Menopause and Abnormal Gynecological Conditions / Osteoporosis and Breast Cancers

Question 1

Hot flashes - Medical terminology

Answer 1

Vasomotor instability

Question 2

Patient with hot flashes, no hx cancer, uterus intact – Tx

Answer 2

• Rx: combined therapy (estrogen + progesterone)

- Prevent uterine hyperplasia; need progesterone to buffer estrogen

Question 3

Progesterone therapy MUST be used in ALL patients with..

Answer 3

• Intact uterus as progesterone protect uterine lining from estrogen effect
• Endometrial hyperplasia and cancer can occur after as little as six months of unopposed estrogen therapy; as a result, a progestin should be added in women who have not had a hysterectomy.
• Women who have undergone hysterectomy should not receive a progestin

Question 4

Patient with hot flashes s/p hysterectomy, no hx cancer – Tx

Answer 4

• Oral vs topical single therapy (estrogen)
• Estrogen is available in many forms: transdermal, oral, topical gels and lotions, intravaginal creams and tablets, and vaginal rings
• All types and routes of estrogen are equally effective for hot flashes, but transdermal preparations are associated with a lower risk of venous thromboembolism and stroke.
• Vaginal symptoms related to menopause = estrogen in a low-dose vaginal cream, tablet or ring is usually a better choice than an oral pill or a skin patch.

Question 5

Patient with hot flashes and hx breast cancer – Tx

Answer 5

• Effexor / Paxil / Prozac / Lexapro / Celexa (SSRI)

- Starting dose of Effexor = 37.5mg (always start low)

Question 6

Tamoxifen SE:

Answer 6

• hot flashes = start SSRI

- Watch out for blood clots!

Question 7

Patient who is 12 months w/out period. On month 13, she gets her period:

Answer 7

• Considered abnormal bleeding after 12 months

- Get transvaginal or pelvic ultrasound r/o pathology

Question 8

Uterine fibroids: Sx + Tx

Answer 8

• Sx: heavy bleeding; bleeding between periods and after intercourse
• Tx: Progesterone only birth control (Mirena)

Procedures:

• Uterine artery ablation (remove blood supply to fibroid)
• Pre-menopausal / women still wants to have children tx = Myomectomy
• Post-menopausal tx = Hysterectomy (does not always remove cervix)

Question 9

Uterine fibroids: Risk factors

Answer 9

• Obesity, diet, early menarche less than 10 years old, African American race

Question 10

Pedunculated fibroids

Answer 10

attached to the uterine wall by a stalk-like growth called a peduncle.

Question 11

Submucosal fibroids

Answer 11

start under the uterine lining (endometrium) and may protrude into the uterine cavity

Question 12

Subserosal fibroids

Answer 12

grows on the outer surface of the uterus, sometimes on a stalk; originate from the myometrium at the serosal surface of the uterus

Question 13

Interstitial (or Intramural) fibroids

Answer 13

grow within the uterine wall; may enlarge sufficiently to distort the uterine cavity or serosal surface.

Question 14

Ovarian cancer Sx + Lab Monitoring

Answer 14

• Sx: Bloating / abdominal pain / bowel pattern changes / weight loss / sometimes no sx!
• Lab: CA-125 (also elevated in fallopian tube cancer but does not have positive endometrial biopsy)

Question 15

Estrogen benefits:

Answer 15

• Prevents osteoporosis (not an on-brand reason to prescribe)
• Tx for vaginal atrophy

Question 16

Vaginal atrophy:

Exam / Sx / Tx

Answer 16

• Exam: vaginal rugae becomes thin, pale (color changes), painful, friable (likely to bleed)
• Libido decreases
• Painful intercourse – OTC water-based or silicone lubricants

Question 17

Post-menopausal pap smear abnormal finding

Answer 17

Endometrial cells

- This would be a normal finding in pre-menopausal pap smear

Question 18

Hormone replacement therapy contraindications:

Answer 18

• Undiagnosed vaginal bleeding
• Known or suspected pregnancy
• Vascular thromboembolic episodes (CVA, MI, DVT, Thrombophlebitis)
• Active liver disease acute or chronic
• Known or suspected cancer of the breast or reproductive tract

Question 19

Estrogen lab levels

Answer 19

Estradiol <30 = Post-menopause

Question 20

Overactive bladder;

Cause + tx

Answer 20

• Involuntary contraction of Detrusor muscle

- Tx: pelvic floor exercises, meds

Question 21

Chronic UTI sx

Answer 21

U/A + STI negative = Interstitial cystitis

Question 22

Normal age range for menopause:

Answer 22

45-55 years old

Question 23

Menstrual change on patient that is using opioids:

Answer 23

Amenorrhea

Question 24

Obesity increases risk of what cancers?

Answer 24

uterine and breast cancer

Question 25

Endometriosis:

Sx + Tx + Dx

Answer 25

• Painful menstruation, tender on exam, bluish nodules in vagina, cervix displacement
• Tx: progesterone oral birth control (have better control vs IUD, shot, arm implant)
• Definitive dx: laparoscopy

Question 26

Most common benign finding on cervix

Answer 26

Polyps

Question 27

PCOS – functional ovarian cysts;

Sx + Monitor

Answer 27

• Most common sx: Pain with ovulation
• Bleeding in between period; tender and enlarged on bi-manual exam
• Test to make sure ovarian cyst is benign = transvaginal or pelvic ultrasound

Question 28

Premenopausal abnormal uterine bleeding:

Lab monitoring

Answer 28

Labs = TSH, CBC, iron panel, pregnancy/HCG

Question 29

Premenopausal prolonged uterine bleeding:

Tx

Answer 29

Cycle progesterone (10 days)

Question 30

Estrogen causes ___ and helps ___

Answer 30

Causes periods and helps with vasomotor sx

Question 31

Progesterone stops ____ and prevents from getting ____

Answer 31

Stops period and prevents from getting cancer

Question 32

Ectopic pregnancy Sx

Answer 32

Pain radiates from groin to shoulder

Question 33

Most common type of breast cancer:

Answer 33

• DCIS (but now is no longer considered breast cancer)

- DCIS on mammogram = calcifications clusters

Question 34

Patient with crusty nipple + discharge:

Answer 34

Consider cancer? Paget’s disease

Question 35

Breast cancer risks:

Answer 35

• Obesity, 1st degree family, early menarche (before 12)
• Most women have no risk factors – why we screen starting at age 40 yearly
• If family hx then start screening 10 years less than family’s dx

Question 36

Mastitis

Answer 36

• Inflammation of breast tissue that sometimes involves an infection.
• Results in breast pain, swelling, warmth and redness; might also have fever and chills.
• Most commonly affects women who are breast-feeding

Question 37

Intraductal papilloma

Answer 37

• A wart-like lump that develops in one or more of the milk ducts in the breast.
• Usually close to the nipple, but can sometimes be found elsewhere in the breast.
• Is a benign (not cancer) breast condition.

Question 38

Diethylstilbestrol (DES) exposure risk

Answer 38

Increase risk of cancer (esp. vaginal)

Question 39

Fosamax administration / considerations

Answer 39

Take once weekly, on empty stomach with glass of water, sit up right 30 minutes afterwards

• Can cause gastritis and esophagitis
• Do not give to pt w/ gastric bypass surgery

Question 40

Fosamax dosages

Answer 40

• Osteoporosis: Dose = 70mg weekly
  + Vitamin d / calcium / weight bearing exercise / estrogen
• Osteopenia: Dose = 35mg weekly

Question 41

Vitamin D supplements:

Answer 41

• Pre-menopausal dose = 600-800u + calcium 1000mg [lower ends]
• Post-menopausal dose = 600-800u + calcium 1000-1200mg

Question 42

Mammogram 2 views:

Answer 42

Craniocaudal + Mediolateral oblique

Question 43

BiRADs Score

Answer 43

• 0 = Incomplete – Additional imaging evaluation and/or comparison to prior mammograms is needed
• 1 = Negative – There’s no significant abnormality to report.
• 2 = Benign (non-cancerous) finding – Benign calcifications, lymph nodes in the breast, or calcified fibroadenomas.
• 3 = Probably benign finding – Follow-up in a short time frame is suggested
• 4+ suspicious – biopsy