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EOR OB/GYN > Menstruation > Flashcards

Menstruation Flashcards

1
Q

premenstrual syndrome and premenstrual dysphoric disorder are marked by BOTH physical and behavioral symptoms that occur when?

A

Second half (luteal phase) of menstrual cycle

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2
Q

when are sx of premenstrual syndrome and premenstrual dysphoric disorder alleviated

A

onset of menses

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3
Q

Do mild sx count as premenstrual syndrome or premenstrual dysphoric disorder?

A

NO

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4
Q

dx premenstrual syndrome

A

at least one symptom associated with economic or social dysfunction during at least part of the 5 days before the onset of menses and recurring in at least three consecutive cycles

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5
Q

sx for premenstrual dysphoric disorder

A

at least one of the following symptoms: mood swings, sudden sadness, increased sensitivity, anger, irritability, depressed mood, anxiety, and tension. In addition, one or more of the following symptoms must be present: difficulty concentrating, change in appetite, diminished interest in usual activities, decreased energy, feeling overwhelmed, breast tenderness, bloating, weight gain, muscle aches, and sleep changes.

must be associated with significant distress or interference with usual activities, such as work, school, or social life

There must be at least five of the above symptoms in total

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6
Q

tx premenstrual disorder

A

selective serotonin reuptake inhibitors, such as sertraline or fluoxetine (first line)

COCs

Gonadotropin-releasing hormone agonists (leuprolide and nafarelin)

Bilateral oophorectomy

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7
Q

what tx for premenstrual disorder is a good option for people desiring contraception

A

COCs

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8
Q

what tx for premenstrual disorder is used in severe cases

A

Gonadotropin-releasing hormone agonists (leuprolide and nafarelin)

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9
Q

last resort tx for premenstrual disorders

A

bilateral oophorectomy

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10
Q

dosing for SSRIs in tx of premenstrual disorders

A

dosed continuously or only during the luteal phase

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11
Q

labs for natural menopause

A

decreased estrogen
elevated FSH

(more specifically estradiol level < 20 pg/mL and a follicle-stimulating hormone level of 21–100 mU/mL)

due to depletion of ovarian follicles

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12
Q

definition of menopause

A

12 consecutive months of amenorrhea without any other alternate causes

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13
Q

premature ovarian failure

A

Women who experience menopause before 40 years of age

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14
Q

perimenopausal period begins an average of how many years before final menstrual period

A

4 years

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15
Q

when should you do further workup for someone with irregular cycles

A

If a woman is < 45 years old, if she is > 45 years old reporting irregular cycles but no other symptoms of menopause

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16
Q

labs if you have to do workup for menopause sx

A

serum hCG to determine whether she is pregnant, serum prolactin to evaluate for hyperprolactinemia, and serum thyroid-stimulating hormone to screen for hyperthyroidism

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17
Q

is measurement of FSH needed to dx menopause

A

no

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18
Q

when might measurement of FSH be useful

A

for women who have undergone a hysterectomy or endometrial ablation and cannot manifest changes to menstrual bleeding

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19
Q

when is measurement of FSH unreliable

A

in women who are taking estrogen-progestin contraceptives

due to exposure of excess exogenous estrogen

would have to measure FSH 2-4 weeks after D/C BC

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20
Q

Secondary amenorrhea

A

cessation of menses for 3 consecutive months (in women who have had previously regular menses) or 6 months (in women who have had previously irregular menses) in women who have passed menarche

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21
Q

MC cause of secondary amenorrhea

A

pregnancy

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22
Q

testing for secondary amenorrhea

A

human chorionic gonadotropin hormone
follicle-stimulating hormone luteinizing hormone
prolactin
thyroid-stimulating hormone

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23
Q

what is warranted in someone with hyperprolactinemia or hypopituitarism

A

brain MRI

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24
Q

tx for secondary amenorrhea w no abnormal lab values

A

10 day course of progestin

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25
Q

Endometriosis

A

growth of endometrial glands and stroma outside of the uterus, particularly in the pelvis and ovaries

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26
Q

in what ages is endometriosis MC

A

women with a mean age of 25 to 35 years

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27
Q

sx endometriosis

A

triad of dysmenorrhea, dyspareunia, and dyschezia
cyclical pelvic pain and urinary symptoms such as dysuria, hematuria, urgency, or frequency

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28
Q

PE for endometriosis

A

tenderness on vaginal exam, nodules in the posterior fornix, adnexal masses, and immobility or lateral displacement of the cervix or uterus

PE may also be normal!!

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29
Q

when is imaging for endometriosis useful

A

only useful if a pelvic or adnexal mass is present

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30
Q

TVUS endometriosis

A

hypoechoic, vascular, or solid mass

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31
Q

definitive dx endometriosis

A

exploratory laparoscopy and biopsy

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32
Q

tx mild to moderate endometriosis

A

nonsteroidal anti-inflammatory drugs and oral contraceptives

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33
Q

tx severe endometriosis

A

Leuprolide with oral contraceptives, laparoscopy, and hysterectomy with bilateral salpingo-oophorectomy (definitive treatment) are reserved for severe endometriosis

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34
Q

PALM-COEIN

A

polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified

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35
Q

MC cause of abnormal uterine bleeding in adolescent women, especially within the first 1–2 years of menarche

A

immature hypothalamic-pituitary axis

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36
Q

what should be performed in all women w abnormal uterine bleeding

A

complete blood count to rule out anemia and a urine hCG to rule out pregnancy

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37
Q

Patients with abnormal uterine bleeding and aged ≥ 45 years warrant consideration for

A

endometrial biopsy to rule out endometrial malignancy

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38
Q

tx for pts with acute heavy menstrual bleeding with stable vital signs

A

short course of estrogen or progestin can abort the bleeding episode

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39
Q

tx for patients with severe uterine bleeding and who are hemodynamically unstable

A

uterine tamponade, intravenous estrogen, and surgical intervention (uterine artery embolization, dilation and curettage, or hysterectomy) may be indicated

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40
Q

at what age can women be clinically diagnosed with menopause

A

≥ 45 years of age

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41
Q

tx for sx associated w menopause in ppl who do have a uterus

A

combined hormone therapy with estrogen and progesterone

The progesterone helps prevent endometrial hyperplasia and endometrial cancer.

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42
Q

tx for sx associated w menopause in ppl who DO NOT have a uterus

A

estrogen alone

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43
Q

tx for vaginal atrophy only and no other bothersome sx of menopause

A

topical estrogen

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44
Q

overview of Premenstrual dysphoric disorder (PMDD)

A

severe form of premenstrual syndrome
sx may become more severe over time
daily functioning at work, school, typical activities, and relationships with others during the luteal phase must be affected for most cycles in the past 12 months

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45
Q

lab testing for PMDD

A

thyroid-stimulating hormone test, human chorionic gonadotropin, complete blood count, and follicle-stimulating hormone level should be ordered

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46
Q

nonpharm tx PMDD

A

acupuncture, relaxation techniques, light therapy, and cognitive behavior therapy. Aerobic exercise can also be helpful, especially in patients who have depression or bloating as predominant symptoms

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47
Q

pharm tx PMDD

A

hormones (e.g., combined oral contraceptives), diuretics (e.g., spironolactone), nonsteroidal anti-inflammatory drugs (e.g., naproxen), and antidepressants (e.g., selective serotonin reuptake inhibitors).

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48
Q

what is curative for PMDD

A

Hysterectomy plus bilateral oophorectomy

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49
Q

Is premenstrual syndrome in the DSM-5

A

no

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50
Q

is PMDD in DSM-5

A

yes

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51
Q

when does menarche usually occur

A

age 11–15 years

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52
Q

primary amenorrhea

A

Failure of the menses to appear by age 15 with normal growth and secondary sex characteristics or by age 13 in the absence of secondary sex characteristics, such as breast developmentd

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53
Q

does primary amenorrhea prompt further evaluation

A

yes

54
Q

MC cause primary amenorrhea

A

gonadal dysgenesis

55
Q

evaluation for primary amenorrhea

A

A pelvic exam should be performed to assess for hymen patency and the presence of a uterus. Initial laboratory evaluation should consist of FSH, LH, prolactin and testosterone levels, TSH, free T4, and a pregnancy test. Pelvic ultrasound is also recommended. MRI of the hypothalamus should be performed when patients have a low or normal FSH and LH, especially if they have high prolactin levels. Patients with a normal uterus, high FSH, and without the features of Turner syndrome should have a karyotype to evaluate for X chromosome mosaicism

56
Q

Postmenopausal bleeding

A

vaginal bleeding that occurs 6 months or more after the cessation of menstruation and should always be evaluated

57
Q

MC causes postmenopausal bleeding

A

endometrial atrophy, proliferation, or hyperplasia; endometrial or cervical cancer; and resulting from exogenous estrogens with or without added progestin

58
Q

Endometrial thickness in postmenopausal women

A

endometrial thickness < 4 mm indicates a low probability of hyperplasia or cancer, but thickness > 4 mm should be evaluated with endometrial biopsy

59
Q

Simple endometrial hyperplasia can be treated with

A

cyclic or continuous progestin therapy (medroxyprogesterone acetate or norethindrone acetate) for 21 or 30 days of every month for 3 months

Endometrial biopsy should be repeated every 3 to 6 months

Alternatively, a levonorgestrel intrauterine system may be used

60
Q

persistent hyperplasia with atypia, endometrial carcinoma, or who do not tolerate medical treatment should undergo

A

total hysterectomy

61
Q

fibroids and classification

A

benign tumors arising from the smooth muscle cells of the myometrium. Fibroids are extremely common and are often classified as submucosal, subserosal, or intramural, according to their anatomic location within the uterus

62
Q

RF fibroids

A

genetics
early menarche

63
Q

sx fibroids

A

abnormal uterine bleeding, pelvic pain or pressure, reproductive dysfunction, and enlarged uterus

MC = heavy or prolonged menses

commonly asx

64
Q

classic pelvic exam for fibroids

A

enlarged, mobile uterus with irregular contour

65
Q

how do fibroids appear on US

A

hypoechoic, round, well-circumscribed masses

66
Q

definitive tx fibroids

A

hysterectomy

67
Q

least invasive tx fibroids

A

levonorgestrel-releasing intrauterine device

68
Q

when do fibroids tend to get smaller and resolve

A

postmenopause

69
Q

Turner syndrome

A

(45,XO) is the most common type of gonadal dysgenesis
commonly presents as short stature, low-set ears, low hairline, high arched palate, webbed neck, and widely spaced nipples

70
Q

Risks of estrogen replacement therapy

A

increased risk of endometrial cancer, thromboembolic disease, stroke, gallbladder disease, increased lipids, and ovarian cancer

71
Q

when is hormone replacement therapy contraindicated

A

patients with undiagnosed uterine bleeding, a history of breast cancer, estrogen-dependent neoplasia, a history of a deep vein thrombosis (DVT) or PE (pulmonary embolism), new-onset DVT or PE, myocardial infarction, stroke, or liver disease or dysfunction

72
Q

Adenomyosis

A

endometrial glands and stroma are present within the myometrium

73
Q

sx adenomyosis

A

heavy menstrual bleeding and dysmenorrhea

74
Q

pelvic exam adenomyosis

A

mobile, globular, boggy uterus

A fixed uterus should increase suspicion for endometriosis, which can occur with adenomyosis

75
Q

first line for eval of adenomyosis

A

TVUS

76
Q

when is MRI indicated when you think someone has adenomyosis

A

if there is a need to differentiate between adenomyosis and leiomyomas for treatment purposes

77
Q

definitive dx adenomyosis

A

histologic evaluation after hysterectomy

78
Q

definitive tx adenomyosis

A

hysterectomy

79
Q

other tx options for adenomyosis (if don’t want hysterectomy)

A

levonorgestrel-releasing intrauterine device is the recommended pharmacologic treatment

depot gonadotropin-releasing hormone analogs or aromatase inhibitors may also be used

80
Q

how long should patients with suspicion for premenstrual syndrome should record their symptoms

A

for 2 months in relation to menstrual cycle

81
Q

further evaluation for persistent thick and irregular endometrium visualized on TVUS

A

tissue biopsy

82
Q

what next If bleeding persists or tissue from an endometrial biopsy is inadequate

A

hysteroscopy with dilation and curettage should be performed

83
Q

If tissue biopsy shows hyperplasia of the endometrium, it is further classified as

A

simple or complex with or without atypia

84
Q

Hyperplasia without atypia

A

a benign condition characterized by the crowding of glands in the stroma without atypia

85
Q

The characteristic appearance of hyperplasia with atypia

A

endometrial glands lined with enlarged cells and increased nuclear activity

86
Q

Hyperplasia with atypia is considered

A

premalignant

87
Q

Conditions with chronically high estrogen levels

A

nulliparity, late menopause, obesity, early menarche, polycystic ovarian syndrome, metabolic syndrome, chronic anovulation, estrogen producing tumors, and unopposed estrogen replacement therapy. Patients with Lynch syndrome are also at an increased risk for both endometrial and colon cancers

88
Q

Patients with complex hyperplasia with or without atypia should undergo

A

dilation and curettage for thorough endometrial sampling as it is necessary to rule out coexisting carcinoma

89
Q

tx for Complex hyperplasia without atypia and hyperplasia with atypia that occurs in patients who wish to preserve fertility

A

progestin therapy - Megestrol acetate and depot medroxyprogesterone acetate are approved treatments

90
Q

when is vaginal or abdominal hysterectomy recommended for complex hyperplasia without atypia and hyperplasia with atypia

A

patients who relapse after progestin therapy
those who cannot tolerate the side effects
those with pathology suggesting coexisting endometrial carcinoma
those who do not desire to preserve fertility

91
Q

What condition is FDA approved for treatment with anastrozole?

A

breast CA

92
Q

Müllerian agenesis, also known as

A

vaginal agenesis or Mayer-Rokitansky-Küster-Hauser syndrome

may result in primary amenorrhea

93
Q

Müllerian agenesis results in

A

congenital absence of the vagina with variable uterine development. Most patients with müllerian agenesis will have cervical and uterine agenesis in addition to vaginal agenesis

94
Q

what Urologic anatomical abnormalities may be seen in Müllerian agenesis

A

unilateral agenesis, horseshoe kidney, or collection system irregularities

95
Q

do pts with Müllerian agenesis have a normal female karyotype

A

yes

96
Q

what is not affected in müllerian agenesis

A

ovaries
pts will have normal secondary sexual characteristics (e.g., breast development, axillary hair, pubic hair)

97
Q

physical exam müllerian agenesis

A

normal external genitalia. While the hymenal tissue is typically normal, examination of the vagina will reveal a dimple or a small vaginal pouch.

98
Q

tx müllerian agenesis

A

nonsurgical vaginal self-dilation

Elective surgery is an option if self-dilation fails

99
Q

are pts w müllerian agenesis able to have normal intercourse after tx

A

yes

100
Q

can ppl w müllerian agenesis carry a pregnancy

A

no

101
Q

family planning options for Müllerian agenesis

A

harvesting the eggs for a gestational surrogate or uterine transplantation

102
Q

Sheehan syndrome

A

rare complication of postpartum hemorrhage that is also referred to as postpartum hypopituitarism. The pituitary gland is enlarged during pregnancy, which makes it particularly prone to infarction from hypovolemia

ischemia of pituitary gland –> decreased release of pituitary hormones

103
Q

classic presentation of Sheehan syndrome

A

failure to lactate after delivery and amenorrhea or oligomenorrhea.

Other possible manifestations due to hypopituitarism include hypotension, hyponatremia, and hypothyroidism

104
Q

Which hormones are produced by the anterior pituitary gland?

A

Follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin, adrenocorticotropic hormone, and growth hormone

105
Q

Which of the following cancers would this patient be at significant increased risk of if she is treated with combined menopausal hormone therapy?

A

breast

106
Q

which of the following cancers would this patient be at significant increased risk of it she is treated with unopposed estrogen if she still has a uterus

A

endometrial

107
Q

what hormones does hypothalamus secrete in relation to menstrual cycle

A

gonadotropin-releasing hormone

108
Q

what hormones does anterior pituitary secrete in relation to menstrual cycle

A

LH and FSH

109
Q

what hormones do ovaries produce in relation to menstrual cycle

A

progesterone and estrogen

110
Q

follicular phase

A

follicle-stimulating hormone causes multiple follicles to be developed, with one ultimately becoming the dominant follicle. As these follicles develop, estrogen levels rise, which produces a spike in luteinizing hormone that triggers ovulation. The rising estrogen levels also cause the cervical mucus to become thin, giving sperm the best chance for fertilization.

The cervical mucus at this stage in the cycle is sometimes described as similar in consistency to a raw egg white. Estrogen levels are high and progesterone levels are low when the cervical mucus is thin

111
Q

Following ovulation, the remainder of the dominant follicle is called the

A

corpus luteum

112
Q

The corpus luteum produces

A

more progesterone than estrogen, and thus progesterone is more prevalent than estrogen during the luteal phase and helps to thicken the endometrial lining. However, the corpus luteum eventually degenerates until it becomes the corpus albicans, which does not produce hormones. Therefore, estrogen and progesterone levels decrease, which leads to shedding of the endometrial lining. This manifests as the vaginal bleeding that represents the start of a new menstrual cycle

113
Q

what is the only diuretic shown to improve symptoms such as bloating, fluid retention, and breast tenderness

A

spironolactone

114
Q

first-line imaging of choice for diagnosing and further evaluating the etiology of abnormal uterine bleeding

A

pelvic US (best is transvaginal)

115
Q

classic pain associated with primary dysmenorrhea

A

crampy, intermittently intense, and located midline in the lower abdomen

116
Q

Indications for a transvaginal ultrasound for primary dysmenorrhea

A

failure to improve after 3 months of nonsteroidal anti-inflammatory drugs, such as ibuprofen, or hormonal contraception (COCs or POPs are equally effective)

117
Q

How long after menarche do ovulatory cycles typically start?

A

2-5 years

118
Q

United States Preventive Services Task Force (USPSTF) screening for osteoporosis

A

all women ≥ 65 years of age and postmenopausal women < 65 years of age at increased risk for osteoporosis (e.g., recurrent fractures, fractures from minimal trauma, history of rheumatoid arthritis)

there is no recommendation for screening in men

119
Q

DEXA T score for osteoporosis

A

≤ −2.5

120
Q

DEXA T score for osteopenia

A

between −1.0 and −2.5

121
Q

postmenopausal women recs for vitamin D and calcium

A

supplemental calcium to attain a goal of 1,200 mg/day
The recommended amount of daily vitamin D is 800 IU

122
Q

Which sign associated with hypocalcemia is characterized by carpal spasm due to ulnar nerve ischemia when a blood pressure cuff is inflated over the upper arm?

A

Trousseau sign.

123
Q

Menometrorrhagia

A

abnormal uterine bleeding that is heavy or prolonged and occurs at irregular intervals

124
Q

first line for Menometrorrhagia

A

NSAIDs

125
Q

Menorrhagia

A

abnormally prolonged (> 7 days per cycle) or heavy (> 80 mL of blood) uterine bleeding that maintains a normal menstrual cycle

126
Q

Metrorrhagia

A

abnormal uterine bleeding in between normal cycles that recur at irregular intervals

127
Q

Polymenorrhea

A

regular menstrual cycles that occur at shortened intervals (< 21 days)

128
Q

dysmenorrhea is due to

A

excess prostaglandin production

129
Q

Which hormone dominates the luteal phase of the menstrual cycle?

A

progesterone

130
Q

Theca cells are stimulated by

A

LH to produce progesterone and androstenedione

131
Q

granulosa cells are stimulated by

A

FSH to convert androstenedione to 17-beta-estradiol

132
Q
A

EOR OB/GYN (18 decks)

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