menstruation Flashcards
steady GnRH used for what?
- suppress FSH, LH, estrogen
- adjuvant for estrogen-receptive breast cancer
- delay precocious puberty
- Tx endometriosis & uterine fibroids
- hormone suppression in transsexual females
USE IN ESTROGEN DEPENDENT DISEASES
pulsatile GnRH used for what?
hypogonadotropic hypogonadism
- low GnRH
- induce normal puberty, menses development, reproductive cycle
- fertility Tx
- preserve reproductive capacity in chemo
RESTORE NORMAL FUNCTION
things that decr GnRH
- mild incr E
- progesterone
- endorphins, opioids (heavy exercise)
- Corticotropin Releasing Hormone (stress, incr cortisol, Cushings)
- prolactin
things that incr GnRH
- rapidly incr E
- Kisspeptin (adipose tissue)
FSH
granulosa cells, androgens to estrogen, inhibin & activin
LH
- theca cells, production of androgens
- ovulation
- convert residual follicle to corpeus luteum
dominant follicle maturation dependent on what?
FSH
what causes release of oocyte?
LH surge
as dominant cell prepares for ovulation, what level increases?
high estrogen
what hormone converts residual follicle to corpeus luteum?
LH
corpeus luteum produces what?
progesterone
progesterone roles
- menses
- implantation
no fertilization…
corpus luteum–> corpus albicans–> gone
fertilization…
HCG from zygote
role of HCG initially
sustain corpus luteum, progesterone secretion for implantation
estrogen effect on lipids, cardiovascular?
decr LDL, incr HDL
vasodilation
lower CAD
estrogen and skin?
thick skin, elasticity, collagen incr, incr melanocytes
estrogen & bone?
inhibits osteoclasts
menopause estrogen
estrone
most potent estrogen
estradiol
pregnancy estrogen
estriol
reproductive years estrogen
estradiol
extra-ovarian production of estrogen
adrenal glands, adipose tissue
breasts, liver
menses E & P
LOW
in follicular phase, pituitary secretes FSH. what is the result?
- ovaries up-regulate FSH receptors (granulosa cells)
- produce E from androgens
- rapid incr E stimulates GnRH
- GnRH causes LH surge
mittelschmerz
feel ovulation pain
luteal phase follicle transformed into what?
corpus luteum
luteal phase progesterone causes what?
neg feedback on LH and FSH
endometrial lining conditioning by what?
PROGESTERONE and E
corpus luteum lifespan
9-11 days
E effects on endometrium
build up
P effects on endometrium
differentiation of components
E & P if no fertilization
major drop E & P, endometrium sloughs
normal menses blood loss, length
20-60 mL
3-7 days
in order for P to be produced in menses, what must occur?
ovulation
if no ovulation
E unchecked (no P), no secretory phase, abnorm bleeding (sloughing irregular)
breast tenderness when?
luteal phase
mucus with E & P
E: thin, P: thick
hypothalmic cause of irreg menses, anovulation. what to order next?
LH
menorrhagia
prolonged bleeding > 7 days
metrorrhagia
bleeding b/t menstrual periods
secondary amenorrhea
no menses 3-6 mo in previously menstruating female
primary amenorrhea
- 13 y/o no menstruation, no secondary sexual characteristics
- 15 y/o no menstruation, yes secondary sexual characteristics
MCC amenorrhea
pregnancy
2 cause amenorrhea
anovulation
female athlete triad
- anorexia
- amenorrhea (b/c decr adipose tissue, excessive exercise)
- osteoporosis (stress Fx)
hypothalmic amenorrhea
anorexia (kisspeptin), excessive exercise (endorphins), stress (cortisol), opioids
MCC pituitary amenorrhea
hyperprolactinemia (decr GnRH)
hypothyroidism causes what?
incr TRH = incr TSH, prolactin
ovary amenorrhea
PCOS, premature ovarian failure
asherman syndrome
uterus scarring, no proliferation, no shedding
= amenorrhea (cause: procedures)
MCC hirsutism
PCOS
DHEA produced where
adrenals
androstenedione produced where
adrenals, ovaries
testosterone produced where
adrenals, ovaries, adipose tissue
DHT produced where
hair, genitals
most potent androgen
DHT
adipose only CONVERTS androstenedione to what?
T and estrone
ovary androgen prod
androstenedione, T, estradiol
adrenals androgen prod
cortisol, androgens
adipose androgen prod
converts to T, estrone
Stein-Leventhal syndr
PCOS
Sx PCOS
-anovulation
-hyperandrogenism (hirsutism, T)
-polycystic ovaries (string of pearls)
(obesity, infertility, miscarriage, metab syndr)
labs PCOS
high LH, low FSH (>2.5-3 LH:FSH)
high free T
high androstenedione
metabolic syndr
- central obesity
- incr TG
- incr BP
- decr HDL
- hyperglycemia (> 100 fasting)
HAIR-AN syndr, assoc with what?
HyperAndrogenism, Insulin Resistance, Acanthosis Nigricans
-PCOS
PCOS pt- no hyperglycemia with blood glucose test. next step?
GTT
impaired GTT (fasting glucose, 2hr GTT, HbA1C)
- fasting glucose: 126
- 2hr GTT: 200
- HbA1C: 6.5
Tx PCOS
wt loss
provera (progesterone)
OCP (desogen, modicon, ortho-cyclen)
Tx infertility: clomid
Tx hyperandrogenism: spironolactone, Vaniqa (topical hair removal)
Tx insulin resistance: metformin
Tx hyperandrogenism (in PCOS)
spironolactone, Vaniqa (topical hair removal)
specific tests to evaluate amenorrhea
P challenge, E-P challenge, FSH levels
provera given, withdrawn. pt bleeds. what does this mean?
PCOS
anovulation
-enough E for endometrium build up, just anovulation
provera given, withdrawn. pt doesn’t bleed. what does this mean? what to do next?
E deficient
E-P challenge next.
premarin given, then provera, withrawn. pt bleeds. what to do next?
FSH in 2 wks
premarin given, then provera, withrawn. pt doesn’t bleed. what does this mean?
anatomic problem
- Asherman (scarred uterus)- can’t build up
- cervical stenosis- can’t expel
E-P challenge. pt bleeds. FSH high. what does this mean?
menopause
-ovaries not responding to FSH
E-P challenge. pt bleeds. FSH low. what does this mean?
anorexia, exercise, opioids, stress, pituitary adenoma
-inappropriate release of FSH, LH (hypothalamus, pituitary problems)
follicles become resistant to FSH (no follicle stimulation). what is this?
menopause
menopausal FSH levels
> 30
premature menopause
before 30 y/o
menopause definition
menses cessation x 1 yr
factors that have no effect on menopause
lactation, menarche age, # of pregnancies, OCP, race
hormones of menopause
testosterone, estrone
Sx of menopause
sleep disturbance, genital atrophy (cystocele, uterine prolapse, vaginitis, mood changes, osteoporosis, incr LDL, decr HDL, thin skin, hirsutism, hot flashes, nightsweats
DEXA -1.0 to -2.5
osteopenia
DEXA < -2.5
osteoporosis
when to start routine bone density scanning
65 y/o
osteoporosis RF
white, incr age, Fx, smoking, dementia, low body wt, estrogen def, alcoholism, chronic corticosteroids, sedentary
osteoporosis Tx
- calcium
- vit D
- bisphosphonates
- SERM: raloxifene
- estrogen replacement
- calcitonin
- progesterone
calcium requirement in menopause
1200-1500 mg/day
vitamin D supplementation in menopause
800-2000 Units/day
active form Vit D
vit D3
how to measure vit D
25-OH Vit D
ADR bisphosphonates
osteonecrosis of jaw, esophageal erosions
-holiday after 5 yrs of use
main management of Sx related to menopause
estrogen replacement
Premarin
estrogen ADR
melasma, gallstones, endometrial CA, incr CAD/stroke/DVT/breast CA/dementia
menstrual Sx
progesterone
Provera, levonorgestrel, norethindron, drospirendone
combined menopause Tx
cyclic: E days 1-25, medroxyprogesterone acetate days 16-25
continuous: together
absolute contraindications to hormonal therapy
unDx vaginal bleeding, thrombophlebitis, cerebral vascular disease, pregnancy, CAD, smoker >35 y/o, impaired liver, breast CA, hyperlipidemia
incr risk of what diseases in hormonal therapy?
MI, thromboembolism, stroke, breast CA
not colorectal CA
monophasic, biphasic, triphasic OCP
- mono: same doses, both, all month
- bi: same E dose, incr progestin dose second 1/2
- tri: varying dose both
progestin only/mini pill 2 indications (take at SAME TIME every day)
> 40 y/o
lactating
break through bleeding with progestin
resolves in 3 mo
depo medroxyprogesterone acetate (Depo-Provera) affects what?
suppress LH (ovulation), no effect on FSH thicken mucus
Depo shot ADR
osteoporosis
PMS, PMDD- what phase ONLY?
luteal phase
P makes women mean!
PMDD
core Sx: depressed, anxiety/tension, sad/tearul/sensitive, irritable/angry
anhedonia, lethargy, insomnia
main contraceptive effect of pill attributed to?
E
spotting on pill, what should you do?
wait 3 months, will go away
PMS
5 days before menses! in 3 menstrual cycles! gone in 4 days of LMP! no drugs!
depression, angry, irritable, confusion, social withdrawal, breast tender, bloating, HA
Tx PMS
- less carbs, caffeine, fat, EtOH
- exercise
- NSAIDs
- SSRI: fluoxetine, sertraline
- calcium, Mg
(danazol)
Tx PMDD
SSRI (GOLD STANDARD)
fluoxetine, sertraline, paroxetine
-14 days before menses
