IMLE Preparatory Course

Lecture 60
Obstetrics and Gynecology

Anomalies of the menstrual

cycle
Infertility
Menopause
Anomalies of the menstrual
cycle
Primary Amenorrhea
Is defined as the absence of
menses by age 16 with 2°
sexual development present,
- Or -
 the absence of 2° sexual
characteristics by age 14.
Which of the following defines primary
amenorrhea?

A) Amenorrhea in the presence of secondary

sexual development at age of 13.
B) Amenorrhea in the presence of secondary
sexual development at age of 15.
C) Amenorrhea in the presence of secondary
sexual development at age of 17.
D) Amenorrhea in the presence of secondary
sexual development at age of 16.
E) Amenorrhea in the presence of secondary
sexual development at age of 18.
Which of the following defines primary
amenorrhea?

A) Amenorrhea in the presence of secondary

sexual development at age of 13.
B) Amenorrhea in the presence of secondary
sexual development at age of 15.
C) Amenorrhea in the presence of secondary
sexual development at age of 17.
D) Amenorrhea in the presence of
secondary sexual development at age of 16.
E) Amenorrhea in the presence of secondary
sexual development at age of 18.
Absence of 2° sexual
characteristics
Constitutional growth delay: The
most common cause.
1° ovarian insufficiency: Most
commonly Turner’s syndrome. Look
for a history of radiation and
chemotherapy.
Central hypogonadism: May be
caused by a variety of factors, including
the following: Undernourishment, stress,
prolactinemia, or exercise.
CNS tumor or cranial irradiation.
Kallmann’s syndrome (isolated
Which of the following defined as primary amenorrhea?

A) Kallman syndrome.
B) Sheehan syndrome.
C) Asherman syndrome.
D) Pregnancy.
E) Premature ovarian failure.
Which of the following defined as primary amenorrhea?

A) Kallman syndrome.
B) Sheehan syndrome.
C) Asherman syndrome.
D) Pregnancy.
E) Premature ovarian failure.
 Kallmann’s syndrome

Results in the
failure or non-
completion of
puberty and
characterized by
hypogonadism and
by anosmia or
hyposmia
 Presence of 2° sexual
characteristics

Müllerian agenesis:
Absence of two-thirds of
the vagina; uterine
abnormalities

Imperforate hymen:
Presents with
hematocolpos that
cannot escape, along with
a bulging hymen.
 Presence of 2° sexual
characteristics

Complete androgen
insensitivity (XY): Patients
present with breast development
(aromatization of testosterone
to estrogen) but are
amenorrheic and lack pubic
hair.
Complete
androgen
insensitivit
y syndrome
Prevents the
masculinization
of male genitalia
as well as the
development of
male secondary
sexual
characteristics
but does not
significantly
impair female
 Primary Amenorrhea
Diagnosis
First step: Get a pregnancy test.
Next step: Obtain a radiograph to
determine if bone age is consistent with
pubertal onset (> 12 years in girls).
If the patient is of short stature (bone
age < 12 years) with normal growth
velocity, constitutional growth delay
(the most common cause of 1°
amenorrhea) is the probable cause.
12 years old female arrives with her upset mother to
clinic that describe that her daughter has not
Mensterued yet. According to mother all the female
sisters menstured by her age and therefore this delay
is concerning. On detailed history the child seems
healthy and asymptomatic. On physical examination
the child has appropriate growth, primary pubic hair,
and early evidence of breast bud. What should be told
to concerned mother?

A) This is primary amenorrhea that requires further

evaluation.
B) This is primary amenorrhea but further evaluation
should only be performed in 6 months.
C) This is not amenorrhea and therefore there is no
reason for further evaluation.
D) The sex sign caused by estrogen administration and
12 years old female arrives with her upset mother to
clinic that describe that her daughter has not
Mensterued yet. According to mother all the female
spouses menstured by age and therefore this delay is
concerning. On detailed history the child seems
healthy asymptomatic. On physical physical
examination the child has appropriate growth, primary
pubic hair, and early evidence of breast bud. What
should be told to concerned mother?

A) This is primary amenorrhea that requires further

evaluation.
B) This is primary amenorrhea but further evaluation
should only be performed in 6 months.
C) This is not amenorrhea and therefore there is
no reason for further evaluation.
D) The sex sign caused by estrogen administration and
If bone age is > 12 years but there are no
signs of puberty, obtain LH/FSH and
consider where the problem is on the HPA
axis.

↓ GnRH, ↓ LH/FSH, ↓ estrogen/progesterone at

prepuberty levels: Points to constitutional growth
delay (puberty has not yet started).
↓ GnRH, ↓ LH/FSH, ↓ estrogen/progesterone:
Hypogonadotropic hypogonadism. Suggests a
hypothalamic or pituitary problem.
↑ GnRH, ↑ LH/FSH, ↓ estrogen/progesterone:
Hypergonadotro-pic hypogonadism. Points to a condition in
which the ovaries fail to produce estrogen.
↑ GnRH, ↑ LH/FSH, high estrogen or testosterone:
Suggests PCOS or a problem with estrogen receptors.
Normal pubertal hormone levels: Indicates an
anatomic problem (menstrual blood can’t get out).
Polycystic ovary syndrome
Work-up for patients with primary
amenorrhea
 Primary Amenorrhea
Diagnosis
Ultrasound may be needed to
evaluate the ovaries.
Normal breast development
and no uterus: Obtain a
karyotype to evaluate for
androgen insensitivity
syndrome.
Stigmata of Turner’s syndrome:
Obtain a karyotype.
Normal breast development
 Primary Amenorrhea
Treatment
Constitutional growth delay: No
treatment is needed.

Hypogonadism: Begin HRT with

estrogen alone at the lowest dose.
Twelve to eighteen months later,
begin cyclic estrogen/progesterone
therapy (if the uterus is present).

Anatomic: Generally requires

surgical intervention.
Secondary Amenorrhea
Defined as the absence of
menses for six consecutive
months in women who have
passed menarche.
Secondary Amenorrhea Diagnosis
First step: Get a pregnancy test .
Second step:
β-hCG: Measure TSH and prolactin.
↑ TSH: Indicates hypothyroidism.
↑ prolactin (inhibits the release of LH and
FSH): Points to a thyroid pathology. Order an
MRI of the pituitary to rule out tumor.
↑↑ prolactin: Suggests a prolactin-secreting
pituitary adenoma.
Normal β-hCG: Initiate a progestin challenge
(10 days of progestin).
Progestin Challenge
Positive progestin challenge (withdrawal
bleed): Indicates anovulation that is likely due
to noncyclic gonadotropin secretion, pointing to
PCOS or idiopathic anovulation. Check LH
levels, and if LH is moderately high, the
etiology is likely PCOS. Marked elevation
of LH can indicate premature menopause.

Negative progestin challenge (no bleed):

Indicates uterine abnormality or estrogen
deficiency. Check FSH levels.
Work-up for patients with secondary
amenorrhea
 Secondary Amenorrhea Diagnosis
↑ FSH: Indicates hypergonadotropic
hypogonadism/ovarian failure.
↓ FSH: Obtain a cyclic estrogen/progesterone
test. A withdrawal bleed points to
hypogonadotropic hypogonadism; a
withdrawal bleed suggests an endometrial or
anatomic problem.

Signs of hyperglycemia (polydipsia, polyuria)

or hypotension: Conduct a 1-mg overnight
dexamethasone suppression test to
distinguish CAH, Cushing’s syndrome, and
Addison’s syndrome.
 Secondary Amenorrhea Diagnosis

If clinical virilization is present:

Measure testosterone, DHEAS, and
17–hydroxyprogesterone.

Mild pattern: PCOS, CAH, or

Cushing’s syndrome.

Moderate to severe pattern: Look for

an ovarian or adrenal tumor.
 Secondary Amenorrhea Treatment
Hypothalamic: Reverse the underlying
cause and induce ovulation with
Gonadotropin.

Tumors: Excision; medical therapy for

prolactinomas (e.g., bromocriptine,
cabergoline).

Premature ovarian failure (age < 40

years): If the uterus is present, treat
with estrogen plus progestin
replacement therapy.
25 years old female seek consultation for amenorrhea.
This is a healthy female that is sexually active of uses
condoms for contraception. History include regular
menses 4/28, last menses about 3 month ago. No
abnormal event since. Which of following correct?

A) There is no reason for concern, progesterone should

be administered to induce menses.
B) This is secondary amenorrhea and hormonal profile
should be obtained to rule out premature ovarian failure.
C) It is likely that she has polycystic ovary syndrome and
ultrasound should be performed to confirm the diagnosis.
D) This is secondary amenorrhea and therefore
pregnancy should be ruled out first.
E) Hysteroscopy to demonstrated uterine cavity should
be performed.
25 years old female seek consultation for
amenorrhea. This is a healthy female that is sexually
active of uses condoms for contraception. History
include regular menses 4/28, last menses about 3 month
ago. No abnormal event since. Which of following
correct?

A) There is no reason for concern, progesterone should

be administered to induce menses.
B) This is secondary amenorrhea and hormonal profile
should be obtained to rule out premature ovarian failure.
C) It is likely that she has polycystic ovary syndrome and
ultrasound should be performed to confirm the diagnosis.
D) This is secondary amenorrhea and therefore
pregnancy should be ruled out first.
E) Hysteroscopy to demonstrated uterine cavity should
be performed.
 Primary Dysmenorrhea
Menstrual pain associated with
ovulatory cycles in the absence of
pathologic findings.

Caused by uterine
vasoconstriction, anoxia, and
sustained contractions mediated by
an excess of prostaglandin
(PGF2α).
Primary Dysmenorrhea Presentation

Presents with low, midline, spasmodic

pelvic pain that often radiates to the back
or inner thighs.

Cramps occur in the first 1–3 days of

menstruation and may be associated with
nausea, diarrhea, headache, and flushing.

There are no pathologic findings on pelvic

exam.
 Primary Dysmenorrhea
Diagnosis and Treatment

A diagnosis of exclusion.
Rule out 2° dysmenorrhea.

Treated by NSAIDs, topical

heat therapy, combined OCPs,
Mirena IUD.
 Secondary Dysmenorrhea
Menstrual pain for which an organic cause
exists.
Common causes include endometriosis
and adenomyosis, tumors, fibroids,
adhesions, polyps, and PID.

Look for pathology. Patients may have a

palpable uterine mass, cervical motion
tenderness, adnexal tenderness, a vaginal or
cervical discharge, or visible vaginal
pathology (mucosal tears, masses, prolapse).
 Secondary Dysmenorrhea Diagnosis
First step: Obtain a β-hCG to exclude
ectopic pregnancy.
Second step: Order the following:
A CBC with differential to rule out infection or
neoplasm.
UA to rule out UTI.
Gonococcal/chlamydial swabs to rule out
STDs/PID.
Stool guaiac to rule out GI pathology.
Third step: Look for pelvic pathology causing
pain
 Abnormal Uterine Bleeding

Normal menstrual bleeding

ranges from two to seven
days.

Vaginal bleeding that

occurs six or more months
following the cessation of
menstrual function
(menapause) is cancer
related until proven
otherwise.
 Assesing the extent of
bleeding
Menorrhagia: ↑ amount of flow (> 80 mL of
blood loss per cycle) or prolonged bleeding
(flow lasting > 8 days); may lead to anemia.
Oligomenorrhea: An ↑ length of time
between menses (35–90 days between
cycles).
Polymenorrhea: Frequent menstruation (<
21-day cycle); anovular.
Metrorrhagia: Bleeding between periods.
Menometrorrhagia: Excessive and irregular
bleeding.
 Abnormal Uterine Bleeding
Diagnosis
Pelvic exam: Look for an enlarged uterus,
a cervical mass, or polyps to assess for
myomas, pregnancy, or cervical cancer.

First step: Obtain a β-hCG to rule out

ectopic pregnancy.

Second step: Order a CBC to rule out

anemia.
 Abnormal Uterine Bleeding
Diagnosis
Third step: Pap smear to rule out
cervical cancer (which can present
with bleeding).

TFTs to rule out

hyper-/hypothyroidism and
hyperprolactinemia.

Obtain platelet count, bleeding

time, and PT/PTT to rule out von
 Ultrasound to evaluate the ovaries,
uterus, and endometrium
Look for uterine masses,
polycystic ovaries, and
thickness of the endo-metrium.

If the endometrium is ≥ 4

mm in a postmenopausal
woman, obtain an
endometrial biopsy.

An endometrial biopsy should

also be obtained if the patient
is > 35 years of age, obese
(BMI > 35), and diabetic.
 Abnormal Uterine Bleeding
Treatment
Heavy bleeding: Since heavy or
prolonged uterine bleeding has likely
due to the endometrial cavity, estrogen
is needed to rapidly promote
endometrial growth.

First step: For hemorrhage, high-dose

estrogen IV stabilizes the endometrial
lining and stops bleeding within one
hour.

Next step: If bleeding is not controlled

 Abnormal Uterine Bleeding
Treatment
Ovulatory bleeding: The goal is to ↓ blood
loss.
First step: NSAIDs to ↓ blood loss.

Next step: If the patient is hemodynamically

stable, treat with OCPs or a Mirena IUD to
thicken the endometrium and control the
bleeding.

If this is not effective within 24 hours, look for

an alternative diagnosis.
 Abnormal Uterine Bleeding
Treatment
Anovulatory bleeding: The goal is to
convert proliferative endometrium to
secretory endometrium.

Give progestins × 10 days to stimulate

withdrawal bleeding.

For young patients with anovulatory

bleeding who may also have a bleeding
disorder, give desmopressin followed by
a rapid ↑ in von Willebrand’s factor and
 If medical management fails
D&C: An appropriate
diagnostic/therapeutic option.

Hysteroscopy: Can help identify

endometrial polyps as well as aid in the
performance of directed uterine biopsies.

Hysterectomy or endometrial ablation:

Appropriate in women who fail or do not
want hormonal treatment, have
symptomatic anemia, and/or experience a
A 41 year old gravida 3 woman presents with
heavy prolonged menstrual bleeding. Up until
8 months ago she had regular monthly
menses which lasted 4-5 days .her physical
examination and pap smear are normal. On
pelvic ultrasound, the endometrium is 14 mm
and there is a 2cmx1.2cm lesion in the
uterine cavity . her B-hcG, TSH, and
endometrial biopsy are normal. Which of the
following is the most likely diagnosis?

a. Endometrial polyp
b. Endometrial hyperplasia
c. Fibroid uterus
A 41 year old gravida 3 woman presents with
heavy prolonged menstrual bleeding. Up
until 8 months ago she had regular monthly
menses which lasted 4-5 days .her physical
examination and pap smear are normal.
On pelvic ultrasound, the endometrium is 14
mm and there is a 2cmx1.2cm lesion in the
uterine cavity . her B-hcG, TSH, and
endometrial biopsy are normal. Which of
the following is the most likely diagnosis?

a. Endometrial polyp
b. Endometrial hyperplasia
c. Fibroid uterus
Infertility
Infertility
Defined as inability to conceive
after 12 months of normal, regular,
unprotected sexual activity.

1° infertility is characterized by no

prior pregnancies.

2° infertility occurs in the setting of at

least one prior pregnancy.
 Male Factors
Presentation
Testicular injury or infection
Medications (corticosteroids,
cimetidine, spironolactone)
Thyroid or liver disease
Signs of hypogonadism
Varicocele
Diagnosis Treatment
TSH Treatment of hormonal
Prolactin deficiency
Karyotype (to rule out Intrauterine
Klinefelter’s syndrome) insemination (IUI)
Semen analysis Donor insemination
In vitro fertilization (IVF)
Semen Morphology

Normal Abnormal sperm

sperm morphology
morpholo
gy
Normal Sperm Parameters
Which of the following findings characterizes a normal
semen sample?

A. Leukocyte count > 1 milion per ml

B. Sperm concentration of 35 milion per ml
C. 4% normal sperm morphology
D. 10% progressive sperm motility
E. A volume of 1 ml
Which of the following findings characterizes a normal
semen sample?

A. Leukocyte count > 1 milion per ml

B. Sperm concentration of 35 milion per ml
C. 4% normal sperm morphology
D. 10% progressive sperm motility
E. A volume of 1 ml
 Ovulatory Factors
Presentation
Age (incidence ↑ with age)
Symptoms of
hyper-/hypothyroidism Treatment
Galactorrhea Treatment depends on
Menstrual cycle abnormalitiesthe
Diagnosis etiology (e.g.,
Basal body temperature levothyroxine,
Ovulation predictor dopamine)
Midluteal progesterone Induction of ovulation
Early follicular FSH +/– with
estradiol clomiphene,
level (ovarian reserve) gonadotropins,
TSH, prolactin, androgens and pulsatile GnRH
Ovarian sonography (antral IUI, IVF
follicle count)
Tubal/Pelvic Factors
Presentation
History of PID, appendicitis,
endometriosis, pelvic
adhesions, tubal surgery
Diagnosis
Hysterosalpingogram,
endometrial
Treatment biopsy
Laparoscopic resection or
ablation of endometriomas or
fibroids.
IVF
 Cervical Factors
Presentation
Abnormal Pap smears, postcoital
bleeding, cryotherapy, conization,
or DES exposure in utero
Diagnosis
Pap smear
Physical exam
Antisperm
antibodies
Treatment
IUI with washed
sperm
IVF
Menopause
 Menopause
Cessation of menses for a
minimum of 12 months as
a result of cessation of
follicular development.

Average age of onset is 51.

“Premature menopause”
is defined as ovarian
failure and menstrual
cessation before age 40.
Main Menopause Signs
HAVOC
Hot flashes (vasomotor
instability)
Atrophy of the Vagina
Osteoporosis
Coronary artery disease
Other Menopause Signs

Insomnia
Anxiety/irritability
Vaginal bleeding
Poor concentration
Mood changes
Dyspareunia
Loss of libido.
Menopause Diagnosis
Labs first show ↑ FSH and then
show ↑ LH.

DEXA scan to follow bone density

for osteoporosis.

Lipid profile (↑ total cholesterol,

↓ HDL).
Vasomotor symptoms
Treatment
HRT (combination estrogen and progestin).
Has been shown to ↑ cardiovascular morbidity
and mortality and may ↑ the incidence of breast
and endometrial cancers.
Posthysterectomy patients do not need
progestin.
Unopposed estrogen in patients with a uterus
predisposes to endometrial cancer.
Contraindications to HRT include vaginal
bleeding, suspected or known breast cancer,
endometrial cancer, and a history of throm-
boembolism, chronic liver disease, or
hypertriglyceridemia.
Vasomotor symptoms
Treatment
Non-HRT
Venlafaxine and, less commonly,
clonidine can be given to ↓ the
frequency of hot flashes.
 Vaginal atrophy Treatment
Long term: Estradiol vaginal ring.

Short term: Estrogen vaginal

cream will relieve symptoms.

Atrophic
Vaginitis
Osteoporosis Treatment
Treat with daily calcium
supplementation and exercise.
Possibly bisphosphonates.
 Head aches
Menopause Hair becomes
and hot Symptoms thinner
flashes
Teeth loosen Breasts drop
and gums and flatten
recede
Risk of Abdomen
cardiovascular looses muscle
disease tone
Skin and
Back aches mucous
membranes
Body and become drier
pubic hair Stress or urge
becomes incontinence
thicker and
Bones loose
darker Vaginal
mass and dryness,
become more itching and
fragile shrinking