Dunn: Amenorrhea, etc. Flashcards

Question

Treatment of PCOS: desired pregnancy

Answer 1

Evaluate for other causes Clomiphene (risk of ovarian hyper stimulation) Second line can use purified human FSH

Answer 2

Ectopic endometrium i.e. “internal menstruation” Requires laparoscopy +/- biopsy for diagnosis Activity is more important than appearance Symptoms do not always correlate with grading

Answer 3

The Classic Triad… Dysmenorrhoea Dyspareunia Infertility But consider also… ``` Pre menstrual staining Pain with defaecation during menstruation Intermenstrual pain Disordered cycles Family history ```

Answer 4

``` A Careful History (The most important) Rule out other Causes of Symptoms (The next most important) Examination (not much help) Ultrasound (of little value) MRI (useful for rectovaginal deposits) Laparoscopy (The gold standard) Serum CA125 (Lacks sensitivity) Iridology (a good guess!) ```

Answer 5

Primary Dysmenorrhoea Irritable Bowel Syndrome Ovulation Pain Pelvic Inflammatory Disease Psychosexual Problems

Answer 6

Two Main Theories: Retrograde menstruation Peritoneal metaplasia ``` Predisposing Factors: Familial predisposition Disordered immunity Environmental toxins Recurrent ovulation Infertile partner Obstructed menstrual flow ```

Answer 7

When the Problem is Pain – Use Medical Rx When the Problem is Infertility – Use Surgical Rx When there is no Problem – Use no Rx

Answer 8

Progestins COC (best in continuous form) Provera or Norethisterone The Mirena IUS Danazol & Gestrinone GnRH agonists +/- Add Back Therapy A question of side effects

Answer 9

Oral & rectal Chinese Herbal Medicine better than Danazol in both pain reduction and shrinkage of masses Auricular acupunture effective in pain relief Inconclusive evidence that NSAIDs are any better than pacebo But side effects certainly can occur COC as effective as GnRHa in control of dysmenorrhoea 6m after therapy but GNRHa better in terms of dyspareunia Oral Provera 100 mg daily more effective than placebo (but not Dyhydrogesterone). IM route no better GnRHa are no more effective than Danazol and side effects are more frequent Laparoscopy with diathermy is more effective than just laparoscopy For up to 12m after for pain For conception (OR 1.66, CI 1.09-2.51) There is no advantage from pre operative medical Rx but one small trial showed less pain if a Mirena is provided after surgery (OR 0.14, CI 0.02-0.75) There is a risk of symptom recurrence if HRT with E2 is used after pelvic clearance

Answer 10

After 12 months of regular sex without contraception... 85 – 90% of couples will achieve pregnancy Another 5% will be pregnant in the next 12 months The age of the woman has a major influence most “infertility” is really subfertility Or failing to conceive when the couple expect to They expect to “switch on” fertility in the same way that contraception switches it off

Answer 11

``` Ovulation problem Sperm Problem Tubal problem Cervical factor Endometriosis ```

Answer 12

Do not ask “How long have you been trying to get pregnant” Ask instead: “How long have you been in your current relationship” What methods of contraception or avoiding pregnancy have you used and… When did you stop using it? Have you ever been pregnant? Or tried in any previous relationship? Have you ever fathered a pregnancy before (or tried in any other relationship). Has that person subsequently proven fertile (become pregnant or fathered a pregnancy) in any subsequent relationship(s)?

Answer 13

Have you ever been treated for inflammation of the pelvis or tubes? Chlamydia? A sexually transmitted infection? Genital Herpes? Wart virus? Pre-cancer of the cervix? Do you know if any of your partners have been treated or suffered from any of these conditions? Have you ever used an intra uterine contraceptive device? When you say your periods are “irregular” does that mean that they are coming more or less often than once in each four weeks? How much earlier? How much later? Most patients with “regular” cycles will be ovulating normally How often is intercourse occurring? This is better than... How often are you trying each month! Do either of you have any problems? Coital problems are rarely a cause of infertility But impotence is a common problem in older males Who may have some difficulty admitting to this problem

Answer 14

A basal body temperature chart (BBT) - Accurate body temperature measured once daily after >8 hours at rest - Progesterone (released only after ovulation) raises BBT by 0.3 – 0.50C S Progesterone luteal phase of the cycle - Preferably 7 days before menstruation LH surge in urine - False positives can occur Endometrial biopsy 2nd half of the cycle - Look for secretory changes on histology

Answer 15

Hysterosalpingogram - Passage of radio-opaque dye from the cervix with pressure and fluoroscopy or still images Laparoscopy with dye studies - The best test because it involves direct observation - And the only way of diagnosing endometriosis All of these tests have potential for therapy if there is minor tubal obstruction - And diathermy of minimal endometriosis reduces “reproductive toxins”

Answer 16

Requires careful cycle timing Because it has to be done when the cervical mucous is receptive This is Day 12 or 13 in a 28 day cycle Take a sample of the mucous 4 – 20 hours after intercourse... And examine microscopically for evidence of progressively motile sperm This is a good backup test for men who cannot or will not produce a semen sample

Answer 17

Requires 48 – 72 hours of abstinence Must collect the whole semen sample Must be examined within 1-2 hours kept at room temperature Count - Should be > 20 million/ml Motility - Should be >50% Morphology - Should be >15% completely normal If abnormal it should be repeated