES OF IRREGULAR BLEEDING Uterine lesion: Myomas, Polyps, endometrial carcinoma Cervical lesion: Neoplasia, polyps, cervical inversion, cervicitis, cervical condylomas Vaginal lesions: Carcinoma, sarcoma, adenosis, laceration, trauma, infections, foreign bodies Other: Urethral carbuncle, urethral diverticulum, GI bleeding, and various labial lesions

54. ABNORMAL UTERINE BLEEDING REMEMBER : R/O CANCER

55. ABNORMAL UTERINE BLEEDING DIAGNOSIS - History: Previous customary cycles, episode of irregular bleeding, heavy bleeding, sexual contact, STD, previous surgery - Exam: Pelvic for possible sites of internal bleeding (vaginal/rectal), uterine or adnexal enlargement - Lab: hCG, CBC, consider Prolactin Coag studies, TFT,LH, FSH, estrogen and Progestin levels. U/S trans vaginal U/S possible CT/MRI - May need biopsy, D&C, and hysteroscopy - Treatment depends of etiology

57. Polypoid mucosa Hyper-stimulated Mucosa

58. Fibroids Polyps

59. Adenocarcinoma

62. TREATMENT - DUB is most common cause of abnormal bleeding - Unremarkable & negative workup - Acute stable :MPA or OBCP 3 to 4 X usual dose - Unstable: IV estrogen 25 mg q4 X6 if uncontrollable need D&C with cytology - Chronic: GnRH inhibitors, ergots, NSAID, various Progestin/EST/PROGEST/OBCP combinations - Surgical D&C, eletrocautery or laser endometrial ablation. Hysterectomy is final option for significant refractory bleeding without pathology

63. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING Always abnormal and is cancer until proven otherwise

64. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING REQUIRES A DEFINITIVE DIAGNOSIS And if chronic re-evaluate every year

65. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING DIAGNOSIS - History: Previous customary cycles, episode of irregular bleeding, heavy bleeding - Exam: Pelvic for possible sites of internal bleeding (vaginal/rectal), uterine or adnexal enlargement - Endometrial biopsy may be required - Possible D&C and hysteroscopy may be helpful.

67. ABNORMAL UTERINE BLEEDING POST MENOPAUSAL BLEEDING TREATMENT - Depends on the final diagnosis refer for cancer or adenomatous hyperplasia - If cystic hyperplasia, proliferative endometrium increase Progestin and repeat 4-6 months - Secretory, non-proliferative or atrophic endometrium : normal provide reassurance but repeat 8-10 months if continues or for any changes - Never except insufficient sample or non definitive

69. PREMENSTRUAL SYNDROME - Increases with use OBCP - 40% + history of sexual abuse (double general) - 15% childhood sexual abuse (triple general) - Increase with pregnancy complicated abortion, preeclampsia, or postpartum depression - Often linked with mid-life crises. - Symptoms rate mild, mod. severe

70. PREMENSTRUAL SYNDROME ETIOLOGY - Neurotransmitter dysfunction - Steroid imbalance (Estrogen:progesterone) - Prostaglandin imbalance - Fluid retention - Vitamin deficiency (A, B 6 , B complex) - Mineral deficiency ( Mg, Zn & Ca) - Psychosomatic illness

72. PREMENSTRUAL SYNDROME DIAGNOSIS - Clinical diagnosis - Symptoms are cyclic & 2 nd half of cycle - Symptoms increase as cycle progress - Symptoms are relief by menses onset - Symptoms complete absence 2-3 days of menses onset - Symptom free during rest of the cycle - Symptoms present during 3 consecutive cycles * - ?Interfere with daily function?