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NM701 Gynecological Health > AUB + Pelvic Pain > Flashcards

AUB + Pelvic Pain Flashcards

1
Q

REALLY study the menstrual cycle

A

back to Mod 1

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2
Q

smooth, deep, fragile, bright red polyps that often bleed after sex

A

endocervical polyps

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3
Q

connective, glandular or muscular tissue polyps that are usually asymptomatic and rarely cancerous

A

endometrial polyps

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4
Q

small areas of endometrium within the myometrium that occur in multiparous women over age 40 usually with a history of miscarriage, curettage, resection, C/S, Tamoxifen use

A

adenomyosis

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5
Q

submucosal (usually bleed) or fibroids (usually asymptomatic) that are benign tumors of the endometrium that is the leading cause for hysterectomy most common benign pelvic tumor

A

Leiomyoma

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6
Q

rare in reproductive age women w/o PCOS and normal BMI

A

malignancy or hyperplasia

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7
Q

consider this when AUB occurs in African American women or PCOS

A

malignancy or hyperplasia

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8
Q

most common symptom of endometrial malignancy/hyperplasia

A

AUB/ postmenopausal bleeding

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9
Q

hormone imbalance that causes anovulatory bleeding, amenorrhea, or oligomenorrhea

A

ovulatory dysfunction

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10
Q 
Causes of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:
PCOS
pituitary tumors (prolactinomas)
thyroid dx
associated w/ excessive exercise
minimal body fat
A

ovulatory dysfunction

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11
Q

Categories of ___________:
Amenorrhea
Anovulatory
Ovulatory

A

ovulatory dysfunction

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12
Q

type of AUB that is typically predictable cyclical w/ heavy bleeding but may involve intermenstrual or prolonged bleeding

A

endometrial

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13
Q

diagnosis of exclusion in which ovulation still occurs, there are no coagulopathies, no structural reasons for AUB, and no medications being taken that would cause AUB

A

endometrial

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14
Q

type of AUB caused by medications of LNG-IUDs

A

Iatrogenic

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15
Q

reasons why aldolescents and perimenopausal women have AUB which is considered normal

A

irregular ovulation

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16
Q

menstrual periods with abnormally heavy or prolonged bleeding

A

menorrhagia

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17
Q 
\_\_\_\_\_\_\_\_\_ AUB Causes:
Endocrine disruption:
thyroid, pituitary
Ovulatory Dysfunction:
Progestin contraceptives/IUDs
2 years post-menarche
Perimenopause
Chlamydia
Gonorrhea
Endometritis
PCOS
Polyps (post-coital)
Adnexal mass
A

Irregular

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18
Q

_________ AUB Causes:

Ovulatory: Fibroids, Polyps, Adenomyosis

A

Regular

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19
Q

_________/__________ AUB Causes:
Ovulatory Dysfunction
Fibroids (heavy, clots, pelvicfullness)

A

Irregular/Regular

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20
Q

new, heavy, irregular bleeding is suspicious for:

A

endometrial cancer

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21
Q

To Rule Out __________:
prolactin
FSH
LH

A

Endocrine causes of AUB

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22
Q

To Rule Out __________:
adrenal studies
testosterone

A

Adrenal causes

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23
Q

Treatment for ____________:
Estrogen (concomitant use of antiemetics d/t nausea)
COCs
Progestogen-only
LNG-IUD
GnRH agonists - short term while waiting for surgical tx
Nonhormonal - NSAIDs (ovulatory-idiopathic)
Tranexamic acid - Lysteda
Surgical - D&C, endometrial ablation

A

Acute Non-life Threatening Heavy AUB

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24
Q 
Treatment for \_\_\_\_\_\_\_\_\_\_\_:
Provera
Norethindrone
Prometrium
Depo-provera
LNG-IUD
A

Chronic Anovulation

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25
Q

painless, spontaneous, heavy, intermenstrual bleeding is indicative of:

A

endometrial hyperplasia

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26
Q 
ALWAYS order \_\_\_\_\_\_\_\_\_\_\_ if:
postmenopausal vaginal bleeding
Older women - risk increases with age
women >/= 45
30-45 w/ negative pregnancy test and med management of AUB fails
A

endometrial biopsy

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27
Q 
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_:
 >/= 40
anovulation
PCOS
fam history
new onset heavy irregular bleeding especially postmenopausal
nulliparity
overweight
unopposed estrogen stimulation of endometrium
tamoxifen tx
infertility
DM Type II
A

endometrial cancer

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28
Q

Need to Know for ___________:
Contraindicated in: Hx of DVT/VTE + coagulopathies
Family Hx of idiopathic VTE
Give antiemetic for nausea
Give progesterone afterwards

A

Estrogen

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29
Q

Need to know for ______________:

If flow does not stop w/in 48 hours - return for further evaluation

A

monophasic COC’s

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30
Q

Need to know for ______________:
for chronic anovulation
Cyclic
repeat endometrial biopsy w/in 3-6 months after initiated
Take at night due to possible fatigue
Caution w/ peanut allergies
Contraindicated: pregnancy - even if she thinks she is but test is negative

A

Progesterone

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31
Q

Need to know for ______________:
Give when awaiting surgery for heavy bleeding
Side effects r/t estrogen deficiency
Caution in anemic patiets

A

GnRH

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32
Q

Need to know for __________:

Contraindicated: ulcers, bronchospastic lung disease

A

NSAIDs

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33
Q

Need to know for __________:
Second line for those who cannot or do not wish to use hormonal options
s/e: VTE, arterial and venous retinal occlusions, rarely nausea and leg cramps
Contraindicated: hx or risk of thrombosis

A

TXA

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34
Q

When ________ can be used for AUB:
Chronic anovulation
Long-term/chronic management
Heavy menstrual bleeding caused by fibroids that do not distort uterine cavity and uterus is less than 12 wks gestation in size

A

LNG-IUD

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35
Q 
Other options for \_\_\_\_\_\_\_\_\_\_:
Surgical - medical therapy fails
D&C
Endometrial ablation
Uterine artery embolization 
Hysterectomy
A

AUB-E

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36
Q

most common causes of ____________:
pregnancy
hypothalamus
PCOS

A

amenorrhea

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37
Q

Evaluate for ______________ if:
No menses by 14 in absence of growth or development of secondary sexual characteristics

No menses by 16 regardless of the presence of normal growth of development of secondary sex characteristics

Women who have menstruated previously, no menses for an interval of time equivalent to a total of at least 3 previous cycles or 6 months

A

amenorrhea

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38
Q

failure to begin menses by age 16

A

primary amenorrhea

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39
Q

3 months w/o menses when menses has been established

A

secondary amenorrhea

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40
Q 
Categories of \_\_\_\_\_\_\_\_\_\_:
Disorders of the genital outflow tract
Disorders of the ovary
Disorders of the anterior pituitary
Disorders of the hypothalamus or CNS
A

Amenorrhea

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41
Q 
Physiological Disorders for \_\_\_\_\_\_\_\_\_\_\_\_:
anatomic defects
ovarian failure
chronic anovulation
anterior pituitary disorders
CNS disorders
A

Amenorrhea

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42
Q

most common cause of amenorrhea

A

ovarian function abnormalities

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43
Q

absence of menses due to suppression of HPOA with no anatomic or organic disease

A

Functional Hypothalamic Amenorrhea

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44
Q

____________ > 40 = functioning ovaries

Low value may be ovarian failure or hypothalamic amenorrhea

A

serum estradiol

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45
Q

low level of ___________ = normal ovulatory function

A

serum FSH

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46
Q

If these diagnostic labs for amenorrhea (estrogen, serum estradiol, progestogen challenge, endometrial thickness, serum FSH, serum prolactin) are normal = ovaries are producing estrogen and FSH normal = diagnosis is:

A

chronic anovulation

47
Q

antidepressants, opiates, CCBs, and estrogens can cause:

A

hyperprolactinemia

48
Q

If hyperprolacteinemia present with amenorrhea - more evaluation needed to rule out:

A

pituitary tumors and hypothalamic mass lesions

49
Q

treatment of choice for hyperprolactinemia

A

dopamine agonist

50
Q

If progestogen challenge test is positive
and no galactorrhea
and prolactin level normal, midwife can rule out:

A

pituitary tumor

51
Q

If progestogen challenge test is positive
and no galactorrhea
and prolactin level normal, diagnosis is:

A

anovulation

52
Q

Treatment for _________:
Progestogen for first 10 days each month to induce menses
CHC
**Evaluate for PCOS

A

Anovulation

53
Q

management is necessary for ____________ because if not treated it can cause endometrial cancer regardless of age

A

Anovulation

54
Q

Anovulation Treatment: Medroxyprogesterone 5-10mg QD for first ___-___ cycle days

A

12-14

55
Q

still possible during progesterone anovulation treatment

A

pregnancy

56
Q

diagnosed when estrogen production is low while serum FSH is high

A

ovarian failure

57
Q

Treatment for ____________:
Karyotype Test for women < age 30 (possible genetic cause)
Test for Anti-Adrenal Antibodies (possible autoimmune- Addison’s disease)

A

Ovarian Failure

58
Q

test to perform when no clear explanation for hypogonadism or hyperprolactinemia in amenorrhea

A

MRI

59
Q

No lesions on MRI means no need for further pituitary testing and diagnosis is:

A

functional hypothalamic amenorrhea

60
Q

PCT is positive if this occurs

A

withdrawl bleeding 7-10 days after progesterone is stopped

61
Q

withdrawl bleed after progesterone is discontinued means there is plenty of __________ and _________ are functioning:

A

estrogen

ovaries

62
Q

________ PCT means:
Minimal/No estrogen → no endometrium → no flow
***Physician consult

A

Negative (Not Positive)

63
Q

Galactorrhea + No withdrawal bleed + High Prolactin

means ______ estrogen

A

Low

64
Q

Prolactinemia + No withdrawal bleed + High Prolactin

means ______ estrogen

A

Inhibited

65
Q

If patient has PCOS, PCT will result:

A

positive (withdrawal bleed)

66
Q

Excess adipose tissue + Withdrawal bleed

means estrogen is:

A

produced in part by adipose tissue

67
Q

No withdrawal bleed means ovaries not producing:

A

estrogen

68
Q 
Clinical Manifestations of \_\_\_\_\_\_\_\_\_\_\_\_\_:
Irregular menses  - HALLMARK FEATURE
Hirsutism
Acne
Alopecia
Virilization
Clitoral hypertrophy
Voice deepening
Increased muscle mass
Breast atrophy
Male pattern baldness
Adrenal or ovarian tumor
Congenital adrenal hyperplasia
Hyperthecosis
Severe Hyperinsulinemia
Menstrual dysfunction
Infertility
Anovulation 
Oligomenorrhea (cycles last 35-199 days)
Amenorrhea cycle > 199 days
--Significant endocrinopathies
--More severe hyperandrogenemia
--Increased serum LH and cortisol levels
--Increased incidence of hyperinsulinemia
Polycystic ovaries
Chronic anovulation (not required for dx)
Obesity (often abdominal)
Insulin resistance (Risk of impaired glucose tolerance and T2DM)
Dyslipidemia
Metabolic syndrome
Cardiovascular disease markers 
Depression
Anxiety
Binge eating
Less sexual satisfaction and overall quality of life 
Cancer risks
A

Hyperandrogenism

69
Q 
Clinical Manifestations of \_\_\_\_\_\_\_\_\_\_\_\_\_:
Irregular menses  - HALLMARK FEATURE
Hirsutism
Acne
Alopecia
Virilization
Clitoral hypertrophy
Voice deepening
Increased muscle mass
Breast atrophy
Male pattern baldness
Adrenal or ovarian tumor
Congenital adrenal hyperplasia
Hyperthecosis
Severe Hyperinsulinemia
Menstrual dysfunction
Infertility
Anovulation 
Oligomenorrhea (cycles last 35-199 days)
Amenorrhea cycle > 199 days
--Significant endocrinopathies
--More severe hyperandrogenemia
--Increased serum LH and cortisol levels
--Increased incidence of hyperinsulinemia
Polycystic ovaries
Chronic anovulation (not required for dx)
Obesity (often abdominal)
Insulin resistance (Risk of impaired glucose tolerance and T2DM)
Dyslipidemia
Metabolic syndrome
Cardiovascular disease markers 
Depression
Anxiety
Binge eating
Less sexual satisfaction and overall quality of life 
Cancer risks
A

Hyperandrogenism

70
Q

Consequences of _____________:
HTN
Impaired glucose tolerance– Type 2 DM
Mood disorders
Infertility/Subfertility
Psychological impact
**3x risk for Endometrial Cancer
Estrogen-Dependent tumors
Dyslipidemia (Low HDL, High LDL and triglycerides)
Metabolic syndrome (Risk for cardiovascular disease and DM)
Systemic inflammation– endothelial vascular dysfunction and coronary artery calcification

A

Hyperandrogenism

71
Q 
Conditions that cause \_\_\_\_\_\_\_\_\_\_\_\_:
PCOS **most common
Congnital adrenal hyperplasia
Hyperthecosis 
Nonclassical adrenal hyperplasia
Androgen producing tumors
Adrenal or ovarian tumor
A

Hyperandrogenism

72
Q

hallmark feature of PCOS

A

menstrual irregularity

73
Q

results from more significant endocrinopathies including more severe hyperandrogenemia
High serum LH, cortisol, and incidence of hyperinsulinemia

A

amenorrhea

74
Q

menstrual cycle dysfunction that rarely occurs with hyperandrogenism

A

polymenorrhea (cycle length < 21 days)

75
Q

regular menses can occur with ______-anovulation

A

oligo

76
Q 
History Questions for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:
Age at onset of:
         Thelarche - breast development
         Adrenarche - pubic hair 
         Menarche
Menstrual pattern
Pregnancy history/ miscarriages
Obesity
Hirsutism
Seborrhea
Acne
Alopecia
Complete medication hx
--Testosterone, anabolic steroids, danazol, certain progestins, glucocorticoids, valproic acid
Virilization (suspicion for androgen-producing tumor)
Libido
Muscle bulk
Voice deepening
Breast atrophy
Clitoromegaly 
Polydipsia/ Polyuria (glucose intolerance)
Galactorrhea
Visual disturbance
Headache
Thyroid dysfunction → hot/cold intolerance, weight loss/gain
Cushing syndrome - striae, mood changes, easy bruising, or weight gain
Cardiovascular and metabolic risk factors
Smoking
Hx of HTN, dyslipidemia, DM, CVD
Family Hx - hirsutism, acne, infertility, DM, CVD - esp first-degree relatives w/ premature CVD before 55 in men and 65 in women, obesity, or dyslipidemia
A

Hyperandrogenic Disorders

77
Q

Physical Exam for ______________:

  • Establish severity and related symptoms
  • Height, weight, BMI
  • BP
  • Skin - hirsutism, acne, alopecia
  • Consider racial, familial, genetic and hormonal influences
  • Acanthosis nigricans - velvety, warty, hyperpigmented on axillae, neck, under breasts (insulin resistance)
  • Thyroid
  • Breast - Galactorrhea
  • Cushing - mone facies, dorsocervical fat pad - buffalo hump, and abdominal striae
  • Pelvic - clitoris for hypertrophy and bimanual for uterine size, ovaries, and mass presence
A

Hyperandrogenic Disorders

78
Q

Diagnostic Labs for _____________:
Prolactin
TSH
Fasting lipid
2-hour oral GTT
Progesterone days 20-24 of menstrual cycle
Free testosterone (more sensitive than total count)
Total testosterone (if tumor suspected)
Serum 17-OHP (rules out congenital adrenal hyperplasia)
Anti-mullerian hormone (AMH) (> 4.5 = PCOS)
Cushings Test (dexamethasone suppression test) **only if sx present
Pelvic ultrasonography (polycystic ovary morphology and endometrial hyperplasia for oligo and amenorrheics)
TVUS (w/ machines used for follicle numbering and morphology)
TVUS of ovaries (if virilizing tumor suspected–adrenal CT if not identified w/ US)
Endometrial biopsy (for longstanding anovulation due to carcinoma risk- consider unopposed estrogen exposure over age )
**Avoid routine adrenal imaging

A

Hyperandrogenic Disorders

79
Q

If Luteal phase < 3 days x 2 cycles, midwife can diagnose:

A

oligo-anovulatory/ PCOS

80
Q

PCOS is diagnosed by:

A

exclusion

81
Q 
Diagnosis of \_\_\_\_\_\_\_\_\_\_\_\_:
(2 of 3)
1. oligo or anovulation
2. clinical/biochemical signs of hyperandrogenism
3. polycystic ovaries
A

PCOS

82
Q

First line treatment for PCOS

A

COCs

83
Q 
Effects of \_\_\_\_\_\_\_\_\_\_ for PCOS:
Inhibits LH and LH-dependent ovarian androgen production
Increases SHBG to bind free testosterone
Cosmetic relief of hirsutism and acne
--Acne - effect w/in 2 months
--Hair growth - effect w/in 9-12 months
Regular menstrual cycle
Endometrial cancer protective
A

COCs

84
Q

Safety Concerns of _______ for PCOS:
May increase insulin resistance
VTE Risk 2x for PCOS with this
VTE Risk 1.5x for PCOS without this

A

COCs

85
Q

PCOS treatments for those who don’t want COCs or have contraindications to COCs

A

First Line Antiadrogens (spironolactone, finasteride, flutamide)
Progestogens (LNG-IUDs, POPs, depo, nexplanon)

86
Q

Alone will not treat hirsutism

A

Progestogens (LNG-IUDs, POPs, depo, nexplanon)

87
Q

PCOS treatments that are endometrial cancer protectives

A

Progestogens (LNG-IUDs, POPs, depo, nexplanon) and COCs

88
Q

Considerations for ___________ PCOS Treatments:
Teratogen (always use w/ effective contraception w/ sexually active)
Hirsutism and androgenic alopecia

A

Antiadrogens (spironolactone, finasteride, flutamide)

89
Q

Other treatments for _______:
Insulin-sensitizing agents - metformin, TZDs
Topical - eflornithine for facial hirsutism
GnRH analogs - leuprolide to tx hirsutism

A

PCOS

90
Q

Reasons for Immediate ___________ in PCOS woman:
Sudden onset or rapid progression of virilization
Endocrinopathies - CAH, HAIR-AN syndrome, Cushing’s, hyperprolactinemia, or androgen-producing tumors
Refractory to treatment
Infertility

A

Referral

91
Q

Chronic mucocutaneous w/ inflammation, epithelial thinning, and depigmentation, and dermal change of the vulva
-Agglutination of labia minora
-Progressive or Remittive
-Sometimes seen in other body areas - trunk, neck, forearm, axillae, under breasts, trauma induced
-Early s/s - Dull, nonspecific vulvar irritation
Progressive = severe pruritus, burning, dyspareunia

A

Lichen Schlerosis

92
Q

Goals for _____________:
s/s relief
Reversal of agglutination
Prevention of further architectural distortion w/ loss of function
Prevention of potential malignant changes

A

Lichen Schlerosis

93
Q

First Line Treatment for _____________:

high or very high potency topical steroid ointment - clobetasol propionate 0.05%; 3 month tapered dosing common

A

Lichen Schlerosis

94
Q

-May be asymptomatic (incidental on imaging)
-Pain mild to moderate and self-limiting
UNLESS d/t hemorrhagic corpus luteum cyst which can cause significant blood loss
-Sudden
-Midcycle
-Most prone to rupture = mimic ectopic
-Hypovolemia only if there is hemoperitoneum
-Abdominal tenderness (often rebound tenderness d/t peritoneal irritation)
-May be able to palpate mass w/ bimanual if not entirely ruptured
-Functional - resolve w/in 3 months

A

Ovarian Cysts

95
Q

Treatment for __________:

Hormonal contraceptives - control repeated episodes but unlikely to resolve

A

Ovarian Cysts

96
Q

GOLD standard for endometriosis diagnosis

A

laparoscopy w/ histology of biopsy

97
Q 
Symptoms of \_\_\_\_\_\_\_\_\_\_\_\_:
Can be asymptomatic
Dysmenorrhea
Deep dyspareunia
Sacral backache during menses
A

Endometriosis

98
Q

endometriosis treatment that removes focal areas, endometriomas, distorting adhesions
Also effective for pain mgmt

A

Laprascopic Conservative

99
Q

definitive diagnostic surgery for endometriosis that allows for elective ovarian preservation to benefit bone and CV effects but has increased risk of recurrent symptoms greatly

A

complete hysterectomy and bilateral salpingo-oophorectomy

100
Q 
Disease that causes:
Infertility
Late miscarriage
Preterm birth
FGR
Antepartum hemorrhage
Progesterone resistance
Subclinical atherosclerosis
A

Endometriosis

101
Q

variant of endometriosis where endometrial cells are located w/in the myometrium

A

Adenomyosis

102
Q

variant of endometriosis where endometrial cells are located w/in the myometrium

A

Adenomyosis

103
Q 
Symptoms of \_\_\_\_\_\_\_\_\_\_\_\_\_\_:
May be asymptomatic
Menorrhagia
Dysmenorrhea
Dyspareunia
Pelvic pain
Diffusely enlarged, boggy, and/or tender uterus that is asymmetrical w/o firm nodularity of fibroids
A

Adenomyosis

104
Q

Adenomyosis is diagnosed by:

A

TVUS, definitively by histology by surgical biopsy

105
Q

Treatment:

May choose hysterectomy w/ ovarian preservation (curative)

A

Adenomyosis

106
Q 
Symptoms of \_\_\_\_\_\_\_\_\_\_\_\_\_:
May be asymptomatic
Uterine bleeding
Pelvic pain or pressure
Dyspareunia
Torsion or rupture = acute pain
Palpation of abdomen reveals mass(es) arising from uterus
May be tender to palpation
May have increased temp and WBCs
**May be confused with subacute salpingo-oophoritis
A

Fibroids

107
Q 
Treatment for \_\_\_\_\_\_\_\_\_\_\_\_\_:
-Decisions based on number, size, location, s/s type and severity, distance to menopause, childbearing plans, preference for uterine preservation
--Medical options
Progestens
GnRH agonists
SERMs
Aromatase Inhibitors
COCs
NSAIDs
Surgical - myomectomy and hysterectomy
A

Fibroids

108
Q

Risk Factors for _____________:
Unopposed estrogen → endometrial hyperplasia
Exogenous - Estrogen therapy, tamoxifen
Endogenous - Early menarche, late menopause, hx of infertility, nulliparity, obesity, chronic anovulation, diabetes, high-fat diet, ovarian cancer
Obesity
Physical inactivity
White race (for incidence)
Black women (for higher grade + aggressive histology)
Genetic predisposition
Lynch syndrome
Cowden disease
Older age
Smoking
Sedentary lifestyle
History of pelvic radiation to treat other cancer
Endometrial hyperplasia

A

Endometrial Cancer

109
Q

Risk Factors for ___________:
Advancing age (increasing at menopause and into 80s)
Family history in 1st degree relative
Gene mutations (assoc w/ family Hx of ovarian or breast cancer before age 50)
Northern european or ashkenazi jewish descent
BRCA1 or BRCA2
Lynch syndrome
Cyclic hormonal stimulation by estrogen
Short or irregular menstrual cycles and late age at menopause
Obesity
talcum powder use
Smoking
BMI>30
Smoking (mucinous type)
Fertility drug use
(Decreased Risk = hysterectomy, tubal ligation, or previous salpingectomy)

A

Ovarian Cancer

110
Q

Most likely to develop _____________:
Unopposed Estrogen
Not Ovulating
PCOS

A

Endometrial/Ovarian Cancer

111
Q

Type II Endometrial cancer rarely presents with enodmetrial lining < ___ mm

A

3

112
Q

In office procedure to directly visualize uterine cavity
Visualize and biopsy
Recommended to do w/ D&C → best opportunity to examine endometriumn and confirm premalignant endometrial lesions

A

Saline-infusion Sono-Hysterography

113
Q

Highest mortality GYN cancer

A

ovarian

114
Q

Gold standard diagnostic for endometrial cancer

A

D+C

NM701 Gynecological Health (5 decks)

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