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REPRODUCTIVE ENDOCRINOLOGY . . . CONT.

History and Physical Exam

Pregnancy Test

TSH and Prolactin

high/low

high (> 100) or symptoms of hyperprolactinemia

hypothyroidism/hyperthyroidism

CT to rule out tumor

Progesterone Challenge

  • +

    withdrawal bleed

no withdrawal bleed

Anovulation

End-Organ Failure or Outlet Obstruction

FSH, LH

high

low

Ovarian Failure

Hypothalamic Dysfunction

Figure 3. Diagnostic Approach to Amenorrhea

p r o g e s t e r o n e c h a l l e n g e t o a s s e s s e s t r o g e n s t a t u s m e d r o x y p r o g e s t e r o n e a c e t a t e ( P r o v e r a ) 1 0 m g O D f o r 1 0 d a y s i f w i t h d r a w a l b l e e d i n g o c c u r s > a d e q u a t e e s t r o g e n i f n o b l e e d i n g o c c u r s > h y p o e s t r o g e n i s m k a r y o t y p e i f i n d i c a t e d U / S t o r u l e o u t c y s t , p o l y c y s t i c o v a r i a n d i s e a s e

Treatment hypothalamic dysfunction • stop drugs, reduce stress, adequate nutrition, and decrease excessive exercise • clomiphene citrate (Clomid) if pregnancy desired • otherwise BCP to induce menstruation hyperprolactinemia • bromocriptine • surgery for macroadenoma premature ovarian failure • treat associated autoimmune disorders • HRT to prevent osteoporosis and other manifestations of hypoestrogenic state hypoestrogenism • karyotype • removal of gonadal tissue if Y chromosome present polycystic ovarian disease • see Polycystic Ovarian Disease section

ABNORMAL UTERINE BLEEDING

90% anovulatory, 10% ovulatory

Hypermenorrhea/Menorrhagia cyclic menstrual bleeding that is excessive in amount (>80 mL) or duration (> 7 days) • adenomyosis • endometriosis • leiomyomata • endometrial hyperplasia or cancer • hypothyroidism

Hypomenorrhea decreased menstrual flow or vaginal spotting • BCP

MCCQE 2000 Review Notes and Lecture Series

Notes

Gynecology 11

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