Chapter 22 Abnormalities of the Menstrual Cycle

Question 1

normal variances of cycle length between

Answer 1

21-35days

Question 2

women may also have spotting to light bleeding at midcycle as a result of slight decline in __ levels that precede ovulation

Answer 2

estrogen

Question 3

primary dysmenorrhea is result from increased levels of ____ pathway

Answer 3

endometrial prostaglandin production derived from arachidonic acid pathway

Question 4

pain of dysmenorrhea occurs with ovulatory cycles on the 1st or 2nd day of menstruation ,

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Question 5

pain from endometriosis may begin 1-2 days to WEEKS before mensturation, worsens 1-2 days before menstruation, and is relieved at or right after onset of menstrual flow

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Question 6

first line medical treatment for primary dysmenorrhea is

Answer 6

nsaids (asa, ibuprofen, ketoprofen, naproxen)

Question 7

ocps are 2nd line of treatment for women who do not get adequate pain relief from ____ and NSAIDS

Answer 7

antiprostaglandin agent

Question 8

more than 90% of women with primary dysmenorrhea find dequate pain relief with the use of oral contraceptives given in a continuous (preferred) or cyclic fashion. same for ortho evra patch and nuvaring

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Question 9

mechanism of relief is either secondary to cessation of ovulation or due to decrease in endometrial proliferation leading to decreased prostaglandin production

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Question 10

most pts who have been cycled 1 year on ocps experienc reduction of symptoms even if discontinued.

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Question 11

if cannot tolerate estrogens, several progestin-only contraceptives also provide relief:

Answer 11

depo-provera, implanon, mirena IUS

Question 12

pregnancy carried to viability will usually decrease the symptoms of primary dysmenorrhea

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Question 13

SECONDARY DYSMENORRHEA: IDENTIFIABLE CAUSE

endometriosis , adenomyosis , fibroids, cervical stenosis, pelvic adhesions.

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Question 14

treatment of cervical stenosis: dilation of cervix. progressively larger dilators are placed through ervical canal until it becomes patent. ultrasound guidance can be helpful in avoiding creation of a false passage or uterine perforation. pregnancy with vaginal delivery often leads to permanent cure

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Question 15

pelvic adhesions from infections including cervicitis, PID, tubo-ovarian abscess may have symptoms of dysmenorrhea secondary to adhesion formation

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Question 16

treatment: laparotomy for safe lysis. pt shold be aware that surgery can lead to further adhesions and further problems with dysmenorrhea, infertility, and/orchronic pelvic paint

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Question 17

treatment of PMS AND PMDD

Answer 17

SSRI - PROZAC. DEMONSTRATED CLEAR EFFICACY IN TREATMENT BOTH PHYSICACL AND MOOD SYMPTOMS
CELEXA (CITALOPRAM)
AXIL (PAROXETINE)
ZOLOFT (SERTRALINE) ALSO SHOWN EFFECTIVE.

Question 18

yaz formulated with low dose estrogen and uses which progestin

Answer 18

drospirenone

Question 19

vitamin supplementation as a treatment for PMS and PMDD:

Answer 19

calcium 600mg bid
vitamin D (800iu/day)

Question 20

normal menstrual cycle bleeding approx 28days . normal range (21-35days) lasting 3-5days

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Question 21

vitamin supplementation for PMS and PMDD:

Answer 21

calcium 600mg bid
vitamin d 800 iu/day
vitamin b6 (<100mg/day)
magnesium (200-360mg/day)

Question 22

normal uterine bleeding average 28 days. ranges from 21-35days. anything outside the norm considered abnormal uterine bleeding.

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Question 23

dysfunctional uterine bleeding describes idiopathic heavy and / or irregular bleeding that cannot be attributed to another cause following a complete evaluation. DUB ost commonly due to anovulation or oligoovulation. most common cause of anovulation in women of reproductive age is PCOS

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Question 24

PALM (structural cause)- Polyps, Adenomyosis, Leiomyoma, and Malignancy and hyperplasia.

COEIN (nonstructural cause) - Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and those etiologies that are Not yet classified.

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Question 25

menorrhagia - flow excssive in its duration (>7days )

describe the blood as flooding or gushing, and may have blood clots along with their excessive flow.

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Question 26

menorrhagia most commonly caused by uterine fibroids, adenomyosis, ,endometrial polyps, and less commonly by endometrial hyperplasia or cancer.

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Question 27

teenagers with menorrhagia should be evaluated for primary bleeding disorders such as

Answer 27

von willebrand disease, thrombocytopenic purpura (ITP), platelet dysfunction, and thrombocytopenia from malignancy

Question 28

hypomenorrhea - pts have regularly timed menses but unusually light amt of flow. this is commonly caused by HYPOGONADOTROPIC HYPOGONADISM- which is seen most commonly in anorexic patients and athletes.

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Question 29

atrophic endometrium can also occur in case of Asherman’s syndrome (intrauterine adhesions / synechiae), congenital malformations, infection, and intrauterine trauma

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Question 30

patients on OCP, depo provera, and progestin IUD also have atrophic endometrium and often have light menses as do women who have undergone endometrial ablation

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Question 31

metrorrhagia - bleeding between reuglar menstrual periods. this bleeding is usually less than or equal to normal menstrual volume. Primary causes:

Answer 31

cervical lesions (polyp, eversion, and carinoma and endometrial polyps and carcinoma)

Question 32

oligomenorrhea periods greater than 35 days apart

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Question 33

most common causes of oligomenorrhea are PCOS, chronic anovulation, and pregnancy. thyroid disease should also be considered. when t has no period for 6 months, SECONDARY AMENORRHEA is diagnosed

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Question 34

polymenorrhea - frequent periods, regular periods that occur less than 21 days apart. this is usually caused by anovulation

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Question 35

evaluation of abnormal uterine bleeding. look for PCOS sequelae - hirsutism, acne, truncal obesity, acanthosis nigricans
thyroid disease (thyromegaly, skin changes, diaphoresis, increased pulse
signs of bleeding disorder (brusing, petechiae).
bimanual exam reveal uterine or adnexal masses, consistent with fibroids, adenomyosis, pregnancy, or cancer.
pap smear used to screen for cervical dysplasia and cancer
cervical cultures taken to rule out infection

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Question 36

bloodwork:
for light / skipped cycles, evaluation would include: pregnancy test, TSH, PRL, and FSH IF menopause of ovarian failure suspected

for heavy , frequent, or prolonged cycles, appropriate laboratory tests would include pregnancy test, TSH, and CBC

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Question 37

obese patients with prolonged oligomenorrhea should undergo endometrial biopsy even if they are younger than 45. these women are at increased risk of endometrial hyperplasia and cancer due to the peripheral conversion of androgens into estrogens in their adipose cells.

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Question 38

treatment of uterine fibroid with heavy bleeding

Answer 38

hormonal , tranexamic acid 650mg tabs (normal renal function with serum
CR <1.4 1300mg (two tabs) three times daily.
CR >1.4-2.8mg/dl: 1300 (two tabs) twice daily
CR >5.7mg/dl: 650mg once daily

uterine artery embolization, myomectomy, endometrial ablation, hysterectomy

Question 39

adenomyosis with heavy bleeding

Answer 39

hormonal management,
MIRENA iud,
endometrial ablation,
hysterectomy

Question 40

cervial polyps with light bleeding

Answer 40

polypectomy

Question 41

endometrial polyps with heavy bleeding

Answer 41

hysteroscopy polypectomy with d&c, endometrial ablation, hysterectomy

Question 42

endometrial hyperplasia

Answer 42

progestin therapy (if no atypia)
d&c
hysterectomy if ATYPIA is present

Question 43

endometrial cancer with heavy bleeding

Answer 43

hysterectomy, bso, radiation

Question 44

hormonal problem, hyperprolactinemia (no bleeding)

Answer 44

treatment: dopamine agonist - bromocriptine (parlodel) 2.5mg tabs take with food. may increase every 2-7days by 2.5mg/day

Question 45

anovulation

Answer 45

combined estrogen/progestin pills, patch or ring, or cyclic progestin

Question 46

dysfunctional uterine bleedinga; most patients with DUB are anovulatory. in these instances, ovary produces estrogen but no corpus luteum is formed, and thus no progesterone is produced. subsequently there is continuous estrogenic stimulation of the endometrium without the usual progesterone-induced bleeding. Instead, in DUB, the endometrium continues to proliferate until it outgrows its blood supply, breaks down, and sloughs off in an irregular fashion. DUB is most likely to occur with anovulatory cycles and thus is most common during times in a woman’s life when she is most likely to be anovulatory such as adolescence, perimenopause, lactation, and pregnancy

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Question 47

pathologic anovulation occurs in hypothyroidism, hyperprolactinemia, hyperandrogenism, and POI/PMOF

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Question 48

diagnosis of dub is made by r/o other causes of abnormal bleeding. in adolescence, risk of structural causes of abnormal bleeding disorder is small. however, any congenital anomalies and bleeding disorders should be eliminated. in the reproductive years, there is an increase risk of strutural and hormonal etiologies for abnormal bleeding. during perimenopause, risk of DUB increases, but so does the risk of other causes of abnormal bleeding including fibroids, polyps, adenomyosis, ,and endometrial hyperplasia and cancer

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Question 49

any woman 45 years and older with abnormal uterine bleeding should undergo an endometrial biopsy to rule out endometrial hyperplasia and cancer

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Question 50

midluteal, day 21-23 serum progesterone level may also indicate if a patient is ovulating. an endometrial biopsy showing decidualized or luteal phase endometrium, is evidence of ovulation and progesterone effect upon the endometrium

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Question 51

treatment of acute hemorrhage in DUB

Answer 51

intravenous estrogen (25mg conjugated estrogen every 4hours up to 24hours provides a quick response, but also carries an increased risk of venous thromboembolic events (dvt, PE)

Question 52

treatment of hemodynamically stable pts in DUB

Answer 52

high-dose oral estrogens can control the bleeding within 24-48 hours. typical dosing might be
2.5mg every 4 hours for 14-21days followed by medroxyprogesterone acetate 10mg per day for 7-10days

ocp taper can also be used for endoemtrial stabilization. typical taper would use a monophasic pill containing 35mcg ethinyl estradiol given three times a day for 3 days, then two times a day for 2 days, then daily for the remainder of the pack.

Question 53

for chronic DUB

Answer 53

nonhormonal therapy with NSAIDS (800mg ibuprofen TID X 5 DAYS has been shown to decrease menstrual blood loss by 20-50%. this therapy may be used in conjunction with estrogen and progesterone therapy

Question 54

menstrual regulation using hormonal therapy is primary treatment for anovulatory DUB. this can include use of combination estrogen and progesterone in form of oral contraceptive pills, ortho evra patch, or nuvaring. may be dosed in a continuous(preferred) or cyclic fashion depending on patient’s desire

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Question 55

in patients whom use of estrogen is contraindicated (hypertension, thrombophilias, history of DVT or PE and those 35 and older who smoke) or those who prefer an alternative to estrogen/progestin combination , similar cycle control can be achieved using progestin-only options. such as

Answer 55

10mg medroxyprogesterone acetate qd x 10days
depo provera
mirena
implanon
last 3 likely to result in light menses / amenorrhea over time.

Mirena IUD particularly is helpful in anovulatory and ovulatory pts with menorrhagia including those who are at increased risk for developing endometrial hyperplasia/cancer

Question 56

the most common cause of postmenopausal bleeding is

Answer 56

endometrial and/or vulvar atrophy, no tcancer.

Question 57

nonegynecologic causes of postmenopausal bleeding: rectal bleeding from hemorrhoids, anal fissures, rectal prolapse, and lower gastrointestinal tumors.

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Question 58

vaginal atrophy is due to lack of endogenous estrogen is the most common source of lower genital tract postmenopausal bleeding.

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Question 59

pathologic causes of PMB from upper genital tract include

Answer 59

endometrial atrophy, endometrial polyps, endometrial hyperplasia, and endometrial cancer.

Question 60

use of exogenous hormones is another common cause of PMB

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Question 61

it is possible to find endometrial hyperplasia or cancer in the base of an otherwise benign-appearing endoemtrial polyp

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Question 62

the addition of exogenous estrogens is contraindicated in any woman with unexplained vaginal bleeding. urogenital atrophy is not an indication for systemic HRT

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Question 63

following polypectomy, pt would likely benefit from low-dose vaginal estrogen to treat her atrophy

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Question 64

diagnosis of pms relies upon demonstrating symptoms worsen in the luteal phase (1-2 weeks prior to onset of menses), and resolve completely with the start/shortly following onset of menses

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Question 65

ssri such as prozac, paxil, celexa, and zoloft, effective for treating both physical as well as mood symptoms associated with PMS. Prozac is FDA approved for this use.

Older studies do not show OCPS to be effective in treating PMS symptoms. however, newer formulations using progestin drospirenone ( a spironolactone with antimineralocorticoid and antiandrogenic activity ) and a 4 day rather than 7 day pill free interal has been shown to be effective in treatment of pMS

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Question 66

if pt having symptoms throughout the cycle and no longer appears to have complete resolution of symptoms following onset of a period, consider underlying mood disorder such as depression

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Question 67

medications in SSRI category are effective in treatment of mood disorders, to treat mood disorders, they must be given on a daily basis and not limited to the luteal phase as it is often done in treatment of PMS

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Question 68

prozac used for PMS/PMDD take menstrual cycle day 7-10 . 10mg which is normal dose for anxiety/depression is too high for PMS/pMDD

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Question 69

common cause of amenorrhea in young women is HYPOTHALAMIC HYPOGONADISM - frequently in athleteswho engage in vigorous dialy exercise as well as in women with eating disorders including anorexia and bulimia. inquiring about her daily exercise and diet is the most correct answer in this situation

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Question 70

post pill amenorrhea can last up to ___ after discontinuation

Answer 70

6 months

Question 71

most common etiologies for anovulation include PCOS, pregnancy, hypo or hyperthyroidism, and hyperprolactinemia.

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Question 72

17-OH progesterone, DHEAS, and testosterone are used to look for causes of hirsutism

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Question 73

ultrasound an be used in supporting dx of PCOS by identifying multiple immature ovarian follicles “string of pearls”

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Question 74

in women with PCOS, chronic anovulation often results in oligomenorrhea / amenorrhea with occasional, irregular episodes of bleeding that can be heavy and prolonged. prolonged stimulation of endometrium by estrogen without regular exposure to progesterone ( at ovulation) can lead to endometrial hyperplasia as well as endometrial cancer.

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Question 75

metformin 500mg once daily, increase to 500mg BID after 1 week, then increase to 500mg TID after another week.
most effective dose for PCOS is 500mg TID. take with meals

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Question 76

the use of intermittent progestins adminstered for 12-14days per month to induce regular bleeding and protect the endometrium from hyperplasia and cancer

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