What feature is always seen with an accessory cavitated uterine malformation?
A normal uterus
- This is presence of a cavity in the myometrium, laterally placed and below the insertion of the round ligament, that is lined by endometrium and surrounded by myometrium-like smooth muscle cells.
- Causes severe dysmenorrhea and chronic pelvic pain
What is Tanner staging?
It is used to stage secondary sexual characteristics.
Which tanner stage is associated with a public hair in a small triangle? What are the other features of that stage?
Tanner Stage 4 - is also associated with “breast mounds”
Which tanner stage is associated with a breast buds? What are the other features of that stage?
2 stages are associated with breast buds:
- Tanner stage 2: forming breast buds and few, long downy pubic hairs on the labia majora
- Tanner stage 3: larger breast buds with pubic hair located centrally
Prepuberty is associated with which Tanner stage?
Tanner Stage 1
- both the breasts and pubic hair growth are prepubertal
Describe the features of Tanner stage 5?
Fully formed breasts and pubic hair in the adult triangle shape, adult quantity and type with spread to the inner thighs.
Which condition is associated with Streak gonads?
Gonadal dysgenesis - 46 XX or 46 XY
Normal karyotype and streak gonads on u/s
Which condition is associated
with streak ovaries?
Turner’s syndrome
XO karyotype and streak ovaries on u/s.
When evaluating primary amenorrhea, what is very important to ask to develop differential diagnoses?
Are secondary sexual characteristics are present?
What is primary amenorrrhea?
Failure to establish menstruation by:
Age 16 if secondary sexual characteristics are present and Age 14 if secondary sexual characteristics (SSC) are not present
Does anorexia nervosa affect thyroid hormone levels?
Yes, decreased fT3.
– anorexia results in starvation, which significantly slows thyroid function.
What are the s/es of bromocriptine?
From head down:
- Headache
- Postural hypotension
- Dizziness
- Drowsiness
- Psychiatric symptoms (esp aggression)
- Nausea
- Vomiting
- Pleural effusion
- Constipation
- Retroperitoneal fibrosis
- Raynaud’s phenomenon
What is the criteria for diagnosis of PCOS?
Rotterdam criteria:
1. Anovulation/ Oligo-ovulation (irregular menses)
- Clinical (acne/hirsutism/male pattern baldness) or biochemical evidence of hyperandrogenism (elevated free testosterone levels)
- Polycystic ovaries on u/s
(12/more peripherally located follicles measuring 2-9mm in diameter in one or both ovaries OR an ovarian volume > 10cm3)
Presence 2 of the 3 criteria is diagnostic for PCOS
What other concomitant issues nay patients with PCOS also have? What is the goal of treatment?
- Obesity (abdominal striae)
- Insulin resistance (acanthosis nigrans)
- Obstructive sleep apnea
TX goal: to improve hirsutism, restore reproductive function, and manage comorbidities.
How is hirsutism and menstrual irregularities treated in a pt with PCOS? Explain.
1) First line: Weight loss
- Always counsel on this as it reduces serum [testosterone] and regulates ovulation.
2) No current fertility desires: with
OCPs.
*OCPs increase SHBP levels –> decreases free androgen levels
*OCPs also decrease circulating LH levels–> decreases ovarian androgen production
3) If allergic to OCPs or if OCP therapy fails after 6/12: Antiandrogens e.g. spironolactone
4). If current fertility desires: clomiphe citrate OR metformin + clomiphene citrate.
*Metformin is indicated for those with impaired glucose tolerance or DM
What are the features and workup for an androgen secreting tumor?
Features:
(i) Rapidly progressive hyperandrogenism with (ii) marked virulization (cliteromegaly, deepening of the voice) and (iii) significantly elevated circulating androgen levels (dehydroepiandrosterone sulphate/DHEA-S >700 micrograms/dL.
Workup:
Adrenal CT
Can DHEA-S be elevated in PCOS?
Yes, it can be mildly elevated.
What is CAH/congenital adrenal hyperplasia and how does it present?
Defn:
CAH is a group of autosomal recessive disorders characterized by impaired cortisol synthesis (caused by deficiency of one of the 5 enzymes required for cortisol synthesis).
Presentation [5]:
1. Premature pubarche,
2. Menstrual irregularities, 3. Acne,
4. Hirsutism, 5. Accelerated bone age
How is CAH classified?
Classical:
- Salt wasting:
-Insufficient aldosterone production leads to salt wasting, failure to thrive –> hypovolaemia and shock–>death.
-A missed diagnosis increases the risk of neonatal morbidity and death.
- Simple virulizing: abnormal development/virulization of external genitalia in females.
- consider CAH in newborns with inaccessible gonads
Non-classical “mild”
- characterized by varying degrees of androgen excess (sometimes asymptomatic)
- serum cortisol is normal (due to subclinical impairment of cortisol snthesis)
- may be noticed late in childhood
With signs of hyperandrogenism (accelerated growth, hirsutism, premature pubarche, menstrual irregularities and secondary pcos.
* in males; early balding and infertility may suggest the diagnosis.
How is CAH diagnosed and treated?
Diagnosis:
- is suggested if 17-hydroxyprogesterone is elevated.
- Confirmatory diagnosis: increased 17-hydroxyprogesterone levels with ACTH administration.
As nonclassical presents with hyperandrogensism, treatment with OCPs is done (menstrual irregularities and hirsutism).
