Cynthia Morris DO, FACOOG, FACOS Medical Director, Women s Wellness Center Fayette County Memorial Hospital

Transcription

1 Cynthia Morris DO, FACOOG, FACOS Medical Director, Women s Wellness Center Fayette County Memorial Hospital Touchdown to CME Eighth District Academy of Osteopathic Medicine & Surgery October

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3 Goals for today

4 And how it relates to the menstrual cycle

5 A quick discussion about STD screening in light of the most recent data presented by the CDC (Think of it as a public service announcement!)

6 Sept 26, 2017 Reuters Health News reported : New STD cases in U.S. set record high in 2016: CDC report Gonorrhea Syphilis Chlamydia Reached more than 2 million cases in 2016, a new record

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9 Ohio HB 124 To prescribe or personally furnish a drug for a sexual partner of a patient diagnosed with chlamydia, gonorrhea, or trichomoniasis, without examining the sexual partner, if all of the following are met: (see handout) Prescriptions made in accordance of this law for no more than two sexual partners of the patient.

10 And how it relates to the menstrual cycle

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13 GnRH: gonadotropin-releasing hormone. Originates from the hypothalamus where its pulsatile release triggers the pituitary to release LH and FSH into the blood stream. LH: luteinizing hormone. In women, is important for ovulation, stimulations of androgens (which then convert to estrogens) from the theca cells, and maintenance of the corpus luteum. FSH: follicle-stimulating hormone. Promotes follicle development.

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20 Hypothalamic-pituitary-ovary axis

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23 Follicular phase: Begins with menstruation and ends the day before the LH surge Early follicular phase: Ovary is least hormonally active. Low estrogen and progesterone levels result in increased GnRh pulsations which increase FSH Mid follicular phase: FSH stimulates follicles to develop and estradiol production increases Late follicular phase: Estradiol increases daily which causes a drop in FSH and LH. Luteal phase: Starts with the LH surge and ends with menstruation No one really understands how the negative feedback of LH suddenly switches to a positive feedback but it does and there is a 10 fold increase in LH. There is an increase in progesterone production by the granulosa cells surrounding the oocyte. Ovulation occurs 36 hours after the LH surge.

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25 Ovarian Follicular Luteal Proliferative Secretory Uterine

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27 Normal Menstrual Periods

28 Frequency Regularity Duration Volume

29 Menstrual cycle: Starts with the first day of menses and ends with the next menses. Average menstrual cycle is 28n to 35 days. Follicular phase is 14 to 21 days on average and the luteal phase is 14 days. 20 to 40 year olds experience much the same cycle. There is much variation in the first 5-7 years after menarche and the 10 years prior to menopause. Menarche: The time of the first menstrual bleed. Menopause: 12 months with amenorrhea clinically defines menopause but it is actually the final ovulation that is menopause. Average age at menopause is 51.4 Secondary Amenorrhea: Lack of menses for more than 3 months in women with regular cycles or 6 months in women with irregular cycles Oligomenorrhea: Fewer than 9 menstrual cycles in a year or greater than 35 days between periods. Menorrhagia: Part of many bleeding abnormalities grouped as Abnormal Uterine Bleeding. Meaning excessive bleeding. PALM-COEIN,

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31 Secondary Amenorrhea

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33 Endocrine Hypothyroid Cushing's disease Adrenal tumor Ovarian testosterone producing tumor Hypothalamic-Pituitary Hypothalamic dysfunction Low body fat Eating disorder Pituitary tumor Sheehan s syndrome Ovarian PCOS Premature ovarian failure oophorectomy Uterine Asherman s syndrome hysterectomy

34 Order a pregnancy test!

35 From UpToDate 2017

36 Pregnancy #1 cause Ovarian 40% 30% PCOS 10% POI Hypothalamic 35% Functional hypothalamic amenorrhea Pituitary 17% 13% hyperprolactinemia 1.5% empty sella 1.5% Sheehan s syndrome 1% Cushing s disease Uterus 7% Asherman syndrome Other `1% Ovarian tumors, adrenal tumors, hypothyroidism,

37 Pregnancy test negative Exam normal? Obese? Thin? History-birth control? Meds? Labs: TSH, testosterone, prolactin TSH abnormal-treat Testosterone elevated-pcos If testosterone >150 do US ovaries Treat PCOS with metformin All normal? Progesterone withdrawl. Bled-great-now what? No bleeding? Now what? Premature ovarian failure FSH, estradiol level Functional hypothalamic amenorrhea (GnRH deficiency)

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40 Female athlete triad Amenorrhea Eating disorder Bone loss Ballet, gymnastics, running especially Weight loss Stress Low BMI Excessive exercise Nutritional disorders Celiac disease Severe illness

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43 Abnormal Uterine Bleeding

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45 P=polyp A=adenomyosis L=leiomyoma M=malignancy and hyperplasia C=coagulopathy O=ovulatory dysfunction E=endometrial I=iatrogenic N=not otherwise classified

46 P=Polyp Endocervical polyps Endometrial polyps

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49 Diagnosis Visualization on exam Ultrasound Hysteroscopy Removal Polypectomy Treatment Dilation and Curettage (D&C) Myosure or similar hysteroscopic surgery

50 A=Adenomyosis Endometriosis of the myometrium Boggy uterus

51 Diagnosis No way to make the diagnosis without pathology High index of suspicion Exam US/ MRI Treatment Hysterectomy Other options to preserve uterus IUD Birth control pills Progesterone Leuprolide or GnRH agonist Endometrial ablation Uterine Artery Embolization (UAE)

52 L=Leiomyoma FIbroid

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54 Diagnosis Exam US/MRI Treatment Hormonal therapy Contraceptives IUD Progesterone GnRH agonists Surgery UAE Myomectomy Endometrial ablation Hysterectomy

55 M=Malignancy Endometrial carcinoma Cervical carcinoma Vulvar/vaginal carcinoma Atypical Endometrial hyperplasia

56 Diagnosis Exam US Endometrial biopsy In office Dilation and Curettage Hysterectomy Treatment

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60 Diagnosis Exam Pap smear with HPV testing Colposcopy with biopsy Biopsy Treatment Hysterectomy Radiation Chemotherapy

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63 C=Coagulopathy O=Ovarian E=Endometrial I=Iatrogenic N=Not Otherwise Classified

64 Diagnosis Labs CBC PT/PTT Further Information 15-24% of women with menorrhagia have a bleeding disorder Most common is von Willebrand disease Thrombocytopenia Platelet function defect Especially need to consider if heavy prolonged bleeding begins with menarche Family history is important Don t forget to check medication list History of other bleeding-nose bleeds, easy bruising

65 More Information Often no identifiable cause Perimenopausal Can be related to stress, weight loss/gain, excessive exercise Factors effecting HPO axis PCOS Thyroid Prolactin Lab Diagnosis and Treatment Correct underlying problem Cycling with progestin

66 Medical Devices or Medications IUD Hormones Hormone related therapy GnRH Aromatase inhibitor SERM Anticoagulant Medications that interfere with ovulation Antipsychotics antidepressants Treatment Remove the IUD Change medications Adjust therapy

67 Diagnosis of exclusion No testing available Treatment Hormone therapy IUD Endometrial ablation Hysterectomy

68 Get a good history of menstruation over the past 6 months. (If it is not a good history and they are not anemic, have the patient do menstrual charting for a few months and return) History (especially medications and surgery history) and physical exam including pap and HPV if have not had done Check pregnancy test and CBC (Do STD screening if appropriate) Check pelvic US Refer to gyn.