1
Week 7 quiz topics
NR 602 Week-7 Quiz Topics, Chamberlain College of Nursing, Course
Code: NR602, Course Title: Primary Care of the Childbearing and
Childrearing Family.
Week 7: Quiz Topics
1. Amenorrhea (Primary and secondary)
Primary Amenorrhea Definition
-no menses by age 13 in the absence of growth or development of secondary sexual characteristics
OR
-no menses by the age of 15 regardless of the presence of normal growth and secondary sexual
characteristics
Amenorrhea Risks
-earliest sign of a decline in general health
-signal an underlying condition such as hypothyroidism or genetic abnormality
-osteoporosis
-in genetic: risk of gonadal tumor
Primary Amenorrhea Etiology
-usually result of genetic or anatomic abnormality but virtually all causes of secondary can cause primary
-chromosomal abnormalities: gondola dysgenesis (ovarian insufficiency due to premature depletion of all
oocytes and follicles)
-absence of necessary pelvic structure (mullerian agenesis)
-physiologic delay of puberty
-PCOS
-isolated GnRH deficiency
-transverse vaginal septum/imperforate hymen
-weight loss/anorexia
-pituitary disease
Amenorrhea Work Up
-rule out pregnancy
-TSH/FSH/prolactin levels
-imaging: pelvic US
-progestin challenge test
-if prolactin is elevated: imaging to evaluate for prolactinoma (MRI) HYPOGONADOTROPHY (disorders
of the anterior pituitary, prolactin secreting adenoma)
Secondary Amenorrhea Definition
-previously had menses
AND
-absence of menses more than 3 months in girls or women who previously had regular menstrual cycles
OR
-six months in girls or women who had irregular menses
Maximal Number of Eggs At
-16 to 20 weeks
-6 to 7 million
HPA Axis Overview
-hypothalamus -> GnRH -> anterior pituitary -> LH/FSH -> ovaries -> progesterone and estrogen -> hypothalamus
Secondary Amenorrhea Etiology
-pregnancy is MC
-pathologically causative systems: ovary, hypothalamus, pituitary, uterus
,2
Week 7 quiz topics
Progestin Challenge Test
-assess the level of endogenous estrogen and the competence of the outflow tract
-parenteral progesterone oil, oral micronized progesterone, oral medroxyproesterone acetate
-within 2-7 days: does vaginal bleeding occur?
-yes -> diagnosis is anovulation; intact outflow tract; estrogen present = means minimal function of the ovary,
pituitary, and CNS
-no -> suggests hypogonadism (move to estrogen/progesterone challenge)
Anvoluatory Amenorrhea Treatment
-require treatment (if untreated unopposed estrogen can lead to endometrial hyperplasia)
-provera for 10 days of each month
-can use OCPs if contraception is also desired
Estrogen and Progesterone Test (After Progestin Challenge)
-give estrogen and progesterone: conjugated estrogen, estradiol, medroxygprogesterone
-if bleeding does not occur: endometrium or outflow tract problem (rare): aggressive curettage (Asherman's
syndrome), infection, genetic anomaly
-if withdrawal bleeding occurs: outflow tract and endometrium are working, there is a problem with the
body's ability to stimulate estrogen production (move to gonadotropin assay)
Gonadotropin Assay (After Estrogen/Progesterone Test)
-if bleeding occurred with estrogen and progesterone together, there is a problem with stimulation of
estrogen production
-follicular activity or gonatotropins
-bioassay the level of gonatotropins
-must do this 2 weeks after the E/P challenge
-draw LH/FSH
-normal: FSH 5-20 with ovulatory midcycle peak about 2x the base level, LH 5-20 with the ovulatory
midcycle peak about 3x the base level
-hypergonadotropic: FSH > 20, LH > 40
-hypogonadotropic: FSH < 5, LH < 5
Hypergonadotropic Etiologies
-bilateral oophorectomy (surgical menopause)
-postmenopausal
-ovarian failure
-ectopic gonadotropin secreting tumors outside the reproductive tract
-gonadotropin secreting pituitary adenomas (associated with HA and vision changes)
-perimenopausal period (rising FSH level)
-resistant or insensitive ovary syndrome
-autoimmune disease: developing follicles are surrounded by nests of lymphocytes and plasma cells; also
evaluate for abnormal thyroid and adrenal function
-galactosemia: autosomal recessive; disorder of galactose metabolism due to an enzyme deficiency;
premature ovarian failure
-17-hydroxylase deficiency: absent secondary sexual development, HTN, hypokalemia, high progesterone
levels
Resistant or Insensitive Ovary Syndrome Overview
-hypergonadotropic
-amenorrhea, normal growth and development, elevated gonadotropins
-ovarian follicles are unresponsive to stimulation
-absent or defective gonadotropin receptors on the follicles
-diagnosis: laparotomy with full thickness ovarian biopsy
Hypogonadotropic Etiologies
-prepubertal
-hypothalamic dysfunction
-pituitary dysfunction
Hypogonadotropic Imaging the Sella Turcica
, 3
Week 7 quiz topics
-start with imaging of sellaturicica and PRL level (MRI pituitary specific imaging)
-insignificant findings: microadenomas
-significant findings: macroadenomas
Microadenomas Overview
-do not grow very rapidly during pregnancy
-rarely progress to macroadenomas
-high recurrence rate after surgery
-natural course is unaffected by dopamine agonist treatment
-no CI to hormone therapy or OCPs
Disorders of Outflow Tract or Uterus Overview
-possible cause of amenorrhea
-no withdrawal bleeding at step 2 (estrogen progesterone test)
-asherman's syndrome
-mullerian anomalies
-mullerian agenesis
-androgen insensitivity (testicular feminization)
Asherman's Syndrome Clinical Presentation
-disorders of outflow tract or uterus
-intrauterine scarring/adhesions
-can also occur after uterine surgery, IUD infections, severe pelvic infections, tuberculosis in the uterus,
myomectomy, multiple curettage
Asherman's Syndrome Diagnosis/Treatment
-hysteroscopy: adhesions
-hysteroscopic lysis of adhesions
Asherman's Syndrome Complications
-infertility
-miscarriages
-dysmenorrhea
Mullerian Anomalies Clinical Presentation
-disorders of outflow tract or uterus
-imperforate hymen, obliteration of the vaginal orifice, lapses in the vaginal continuity, presence or absence
of uterus or cervix
-pelvic pain
-infertility or recurrent miscarriages
-renal anomalies are found sometimes (renal US or IV pyelogram should be obtained)
Mullerian Anomalies Diagnosis
-MRI (gold standard)
-hysterosalpingogram can be helpful in visualizing communication
Mullerian Anomalies Treatment
-individualized
-reestablishment of mullerian duct continuity usually can be achieved surgically
Mullerian Agenesis Clinical Presentation
-disorders of outflow tract or uterus
-lack of Mullerian development
-mayer-rokitansky-kuster-hauser syndrome
-absence or hypoplasia of the internal vagina; may have absence of uterus and fallopian tubes
Mullerian Agenesis Physical Exam
-female karyotype
-normal ovarian function
-normal growth and development
Mullerian Agenesis Treatment
-vaginal dilators (Frank) or surgical
-watch for associated: renal tract abnormalities, skeletal anomalies
Androgen Insensitivity (Testicular Feminization) Clinical Presentation
Week 7 quiz topics
NR 602 Week-7 Quiz Topics, Chamberlain College of Nursing, Course
Code: NR602, Course Title: Primary Care of the Childbearing and
Childrearing Family.
Week 7: Quiz Topics
1. Amenorrhea (Primary and secondary)
Primary Amenorrhea Definition
-no menses by age 13 in the absence of growth or development of secondary sexual characteristics
OR
-no menses by the age of 15 regardless of the presence of normal growth and secondary sexual
characteristics
Amenorrhea Risks
-earliest sign of a decline in general health
-signal an underlying condition such as hypothyroidism or genetic abnormality
-osteoporosis
-in genetic: risk of gonadal tumor
Primary Amenorrhea Etiology
-usually result of genetic or anatomic abnormality but virtually all causes of secondary can cause primary
-chromosomal abnormalities: gondola dysgenesis (ovarian insufficiency due to premature depletion of all
oocytes and follicles)
-absence of necessary pelvic structure (mullerian agenesis)
-physiologic delay of puberty
-PCOS
-isolated GnRH deficiency
-transverse vaginal septum/imperforate hymen
-weight loss/anorexia
-pituitary disease
Amenorrhea Work Up
-rule out pregnancy
-TSH/FSH/prolactin levels
-imaging: pelvic US
-progestin challenge test
-if prolactin is elevated: imaging to evaluate for prolactinoma (MRI) HYPOGONADOTROPHY (disorders
of the anterior pituitary, prolactin secreting adenoma)
Secondary Amenorrhea Definition
-previously had menses
AND
-absence of menses more than 3 months in girls or women who previously had regular menstrual cycles
OR
-six months in girls or women who had irregular menses
Maximal Number of Eggs At
-16 to 20 weeks
-6 to 7 million
HPA Axis Overview
-hypothalamus -> GnRH -> anterior pituitary -> LH/FSH -> ovaries -> progesterone and estrogen -> hypothalamus
Secondary Amenorrhea Etiology
-pregnancy is MC
-pathologically causative systems: ovary, hypothalamus, pituitary, uterus
,2
Week 7 quiz topics
Progestin Challenge Test
-assess the level of endogenous estrogen and the competence of the outflow tract
-parenteral progesterone oil, oral micronized progesterone, oral medroxyproesterone acetate
-within 2-7 days: does vaginal bleeding occur?
-yes -> diagnosis is anovulation; intact outflow tract; estrogen present = means minimal function of the ovary,
pituitary, and CNS
-no -> suggests hypogonadism (move to estrogen/progesterone challenge)
Anvoluatory Amenorrhea Treatment
-require treatment (if untreated unopposed estrogen can lead to endometrial hyperplasia)
-provera for 10 days of each month
-can use OCPs if contraception is also desired
Estrogen and Progesterone Test (After Progestin Challenge)
-give estrogen and progesterone: conjugated estrogen, estradiol, medroxygprogesterone
-if bleeding does not occur: endometrium or outflow tract problem (rare): aggressive curettage (Asherman's
syndrome), infection, genetic anomaly
-if withdrawal bleeding occurs: outflow tract and endometrium are working, there is a problem with the
body's ability to stimulate estrogen production (move to gonadotropin assay)
Gonadotropin Assay (After Estrogen/Progesterone Test)
-if bleeding occurred with estrogen and progesterone together, there is a problem with stimulation of
estrogen production
-follicular activity or gonatotropins
-bioassay the level of gonatotropins
-must do this 2 weeks after the E/P challenge
-draw LH/FSH
-normal: FSH 5-20 with ovulatory midcycle peak about 2x the base level, LH 5-20 with the ovulatory
midcycle peak about 3x the base level
-hypergonadotropic: FSH > 20, LH > 40
-hypogonadotropic: FSH < 5, LH < 5
Hypergonadotropic Etiologies
-bilateral oophorectomy (surgical menopause)
-postmenopausal
-ovarian failure
-ectopic gonadotropin secreting tumors outside the reproductive tract
-gonadotropin secreting pituitary adenomas (associated with HA and vision changes)
-perimenopausal period (rising FSH level)
-resistant or insensitive ovary syndrome
-autoimmune disease: developing follicles are surrounded by nests of lymphocytes and plasma cells; also
evaluate for abnormal thyroid and adrenal function
-galactosemia: autosomal recessive; disorder of galactose metabolism due to an enzyme deficiency;
premature ovarian failure
-17-hydroxylase deficiency: absent secondary sexual development, HTN, hypokalemia, high progesterone
levels
Resistant or Insensitive Ovary Syndrome Overview
-hypergonadotropic
-amenorrhea, normal growth and development, elevated gonadotropins
-ovarian follicles are unresponsive to stimulation
-absent or defective gonadotropin receptors on the follicles
-diagnosis: laparotomy with full thickness ovarian biopsy
Hypogonadotropic Etiologies
-prepubertal
-hypothalamic dysfunction
-pituitary dysfunction
Hypogonadotropic Imaging the Sella Turcica
, 3
Week 7 quiz topics
-start with imaging of sellaturicica and PRL level (MRI pituitary specific imaging)
-insignificant findings: microadenomas
-significant findings: macroadenomas
Microadenomas Overview
-do not grow very rapidly during pregnancy
-rarely progress to macroadenomas
-high recurrence rate after surgery
-natural course is unaffected by dopamine agonist treatment
-no CI to hormone therapy or OCPs
Disorders of Outflow Tract or Uterus Overview
-possible cause of amenorrhea
-no withdrawal bleeding at step 2 (estrogen progesterone test)
-asherman's syndrome
-mullerian anomalies
-mullerian agenesis
-androgen insensitivity (testicular feminization)
Asherman's Syndrome Clinical Presentation
-disorders of outflow tract or uterus
-intrauterine scarring/adhesions
-can also occur after uterine surgery, IUD infections, severe pelvic infections, tuberculosis in the uterus,
myomectomy, multiple curettage
Asherman's Syndrome Diagnosis/Treatment
-hysteroscopy: adhesions
-hysteroscopic lysis of adhesions
Asherman's Syndrome Complications
-infertility
-miscarriages
-dysmenorrhea
Mullerian Anomalies Clinical Presentation
-disorders of outflow tract or uterus
-imperforate hymen, obliteration of the vaginal orifice, lapses in the vaginal continuity, presence or absence
of uterus or cervix
-pelvic pain
-infertility or recurrent miscarriages
-renal anomalies are found sometimes (renal US or IV pyelogram should be obtained)
Mullerian Anomalies Diagnosis
-MRI (gold standard)
-hysterosalpingogram can be helpful in visualizing communication
Mullerian Anomalies Treatment
-individualized
-reestablishment of mullerian duct continuity usually can be achieved surgically
Mullerian Agenesis Clinical Presentation
-disorders of outflow tract or uterus
-lack of Mullerian development
-mayer-rokitansky-kuster-hauser syndrome
-absence or hypoplasia of the internal vagina; may have absence of uterus and fallopian tubes
Mullerian Agenesis Physical Exam
-female karyotype
-normal ovarian function
-normal growth and development
Mullerian Agenesis Treatment
-vaginal dilators (Frank) or surgical
-watch for associated: renal tract abnormalities, skeletal anomalies
Androgen Insensitivity (Testicular Feminization) Clinical Presentation
