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Toronto Notes 2019 Disorders of Menstruation Table 4. Management of Amenorrhea (continued)
Gynecology GY9
2o amenorrhea is pregnancy until proven otherwise
Etiology
2o AMENORRHEA
Uterine defect Asherman’s syndrome
HP-axis dysfunction Premature ovarian failure Hyperprolactinemia
Polycystic ovarian syndrome
Management
Evaluation with hysterosalpingography or sonohysterography Hysteroscopy: excision of synechiae
Identify modifiable underlying cause
Combined OCP to decrease risk of osteoporosis, maintain normal vaginal and breast development (NOT proven to work)
Screen for DM, hypothyroidism, hypoparathyroidism, hypocorticolism
Hormonal therapy with estrogen + progestin to decrease risk of osteoporosis; can use OCP after induction of puberty
MRI/CT head to rule out lesion
If no demonstrable lesions by MRI
Bromocriptine, cabergoline if fertility desired
Combined OCPs if no fertility desired Demonstrable lesions by MRI: surgical management
See Polycystic Ovarian Syndrome, GY23
Abnormal Uterine Bleeding
Abnormal Uterine Bleeding (AUB)
Regular (predictable cycle)
Irregular (unpredictable cycle)
AUB and/or unpredictable AUB
AUB-O AUB-M
Heavy
AUB-A AUB-LSM AUB-C AUB-E
Intermenstrual Bleeding AUB-P
Figure 7. Diagnostic approach to abnormal uterine bleeding
Approach
• menstrualbleedingshouldbeevaluatedbyascertaining:frequency/regularityofmenses,duration, volume of flow, affects on quality of life and timing (inter or premenstrual or breakthrough)
• isitregular?
■ regular: cycle to cycle variability of <20 d – “Can you predict your menses within 20 days?” ■ irregular: cycle to cycle variability of ≥20 d
• isitheavy
■ ≥80 cc of blood loss per cycle or
■ ≥8 d of bleeding per cycle or
■ bleeding that significantly affects quality of life
• is it structural? ■ PALM
• isitnon-structural? ■ COEIN
Postmenopausal bleeding is endometrial cancer until proven otherwise
Abnormal Uterine Bleeding
Change in frequency, duration, or amount of menstrual flow that affects quality of life