Dunn: prolapse, bleeding, menopause Flashcards

Question

Atrophic Endometrium

Answer 1

Hypoestrogen causes atrophy of the endometrium and vagina results in microerosions which is prone to light bleeding or spotting Classic vaginal findings: pale, dry vaginal epithelium that is smooth and shiny with loss of most rugation

Answer 2

Proliferation of endometrial glands resulting in greater gland-to-stroma ratio than observed in normal endometrium Postmenopausal women should be estrogen deficient, so endometrial hyperplasia is abnormal and requires an explanation Endogenous estrogen production from ovarian or adrenal tumors or exogenous estrogen therapy are possible causes Obese women have high levels of endogenous estrogen due to the conversion of androgens to estradiol, which occur in peripheral adipose tissue Classification - Simple or complex hyperplasia without atypia - Simple or complex hyperplasia with atypia

Answer 3

Approx 5-10% of PMB is endometrial cancer Incidence increases with age Adenocarcinoma of the endometrium is the most common genital cancer in women over 45 years of age

Answer 4

Exclusion of cancer is the main objective; therefore, treatment is usually unnecessary once cancer) or premalignant histology) has been excluded Atrophy - Vaginal estrogen therapy Endometrial polyp - Polypectomy Endometrial hyperplasia - Cyclic progestin therapy Endometrial hyperplasia with atypia - Hysterectomy Carcinoma of endometrium - Hysterectomy with BSO and LND for staging

Answer 5

Perimenopause – time leading up to menopause -0 the time when ovarian function and hormone production are declining but have not yet stopped Menopause: a permanent cessation of the menstrual cycle Greek “meno” (month) and “pausis” (a pause) Defined as not having a period for 12 months Post menopause: time in woman’s life after last period Premature menopause: menopause occurring before age 40

Answer 6

Vasomotor symptoms- hot flshes Sleep quality Mood changes Urogenital symptoms Sexual well-being Skin changes

Answer 7

``` Menopause signifies old age Women go crazy at menopause A woman’s sex life is over at menopause Menopause always causes weight gain Menopause is a medical condition that always needs to be treated ```

Answer 8

``` Well Established: Vasomotor Symptoms Urogenital Disorders CHD Risk Factor (Lipids) Skin Changes ``` Association: Cardiovascular Disease Bone Loss/Osteoporosis

Answer 9

``` Irregular periods Premenstrual syndrome (PMS) ```

Answer 10

``` Decrease in mood Diminished energy Impaired sexuality Muscle weakness Osteopenia ```

Answer 11

It is known with good certainty that HT does not increase CHD risk in women who initiate therapy close to the onset of menopause( within-5 years of last menses) HT does not prevent and may increase the risk of CHD in women who initiate therapy years after menopause VTE is an infrequent but well established risk of HT Risk increases approximately 2-fold with HT use Greatest risk occurs in the first year of use Absolute risk remains low in HT users due to the low baseline incidence of VTE in the general, non-hospitalized population

Answer 12

Coronary Heart Disease Osteoporosis Breast Cancer (?) Colon Cancer (?) Dementia (?)

Answer 13

Age at initiation of HT determines cardiovascular risk is confirmed Initially thought to increase risk However, 18.3% of never-users vs 6.9% of HT users died during follow-up Starting early equals the most benefit. JAMA 2007: Women who initiated hormone therapy closer to menopause tended to have reduced CHD risk compared with the increase in CHD risk among women starting HRT more distant from menopause.

Answer 14

Critical window! Estrogen protects against dementia when taken early in peri-menopause or early in menopause. In contrast to WHI – (mean age of initiation was 63)

Answer 15

A WHI analysis confirms a small risk of breast cancer mortality with estrogen-progestin HT E/P hazard risk was 1.26 in WHI Now, after follow up for 11 years, combination HT users have similar risk vs. nonusers Tumors more likely node +

Answer 16

Estrogen only HT has different risk for breast cancer than E/P HT. Estrogen only HT decreases risk in all age groups, but benefits younger women more. (Young = 60 years or less and within 10 years of menopause onset)

Answer 17

E3N student has shown no increased risk of VTE Risk of CVA similar to non-users And in fact, decreased

Answer 18

The authors believe evidence will eventually point to a superior safety profile for transdermal estrogen vs oral Offer estradiol gel or spray if patch causes irritation (should have same safety profile) Micronized progesterone appears safer when progesterone is required

Answer 19

``` For mild vasomotor symptoms Lifestyle changes (limited efficacy) Nonprescription remedies—tested only short term with little efficacy over placebo but no evidence of harm Dietary isoflavones Black cohosh Vitamin E ```

Answer 20

``` Hormone therapy is the only FDA-approved treatment “gold standard” SSRIs and gabapentin early studies show efficacy women studied have fewer hot flashes than those in HT trials Progestogens effective however, large doses required Clonidine (oral or transdermal) ```

Answer 21

FDA 20031 Recommends shortest duration and lowest dose consistent with treatment goals ACOG 20042 The lowest effective estrogen dose should be used for the shortest possible time to alleviate symptoms NAMS 20043 Recommends duration and dose consistent with treatment goals

Answer 22

Hormone therapy remains an effective therapy for treating women with vasomotor symptoms and vaginal atrophy. The benefits and risks should be discussed in detail with each patient before initiating therapy and when renewing her annual prescription so that she can make the best decision for her own health.”

Answer 23

For women who need or prefer an alternative to HT, data support the use of bisphosphonates or SERMs In women with menopausal symptoms, HT may be appropriate as a first choice of therapy All women should be advised to have adequate intake of vitamin D and calcium intake of at least 1,000–1,500 mg/d After discontinuation of HT or bisphosphonates, the effect of HT withdrawal on bone density should be assessed

Answer 24

If normal – HCG should double every 48 hours If abnormal – HCG can stay the same, decrease, or increase minimally

Answer 25

1ST Trimester bleeding(threatened abortion aka threatened miscarriage) Physical Findings – cervical os closed, cardiac activity Transvaginal US – Gestational Sac at 1,500 – 2,000 MIU

Answer 26

Miscarriage Abnormal placental implantation IUGR

Answer 27

Missed abortion Complete abortion Incomplete abortion Molar pregnancy

Answer 28

``` Maternal age Age 20 to 30 years (9 to 17 percent), age 35 years (20 percent), age 40 years (40 percent), and age 45 years (80 percent) Previous spontaneous abortion ? Increasing gravidity Prolonged time to implantation interval Prolonged time to conception Smoking >10 cigarettes per day EtOH Cocaine NSAIDs around time of conception Caffeine Low folate levels Extremes of maternal weight Fever during early pregnancy Unrecognized celiac disease ```

Answer 29

Chromosomal abnormalities 50% of all spontaneous abortions Most commonly due to aneuploidies - 52% autosomal trisomy; 19% monosomal X; 22$ polyploidies - Trisomy 16 is most common, almost always lethal Congenital abnormalities Trauma - Consider chronic villus sampling and amniocentesis

Answer 30

Uterine structural issues - Ex: uterine septum, sub mucosal leiomyoma, intrauterine adhesions Acute maternal infections - Ex: Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus Maternal endocrinopathies - Ex: thyroid dysfunction, Cushing’s syndrome, PCOS Hypercoagulable states: - Ex: SLE, antiphospholipiod syndrome Unexplained

Answer 31

Vaginal bleeding Pelvic pain Absence of fetal movement (rate, as usually before movement is perceived) Incidental finding on US/hand-held Doppler

Answer 32

Hand-held Doppler Pelvic exam - Source and severity of bleeding - Size of uterus Pelvic US - Potential predictors include: abnormal gestational sac, abnormal yolk sac, slow fetal HR, sub chorionic hematoma hCG - Single value is usually not predictive, but may be useful for BL value if dx is initially uncertain Blood type antibody screen - Administer anti-D for Rh(D) negative mothers Serum progesterone >4ng/mL is associated with a nonviable pregnancy

Answer 33

Expectant management if dx in question The criteria for spontaneous abortion on pelvic ultrasound: - A gestational sac >25mm in mean diameter that does not contain a yolk sac or embryo - An embryo with a crown rump length (CRL) >7 mm that does not have cardiac activity --- If gestational sac or embryo are too small for these dimensions, repeat in 1-2 weeks Criteria for the diagnosis of a failed pregnancy based upon lack of development over time: - After a pelvic ultrasound showed a gestational sac without a yolk sac, absence of an embryo with heartbeat in >2 weeks - After a pelvic ultrasound showed a gestational sac with a yolk sac, absence of an embryo with a heartbeat in >11 days

Answer 34

Diagnostic criteria for spontaneous abortion are not met Vaginal bleeding has occurred and the cervical OS is closed First trimester bleeding may be associated with adverse outcomes later in pregnancy - Prognosis is worse when the bleeding is heavy or extends into the second trimester Up to 50% will miscarry Tx: bed rest and expectant management

Answer 35

Symptoms of vaginal bleeding, crampy pelvic pain, and dilated cervix - Products of conception can often be felt or visualized through the internal cervical os - No passage of fetal tissue per os Tx options: - Medical abortion - -- Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual) - Surgical abortion - -- D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis - Expectant management: - -- Majority of expulsions occur in the first two weeks after diagnosis

Answer 36

Vaginal bleeding and/or pain are present, the cervix is dilated, and products of conception are found within the cervical canal on examination After 12 weeks , the membranes often rupture, and the fetus is passed, but significant amounts of placental tissue may be retained, leading to an incomplete abortion Tx options: - Medical abortion - -- Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual) - Surgical abortion - -- D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis - Expectant management: - -- Usually Staph aureus or mixed infections

Answer 37

Products of conception are entirely out of the uterus and cervix Cervix is closed and the uterus is small and well contracted Vaginal bleeding and pain may be mild or may have resolved More common outcome than incomplete >12 weeks gestation Tx: examination of passed tissue to confirm products of conception, transvaginal US to visualize empty uterus, follow hCG levels until zero (should halve within 48-72) hours

Answer 38

Patient with or without symptoms having a closed cervical OS - Women may notice that symptoms associated with early pregnancy such as nausea, breast tenderness, etc. have abated and they do not “feel pregnant” anymore Tx options: - Medical abortion - -- Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual) - Surgical abortion - -- D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis - Expectant management: - -- Majority of expulsions occur first two weeks after diagnosis

Answer 39

``` Previous Ectopic * PID (worst agent is chlamydia) Assisted Reproductive Technology History of peritonitis Smoking Previous Tubal Ligation ``` Note-- IUD does not increase risk

Answer 40

Medical – Methotrexate – Folic acid inhibitor Surgical – Removal of ectopic Removal of tube * future fertility is identical