Final Exam in Health Promotion Flashcards
At what age does the initiation of menstruation (menarche) start?
At ages 12 and 15
Menstrual cycles usually continue until age
45 to 55
What is the most frequent reasons why women visit the clinician?
Changes in menstruation
The normal menstrual cycle is how many days?
21 to 35 days with menstrual flow lasting 3 to 5 days, although a flow as few as 2 days or as many as 7 days is still considered normal
You want to reassure your patient that menstrual cycle that occur during first 1 to 1.5 years after menarche are frequently irregular , why?
due to immaturity of the hypothalamic-pituitary-ovarian axis
Fill the blank. Hypothalamus releases (what?) hormone that stimulates pituitary gland to produce
(which?) hormones?
Hypothalamus releases gonadotropin-releasing hormone (GnRH) and this hormone stimulates the pituitary gland to produce follicle stimulating hormone (FSH) and luteinizing hormone (LH).
What are the two hormones secreted by ovaries?
Estrogen and progesterone at the command of FSH and LH
Which hormone targets the ovaries and results in production of estrogen and progesterone?
FSH
Which hormone targets developing follicle within ovary and responsible for ovulation, corpus luteum formation, and hormone production in the ovaries
LH
Which hormone is responsible for preparing the mammary gland for lactation?
Prolactin (PRL)
What are the three phases of ovarian cycle?
follicular phase
ovulation
luteal phase
What are the 3 phases in endometrial cycle?
proliferative phase
secretory phase
menstruation
What is the negative feedback effect in hormonal feedback system?
GnRH pulses stimulate the release of FSH and LH, as a result ovarian follicles develop and produce estrogen.
As the amount of estrogen in the circulation increases and reaches pituitary gland, it affects the amount of FSH and LH secreted—– this is called negative feedback
What is the positive feedback?
When the estrogen level becomes high enough, the negative feedback of pituitary is reversed and estrogen causes midcycle positive feedback effect on the pituitary which results in a surge of LH and FSH and causes ovulation
Which hormone influences the ruptured follicle to become corpus luteum?
LH-luteinizing hormone
Corpus luteum secretes which hormone?
Progesterone
Does progesterone reduce or increase the frequency of the hypothalamic GnRH pulses?
The presence of progesterone reduces the frequency of the hypothalamic GnRH pulses but the amount of LH released from pituitary is proportionally increased to sustain the corpus luteum and the production of progesterone.
What happens to corpus luteum and progesterone in the absence of pregnancy?
In the absence of pregnancy the corpus luteum degenerates, progesterone levels decline and menstruation occurs
What are the three phases that comprise ovarian cycle?
follicular phase
ovulatory phase
luteal phase
What is the primary role of FSH in follicular phase?
The primary role of FSH is to induce the development of increased receptors on the granulosa cells and thereby stimulate estrogen production
What is the preliminary role of LH in follicular phase?
To stimulate the cell’s production of androgen and that will be converted to estrogen by granulosa layers.
What is the name of the dominant follicle?
Graafian follicle
When does proliferative phase begin?
It begins about the fourth or fifth day of the cycle and usually last approximately 10 days ending with the release of the ovum
What are the three phases of endometrial cycle?
Proliferative, secretory and menstrual
When does secretory phase begin?
Secretory phase begins at ovulation, when it is part of a 28-day cycle it usually lasts from day 15 to day 28
When does menstrual phase begin?
The menstrual phase begins with initiation of menses and lasts 3 to 5 days
What are some health benefits of contraceptives?
Condoms reduce transmission of infectious disease
Risk for endometrial cancer is reduced with combined hormonal contraceptives ( CHC) and DMPA and non-medicated IUCs
Risk reduced for ovarian cancer even in women with BRCA1 and BRCA 2
helps and regulates withdrawal bleeding and dysmenorrhea
menstrual blood loss in menorrhagia reduced with use of CHC
Acne
Perimenopause- positive effect on bone mineral density ( role of estrogen in bone health)
You will educate your pt after femal sterilization to use another method for how long
for first 3 months
Next effective second from top method after sterilization
is depo shot , pill, patch, IUD, diaphragm
Do injections on time
Change diaphragm every time you have intercourse
Next level contraception third from top in the slide is
male condom, female condom used with spermicide, withdrawal method, sponge
Most common form of contraception reported by US females is
sterilization
Female sterilization health benefits
decreses risk of ovarian cancer
Female sterilization health benefits
decreses risk of ovarian cancer
With male-vasectomy, make sure you educate your pt
Make sure other methods of contraception used for first 3 months
What is the top tier of contraceptive
IUCs and implant (expalon?)
Copper T and ParaGard do not have hormone so they can be left for how long?
10 years
Levonogesterol can be inserted any time and health benefits are
Before IUD you want to make sure what tests done?
chlamydia and pap smear
IUD that has 52 mg of progesterone
reduces menorrhagia, heavy bleeding
Most side effect of LARC
Irregular bleeding/spotting
Copper IUC has what side effect?
has cramping
Copper IUC may be used as emergent contraception up to
7 days after intercourse and can be kept up to 10 days
WHO has list of medical problems that can exacerbate when using hormonal contraception, what is one of them?
migraines with aura is a contraceptive and pt can have ischemic stroke
Estrogen has been linked to with what condition
blood clots / stroke
if a woman more than 35 and migraine with aura you can offer what alternative
progestin-only, intrauterine and barrier methods
Patch is less effective in what kind of women
obese
What are independent risk factors for VTE
OBESITY
COC
age
What are the contraceptives for obese women over 35 ?
DMPA
progestin implant
IUC
vasectomy of partner
barrier methods
What is the oral EC for obese women?
ulipristal acetate
What are some medications that may reduce contraceptive efficacy via enzyme induction?
carbamazepine
felbamate
oxcarbazepine
phenobarbital
phenytoin
primidone
topiramate
What are other drugs that interfere with COC hormone levels
rifampin
In what medical condition would you use progestin only COC ?
Systemic lupus erythematosis
What are contraindications to contraceptives?
postpartum < 21 days ( breastfeeding and not breastfeeding
smoker > 35 years > 15 cigarettes a day (COC, patch, ring)
HTN > 160 SYS >100 and with vascular disease (COC,patch, ring)
Past hx of DVT PE DVT/PE and using anticoagulants, known thrombophilia
major surgery with prolonged immunization
previous or current ischemic heart diseae
migraine with aura
systemic lupus eryth
antiphospholipid SYNDROME
AB+
Other contraindications slide 27
distorted uterine cavity
unexplained vaginal bleeding
current breast cancer
active viral hep-s ( COC, patch, ring)
severe cirrhosis ( COC, patch, ring
hepatocellular adenoma
malignant tumor ( COC, patch, ring
cervical or endometrial cancer
postseptic abortion
puerperal sepsis
current PID
gonorrhea, chlamydia, purulent cervicitis
active gestationsl trophoblastic disease
pelvic tuberculosis
pregnancy
When you do first pap smear
Age 21
What is the cause for abnormal cervical cells?
HPV
Most common STI in U.S
HPV
Most commonly reported STI in U.S
Chlamydia
Treatment for genital herpes
1st infectionacyclovir 400 mg tid for 7-10 days
pt comes back month or two later– 400 mg TID for 5 days
pt comes back 3 months later—- acyclovir suppressive therapy 400 mg twice a day for a year
Trichomoniasis treatment
Flagyl 500 mg twice a day for 7 days
Risk factors for chlamydia
multiple sex partners
failure to use barrier methods of contraception
treatment for gonorrhea
Rocephin 500 mg IM once
treatment for chlamydia
doxycycline 100 mg twice a day for 7 days
if allergic then zithromax
PID treatment
rocephin 500 mg im
doxycycline 100 mg bid for 14 days
flagyl 500 mg bid 14 days
classic symptoms of PID
cervical motion tenderness
treatment for syphilis
2.4 million units im one time
phases of syphilis
primary—lesion, chancre
secondary—- rash on palms of hands, soles of feet
tertiary— neurologic deficits like dementia
latent—- untreated asymptomatic syphilis
most common chronic blood borne infection
hepatitis C
leading cause of liver transplants in U.S
hepatitis C
Vaccine preventable hepatits
Hepatitis B
All pregnant women should be screened for ….
at first prenatal visit
HIV
Syphilis
Hepatitis B surface antigen
C. trachomatis
The most common cause of chronic pelvic pain is
endometriosis
Which labs will you order for patients with chronic pelvic pain?
CBC
ESR
Serologic testing for syphilis
Urinalysis and urine culture
Pregnancy testing
Vaginal smears and cultures to rule out infection
Stool guaic to evaluate GI pathology
TSH thyroid stimulating hormone
What tests will you order for imaging for pt with pelvic pain?
US- transvaginal
CT scan
Barium enema
Flexible sigmoidoscopy/ colonoscopy
Pelvic venography
Cystoscopy
Laparoscopy
List two diagnosis that are non gynecological reasons for pelvic pain
diverticulitis
irritable bowel syndrome
can be gastroenteritis
colon cancer
UTI
Renal calculi
pyelonephritis
bladder neoplasm
For 25 and below and sexually active with pelvic pain make sure to screen for —–??
STI
After 2 months with no period pt comes with spotted bleeding, what are your initial steps in treating this pt?
order vaginal pelvic US
and refer to GYN
The milk duct is dilated, what is the term
ectasia is a benign non-cancerous breast condition
For a woman with uterus you as a provider will never give….. what? think of hormone replacement therapy
Unopposed estrogen( without progesterone).
For patients with HTN, Stroke, DVT what are the medications to give instead of hormone therapy
venlafaxine
gabapentin
escitalopram
For woman in menopause at risk for osteoporosis what minerals will you prescribe?
Calcium 1200mg + vitamin D 800 mg
What is the primary reason for menopause?
Aging
Menopause is
Permanent cessation of menses after 1 year with no bleeding
Menopause naturally occur at what age?
51
What is one cause of premature menopause from medical intervention?
Bilateral oophorectomy
chemotherapy
You have pt in your clinic with menopause that occurred before age 40, what are your steps?
Will consult GYN since this person at risk for osteoporosis
What condition puts pt at risk for amenorrhea and what medication can help with it think of diabetes med
PCOS, metformin helps with insulin resistance
What symptoms will pt report with menstrual bleeding changes ?
cycle closer together
cycles long cause ovaries trying to figure out now how to make more estrogen
skipped menstrual period
vaginal dryness
hot flashes
What treatment will you recommend for patients with vaginal dryness, painful intercourse?
regular sexual activity
lubricants
moisturizers
local vaginal estrogen
Patients with vaginal atrophy are at increased risk for STI, true or false
True, so educate your patients on risk of STI because older women may not be as knowledgeable as younger women about the infection risks
Memory/concentration related to menopause, true or false
false, these related to normal aging/ mood/ stress/ life circumstances
What is a serious threat for aging woman?
Osteoporosis associated with lower estrogen
What is a T score for osteoporosis?
T score less than equal negative 2. 5
What are the risk factors for osteoporosis?
low femoral BMD
age 50-90
parent hx of fracture
female sex
current tobacco smoking
weight
long term glucocorticoids use
height
rheumatoid arthritis
alcohol more than 3 units a day
Menopause associated with increased cancer risk, true or false
False
Screen for breast cancer
mammogram every 2 years 50-74 according to USPSTF
Screen for colon cancer
colonoscopy every 10 years
fecal occult blood
sigmoidoscopy
barium enema every 5 years age 50
screen for endometrial cancer
evaluate postmenopausal bleeding
with pelvic US and endometrial biposy
screen for ovarian cancer
no satisfactory screening test but timely evaluation needed if present with bloating, pelvic pain, urinary urgency
Screen for cervical cancer
Pap test every 3 years
(or every 5 years if combined with HPV) after a normal report 3 years in a row for women 50-64
If pt older than or 65 pap test not necessary with 3 or more normal pap in a row, no abnormal pap in past 10 years, or 2 or more negative HPV in past 10 years, is this statement true or false
True
For a patient with uterus, which HR therapy?
estrogen + progesterone therapy
Estrogen+progesterone increases risk of breast cancer true or false
True
Estrogen therapy alone lowers risk of breast cancer true or false,,,
True
What is one question you will ask when doing thorough assessment of the menstrual cycle?
What does a normal menstrual cycle look like for you?
AUB can be a sign of significant potential pathology, what are those?
ectopic pregnancy
endometrial cancer
What is the system PALM-COEIN stand for?
PALM describes objective structural criteria
P-polyp
A- adenomyosis
L- leiomyoma
M-malignancy and hyperplasia
COEIN- describes categories unrelated to structural abnormalities
C-coagulopathy
O-ovulatory disfunction
E- endometrial
I- iatrogenic
N-not otherwise classified
What is defined as chronic AUB?
chronic nongestational AUB in reproductive years as bleeding from uterus that is abnormal in duration, volume, frequency, and/or regularity that has been present for the majority of preceding 6 months
What is defined as AUB?
episode of heavy bleeding that is sufficient quantity to require immediate intervention to minimize or prevent further blood loss
What is intermenstrual bleeding?
bleeding between cyclically regular onset of menses, can be random or cyclic, can occur early, middle, late part of menstrual cycle
What are the seven attributes of the symptom with AUB?
Location
Quality
Quality or Severity
Timing
Setting in which occurs
Remitting or exacerbating factors
Associated manifestation
To assess the location of AUB what question will you ask?
Where is the bleeding coming from?
Does the person have pain?
Where is the pain located?
Where does it radiate?
To assess the quality of AUB what question will you ask?
What is the pain like?
What is the bleeding like?
What is the pattern of bleeding like?
To assess he quantity and severity of AUB what question will you ask?
How severe is the bleeding?
How concerning is the bleeding to the person?
How often do they need to change their pad or tampon?
To assess the timing of AUB what question will you ask?
When did the bleeding start?
How often does it occur?
When does it occur in relation to the menstrual cycle?
How long does the bleeding last?
To assess the setting in which AUB occurs what questions will you ask?
Ask about environmental factors, personal activities,
emotional reactions, other significant life events, such as childbirth, initiation of birth control that may contribute to AUB
Has the person experienced bleeding like this in the past?
How long did it last?
To assess the remitting or exacerbating factors what will you ask?
What makes it better?
What makes it worse?
To assess for associated manifestations in AUB what will you ask?
Have you noticed anything else that accompanies AUB?
There are many potential sources of genital tract bleeding, what are they?
Lower genital tract: vulva, vagina, cervix
Urinary tract
Gastrointestinal tract
What is the most important component of the history-taking process for a person who presents with AUB?
A detailed menstrual history
What is one question will you ask to assess the menstrual history?
When was the first day of your last menstrual period and several previous menstrual periods?
Some other questions to ask in assessing the AUB
How many days does the bleeding continue?
How many days of full bleeding do you have , and have many days of light bleeding or spotting?
Does bleeding occur between menstrual periods?
How heavy is the bleeding?
Does it wake you up from sleep?
Interfere with work activities?
Cause you to soak through tampons or pads at rapid rate?
If bleeding is irregular, how many bleeding episodes have there been in the past 6 to 12 months?
What is the average time from the first day of one bleeding to the next?
In addition to menstrual history make sure to obtain
sexual history for AUB…..
and contraceptives, what are the rationales behind these assessments?
Risk for STI
Risk for pregnancy
Using contraception for menstrual control
Also you want to assess what method of contraception has been used
duration of use
if the method has been used correctly
Taking a thorough contraceptive history in AUB may reveal what?
bleeding is mechanically caused by an intrauterine device (IUD)
related to the use of hormonal contraception such as oral contraceptives or injectable depot medroxyprgesterone acetate (Depo-Provera)
inquire about hormone therapy in postmenopausal women to rule out history of taking unopposed estrogen
Make sure to ask about thyroid disorder and hormone secreting tumors in AUB, what questions will you ask?
Cold intolerance
Fatigue
Hyperactivity
Weight gain or loss
hair loss
changes in breast size
hirsutism
headache
breast discharge
What kind of change on skin do you see in PCOS?
Make sure you look for it when doing physical in AUB
Acanthosis nigricans
Signs and symptoms of hyperprolactinemia are…
you want to make sure you include these areas in your physical exam with AUB
do breast exam and check for galactorrhea—bilateral milky breast discharge
Assess for signs of hyperandrogenism such as….
when evaluating pt with AUB
hirsutism
acne
clitoromegaly
male pattern baldeness
A bimanual exam provides the opportunity to assess for …….
presence of tumors
cervical polyps
ovarian cysts
uterine tenderness
adnexal pain or masses
A speculum exam enables observation of vagina and. cervix for evidence of
infection,
trauma
foreign objects
Observe external genitalia during pelvic exam for signs of
clitoral hypertrophy
pubic hair
bruising
lacerations
lesions
evidence of infection
General lab tests for all types of AUB are
Urine HCG
Serum HCG
CBC if anemia suspected
TSH if hypo/hyperthyroidism suspected
Prolactin if pt reports h/a, galactorrhea, peripheral vision changes
Pap test unless the person younger than 21
Nucleic acid amplification test for gonorrhea, chlamydia if person sexually active
Microscopic wet mount exam of vaginal secretions with normal saline and potassium hydroxide if infection is suspected
Coagulation studies if there is a history of abnormal bleeding, easy bruising, unexplained menorrhagia, include prothrombin time PT and activated partial thrombolastin time APTT
What is the reliable first-line diagnostic tool for AUB?
Transvaginal ultrasonography (TVS)
AUB- P stands for what?
Endocervical polyps— benign growths on the cervix, bleeding occurs after intercourse
Endometrial polyps —- benign growths on the endometrium
AUB- A stand for ?
Adenomyosis, small areas of endometrial tissue within myometrium
AUB-L stand for?
Leiomyoma— known as fibroids in the myometrium— common benign pelvic tumors and leading cause of hysterectomy
AUB- M stand for?
M-malignancy and hyperplasia
AUB- C stand for?
Coagulopathy, one of the most commonly inherited bleeding disorder is von Willebrand disease
AUB-O stand for?
Ovulatory dysfunction
Many causes of AUB-O stem from endocrinopathies including thyroid disorders, PCOS, excessive exercise, extreme mental distress
What are subcategories of AUB-O ………..?
amenorrhea (absence of bleeding)
ovulatory uterine bleeding
anovulatory uterine bleeding
Amenorrhea associated with elevated prolactin level is due to
prolactin inhibition of GnRH
What is the treatment for acute non-life-threatening AUB
estrogen
combines-oral contraceptives
progestin-only therapy
levonorgestrel-releasing IUDs
What is precocious menstruation?
Menarche before age 9
What is the most common cause of amenorrhea?
Ovarian function abnormalities
What is the most reliable measure of ovarian function?
Estrogen production, tests to assess estrogen production include serum estradiol levels, progestogen challenge test, US measurement of endometrial thickness, serum FSH concentration
A random serum estradiol level that is greater 40 pg/ml indicates functioning ovaries, true or false
true
What are the medications that can increase prolactin levels?
antidepressants
opiates
calcium-channel blockers
estrogens
Primary amenorrhea
Absent menarche by 15 years of age
amenorrhea
no bleeding for 90 days
secondary amenorrhea
amenorrhea for 6 months with previous normal menstrual cycle
