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Block I: Reproduction & Sexuality > Clinical: Menstruation and ART > Flashcards

Clinical: Menstruation and ART Flashcards

1
Q

Define the follicular phase

A

Begins with the onset of menses and ends on the day of the luteinizing hormone (LH) surge

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2
Q

Hormone levels in late luteal phase

A

Withdrawal of estrogen and progesterone

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3
Q

Phase in which the ovary is least hormonally active

A

Early follicular phase (low serum estradiol and progesterone)

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4
Q

GnRH and FSH levels during the early follicular phase

A

Release from negative feedback effects of estrogen and progesterone = increased GnRH pulse frequency –> 30% increase in serum [FSH]

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5
Q

Number of primordial follicles stimulated by FSH release from pituitary during the follicular phase

A

5 - 15

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6
Q

When is a single dominant follicle selected?

A

By late follicular phase

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7
Q

Describe the 2-cell process by which the developing dominant follicle produces estrogen

A
  • Theca interna cells produce androstenedione in response to LH stimulation
  • Granulosa cells conert androstenedione –> estradiol when stimulated by FSH
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8
Q

Effects of estrogen on the uterine lining during the follicular phase

A

Thicken/proliferate

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9
Q

GnRH and LH levels during the follicular phase

A

GnRH pulse frequency increases –> rise in LH

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10
Q

Effect of raised LH levels during the follicular phase

A

Stimulation of androgen synthesis –> androgens converted to estrogens

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11
Q

Peak of serum estradiol concentrations

A

Approx 1 day before ovulation

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12
Q

Midcycle LH levels (~day 14)

A

LH spike in response to estrogen surge

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13
Q

Why does ovulation occur?

A

Increase in LH level causes the follicle to rupture and release mature ovum

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14
Q

Describe the effect of rising estradiol levels at the end of the follicular phase on LH concentration

A

10-fold increase (positive feedback switch from negative feedback; poorly-understood phenomenon)

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15
Q

When does the oocyte in the dominant follicle complete the 1st meiotic division

A

In response to the LH surge

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16
Q

When is the oocyte released from follicle at ovarian surface?

A

~36 hours after LH surge

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17
Q

Even before the oocyte is released, what do the granulosa

A
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18
Q

When does the luteal phase begin?

A

After ovulation

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19
Q

What does the remnants of the follicle become after ovulation

A

Corpus luteum

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20
Q

Time it takes for the ovum to travel down the tube to the uterus

A

3 -4 days

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21
Q

When must fertilization occur and what is the consequence of it not occuring?

A

Must occur within 24 hours of ovulation or ovum degenerates

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22
Q

What forms the corpus luteum cyst and when

A

Granulosa and theca interna cells lining the wall of the follicle after ovulation

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23
Q

Function of corpus luteum

A

Synthesize estrogen and large amounts of progesterone

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24
Q

Effect of progesterone on endometrium

A

Stimulate endometrium to become more glandular/secretory in preparation for implantation of fertilized ovum

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25
Q

Substance synthesized by trophoblast if fertilization occurs

A

Human chorionic gonadotropin (hcg)

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26
Q

Function of HCG

A

Maintain the corpus luteum so it may continue producing estrogen and progesterone to support the endometrium

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27
Q

When is the placenta developed and what function does it take over?

A

8-10 weeks gestation

Takes over production of estrogen and progesterone

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28
Q

8 events occuring in the luteal phase if fertilization does not occur

A
  • Corpus luteum is not maintained by HCG
  • Corpus luteum degenerates after ~14 days
  • Estrogen and progesterone levels fall
  • Increased prostaglandins and leucocytes in endometrium
  • Constriction of spiral arteries
  • Desquamation and ischemia of endometrium
  • Arteriolar relaxation, bleeding and tissue breakdown
  • FSH levels slowly rise again in absence of negative feedback
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29
Q

2 types of dysfunctional uterine bleeding (DUB)

A

Anovulatory

Ovulatory

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30
Q

4 types of organic disease linked to abnorma uterine bleeding

A
  • Systemic
  • Reproductive disease
  • Pregnancy-related
  • Iatrogenic
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31
Q

6 common terminologies for abnormal uterine bleeding

A
  • Menorrhagia
  • Metrorrhagia
  • Menometorrhagia
  • Hypermenorrhea
  • Polymenorrhea
  • Oligomenorrhea
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32
Q

Bleeding cycle of menorrhagia

A

Regular cycles, prolonged duration, excessive flow

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33
Q

Bleeding pattern of metrorrhagia

A

Irregular cycles

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34
Q

Bleeding pattern of menometorrhagia

A

Irregular, prolonged, excessive

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35
Q

Bleeding pattern of hypermenorrhea

A

Regular, normal duration, excessive flow

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36
Q

Bleeding pattern of polymenorrhea

A

Frequent cycles

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37
Q

Bleeding pattern of oligomenorrhea

A

Infrequent cycles

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38
Q

When can anovulatory bleeding occur?

A

First year after menarche

Perimenopause

39
Q

6 conditions where anovulatory bleeding can occur

A
  • Polycystic Ovary Syndrome (15% all women)
  • Adult-onset Congenital Adrenal Hyperplasia
  • Androgen producing tumors
  • Hypothalamic dysfunction
  • Hyperprolactinemia
  • Pituitary disease
40
Q

Typical bleeding pattern of anovulatory bleeding

A

Irregular, heavy, and-or prolonged

41
Q

4 identifiable causes of abnormal ovulatory bleeding

A
  • Fibroids
  • Adenomyosis
  • Polyps
  • Infection
42
Q

5 risk factors for fibroids

A
  • Nulliparity
  • Obesity
  • Fam Hx
  • HTN
  • African-American
43
Q

Bleeding pattern associated with fibroids

A

Heavier periods

44
Q

Define adenomyosis

A

Endometrial glands within the myometrium

45
Q

Symptoms and bleeding patterns of adenomyosis

A
  • Usually asymptomatic (symptoms usually occur after age 35- 45)
  • Potential heavy or prolonged bleeding
  • Often dysmenorrhea (painful periods) up to one week before menstruation
46
Q

3 bleeding patterns of endometrial polyps

A
  • Intermenstrual bleeding
  • Irregular bleeding
  • Menorrhagia
47
Q

2 bleeding patterns of cervical polyps

A
  • Intermenstrual spotting
  • Postcoital spotting
48
Q

3 infectious causes of abnormal uterine bleeding

A
  • Pelvic Inflammatory Disease (PID)
  • Chronic endometritis
  • Endocervicitis
49
Q

3 usual symptoms of PID

A
  • Fever
  • Discomfort
  • Adnexal tenderness

NOTE: Can present atypically

50
Q

2 bleeding patterns associated with PID

A

Menorrhagia or metrorrhagia

51
Q

When does PID most commonly occur?

A

During menstruation and with bacterial vaginosis

52
Q

3 reasons why oral contraceptice pills may cause contraceptive bleeding

A
  • Lower dose contraceptives
  • Skipped pills
  • Altered absorption/metabolism (i.e. upset GI)
53
Q

3 causes of contraceptive bleeding

A
  • Oral Contraceptive Pills
  • Intra-uterine device (IUD)
  • Depo Provera
54
Q

5 prescriptions medications that may cause abnormal uterine bleeding

A
  • Anticoagulants
  • SSRI’s
  • Antipsychotics
  • Corticosteroids
  • Tamoxifen
55
Q

4 OTC medications that may cause abnormal uterine bleeding

A
  • Soy supplements
  • Gingkgo
  • Ginseng
  • St. John’s Wort
56
Q

Why might ginseng cause abnormal uterine bleeding?

A

Estrogenic properties

57
Q

Why might St. John’s Wort cause abnormal uterine bleeding

A

Interaction with oral contraceptive –> breakthrough bleeding

58
Q

2 endocrine abnormalities that may cause abnormal uterine bleeding

A
  • Hyperthyroidism
  • Hypothyroidism
59
Q

4 bleeding patterns associated with hyperthyroidism

A
  • Amenorrhea
  • Oligomenorrhea (most common)
  • Hypermenorrhea
  • Polymenorrhea
60
Q

4 bleeding patterns associated with hypothyroidism

A
  • Amenorrhea
  • Oligomenorrhea
  • Polymenorrhea
  • Menorrhagia

NOTE: Occurs more frequently with severe hypothyroidism

61
Q

Two most common bleeding disorders that may cause abnormal uterine bleeding

A
  • Von Willebrand’s disease
  • Thrombocytopenia
62
Q

First step of homeostasis during menstruation

A

Formation of a platelet plug

63
Q

When may abnormal uterine bleeding due to a bleeding disorder may be particularly severe and why

A

At menarche due to the dominant estrogen stimulation causing increased vascularity

64
Q

5 lab studies for abnormal uterine bleeding

A
  • CBC
  • Urine or serum pregnancy test
  • TSH
  • PT, PTT, and bleeding time
  • PCOS/adult-onset CAH investigations
65
Q

5 substance levels tested for PCOS/Adult-onset CAH

A
  • LH
  • FSH
  • Testosterone
  • Androstenedione
  • Basal 17-hydroxyprogesterone (17-HP)
66
Q

3 things to evaluate in ultrasound to investigate abnormal uterine bleeding

A
  • Ovaries for PCOS
  • Fibroids
  • Endometrial stripe
67
Q

Define PMS

A

Recurrent psychological or physical symptoms during the luteal phase of menstrual cycle, resolves by the end of menstruation, and **interferes **with some aspect of function

68
Q

Define Premenstrual Dysphoric DIsorder (PMDD)

A

More severe form of PMS meeting DSM-IV criteria

69
Q

4 general UCSD criteria for diagnosing PMS

A
  • >1 somatic and affective symptom 5 days prior to menses x 3 cycles
  • Resolve within 4 days onset of menses and symptom free until day 12 of cycle
  • Not due to meds, drugs, or EtOH use
  • Causes dysfunction
70
Q

6 somatic symptoms that can be used to diagnose PMS

A
  • Depression
  • Anger
  • Irritability
  • Confusion
  • Social withdrawal
  • Fatigue
71
Q

4 affective symptoms that can be used to diagnose PMS

A
  • Breast tenderness
  • Bloating
  • Headache
  • Swelling
72
Q

5 DSM-IV criteria to diagnose PMDD

A
  • >5 symptoms of PMS 1 week prior to and resolve during menses
  • >1 psychological symptom x 1 year during most cycles
  • Interferes with social, occupation, sexual or school functioning
  • symptoms discretely related to menstrual cycle and not a worsening of a psychiatric or medication condition
  • Documented symptoms meeting criteria for at least 3 cycles
73
Q

4 psychological symptoms that can be used to diagnose PMDD

A
  • Depressed mood
  • Increased sensitivity
  • Anxiety
  • Irritability
74
Q

7 differential diagnoses for PMS

A

Menstrual exacerbation of

  • Psychiatric disorder
  • Medical condition:
    • Dysmenorrhea
    • Hyper- or hypo- thyroidism
    • Peri-menopause
    • Migraine
    • Chronic fatigue syndrome
    • Irritable bowel syndrome
75
Q

4 prescriptions for mild to moderate PMS with at least some evidence

A
  • Vit B6 during luteal phase
  • Calcium
  • Evening primrose oil
  • Magnesium
76
Q

7 Rx of mild to moderate PMS with unknown benefits

A
  • Exercise
  • Relaxation
  • Chiropractic manipulation
  • CBT
  • Light therapy
  • Eliminating caffeine
  • Reducing sugar and salt
77
Q

Beneficial treatment for moderate to severe PMs

A

Spirolactone 500-200 mg OD during luteal phase

78
Q

Contraindication for spirolactone as treatment for PMS

79
Q

6 treatments for moderate to severe PMS that are likely beneficial

A
  • Alprazolam 0.25-1 mg TID in luteal phase
  • Buspirone 5 - 10 mg TID
  • GnRH analogues
  • Metolazone
  • NSAIDs in luteal phase
  • OCP
80
Q

3 PMS symptoms improved by spirolactone

A
  • Breast tenderness
  • Weight gain
  • Mood
81
Q

Risk of using alprazolam as PMS treatment

A

Dependence

82
Q

Benefit of buspirone

A

Global symptoms improvement

83
Q

When is GnRH analogue considered as treatment for PMS

A

Patients not responding to other therapies (short term Rx only)

84
Q

5 disadvantages of using GnRH analogues as treatment for PMS

A
  • 11% bone loss with continuous treatment (should not exceed 6 months without add-back hormone therapy)
  • Hot flashes
  • Nausea
  • Night sweats
  • Headaches
85
Q

Advantage of using GnRH analogue as treatment for PMS

A

Given in luteal phase = improved breast tenderness

86
Q

3 benefits of Metolazone as treatment for PMS

A

Improved

  • Weight gain
  • Mood
  • Swelling
87
Q

3 improved PMs symptoms by OCP

A
  • Acne
  • Appetite
  • Food cravings
88
Q

4 treatments for PMS that have a trade-off between benefit and harm

A
  • Clompramine
  • Danazol 200 mg OD
  • SSRI’s
  • Progesterone
89
Q

Benefits/harm of clompramine as PMS treatment

A
  • Benefit = improve psychological symptoms only
  • Harm = significant drowsiness, nausea, vertigo, headache
90
Q

Benefits/harm of danazol 200 mg as treatment for PMS

A

Effective but masculinization

91
Q

Benefits/harm of SSRI’s as treatment for PMS

A

Effective but may increase risk of suicide (warnings about use in children and adolescents)

92
Q

5 potential adverse effects of progesterone as treatment for PMS

A
  • Bleeding
  • Dysmenorrhea
  • Abdo pain
  • Nausea
  • Headache
93
Q

4 lab tests for PMS

A
  • CBC
  • -lytes
  • TSH
  • +/- menopause workup

Block I: Reproduction & Sexuality (23 decks)

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