Menstruation

Question 1

Gonadotropin-Releasing Hormone (GnRH)

Answer 1

Stimulates release of FSH and LH initiating puberty and sustaining menstrual cycle
Secreted by hypothalamus

Question 2

Follicle-stimulating hormone (FSH)

Answer 2

Secreted by anterior pituitary gland during 1st half of menstrual cycle
Stimulates growth and maturation of Graafian follicle before ovulation
Thins the endometrium

Question 3

Luteinizing Hormone (LH)

Answer 3

Secreted by the anterior pituitary gland
Stimulates final maturation of Graafian follicle
Surge of LH about 14 days before next menstrual period causes ovulation
Stimulates transformation of Graafian follicle into corpus luteum
Thickens the endometrium

Question 4

Estrogen

Answer 4

Secreted primarily by the ovaries, corpus luteum, adrenal cortex, and placenta in pregnancy
Stimulates thickening of the endometrium; causes suppression of FSH secretion
Responsible for the development of secondary sex characteristics
Stimulates uterine contractions
High estrogen concentration inhibits secretion of FSH and prolactin but stimulates secretion of LH
Low estrogen concentration after pregnancy stimulates secretion of prolactin

Question 5

Progesterone

Answer 5

Secreted by the ovary, corpus luteum and placenta during pregnancy
Inhibits secretion of LH
Has thermogenic effect
Relaxes smooth muscles thereby decreases contractions of uterus
Causes cervical secretion of thick mucus
Maintain thickness of endometrium
Allows pregnancy to be maintained
Prepares breasts for lactation

Question 6

Prolactin

Answer 6

Secreted by anterior pituitary gland

Stimulates secretion of milk

Question 7

Oxytocin

Answer 7

Secreted by posterior pituitary gland
Stimulates uterine contractions during birth and compress uterine blood vessels and control bleeding
Stimulates let-down or milk-ejection reflex during breastfeeding

Question 8

Prostaglandins

Answer 8

Fatty acids categorized as hormones
Produced by many organs of the body, including endometrium
Affects menstrual cycle
Influences the onset and maintenance of labor

Question 9

Follicular phase of menstruation

Answer 9

Varies in length more than other phases

In the first half, the primary event is growth of recruited follicles

Question 10

Levels of estrogen, progesterone, FSH, and LH in first half of follicular phase

Answer 10

Estrogen and progesterone production is low. As a result, overall FSH increases slightly
Circulating LH levels increase slowly

Question 11

What happens with estradiol with recruited ovarian follicles?

Answer 11

It increases

Question 12

What occurs during the second half of the follicular phase?

Answer 12

The follicle selected for ovulation matures
FSH levels decrease; LH levels are affected less
Levels of estrogen increase exponentially

Question 13

Ovulatory phase- estradiol and progesterone

Answer 13

Ovulation occurs. Estradiol levels usually peak as the phase begins
Progesterone levels also begin to increase

Question 14

LH levels during ovulatory phase

Answer 14

Stored LH is released in massive amounts, usually over 36-48 hrs

Question 15

How are estradiol and progesterone levels affected during the LH surge in the ovulatory phase?

Answer 15

Estradiol levels decrease, but progesterone levels continue to increase

Question 16

How LH works during the ovulatory phase

Answer 16

Surge stimulates enzymes that initiate breakdown of the follicle wall and release of the now mature ovum within about 16-32 hrs. It also triggers completion of the first meiotic division of the oocyte within about 36 hrs

Question 17

What occurs during the luteal phase?

Answer 17

The follicle is transformed into a corpus luteum
The corpus luteum secretes primarily progesterone in increasing quantities, peaking 6-8 days after ovulation, which stimulates development of the secretory endometrium

Question 18

What occurs with LH and FSH during the luteal phase?

Estradiol and progesterone?

Answer 18

LH and FSH levels decrease

Estradiol and progesterone levels decrease late in this phase

Question 19

What happens if implantation occurs?

Answer 19

The corpus luteum does not degenerate but remains, supported by hCG that is produced by the developing embryo

Question 20

Amenorrhea

Answer 20

Absence of menses

Question 21

Dysmenorrhea

Answer 21

Painful menstruation

Question 22

Oligomenorrhea

Answer 22

Scanty menstruation

Question 23

Polymenorrhea

Answer 23

Too frequent menstruation

Question 24

Menorrhagia

Answer 24

Excessive menstrual bleeding

Question 25

Metorrhagia

Answer 25

Bleeding between periods of less than 2 wks (can be spotting or heavy)

Question 26

Hypomenorrhea

Answer 26

Abnormally short menses

Question 27

Hypermenorrhea

Answer 27

Abnormally long menses

Question 28

What ties all the s/sx of PMS together?

Answer 28

They affect your pt only in the 14 days just before her monthly period During luteal phase

Question 29

Emotional and behavioral sx of PMS

Answer 29

``` Tension or anxiety Depressed mood Crying spells Mood swings and irritability or anger Appetite changes and food cravings Trouble falling asleep Social withdrawal Poor concentration ```

Question 30

Physical signs and sx of PMS

Answer 30

``` Joint or muscle pain HA Fatigue Wt gain from fluid retention Abdominal bloating Breast tenderness Acne flare-ups Constipation or diarrhea ```

Question 31

Tx options for PMS

Answer 31

``` Antidepressants NSAIDs Diuretics Oral contraceptives Depo Provera ```

Question 32

Alternative med ideas for PMS

Answer 32

``` Calcium Magnesium Vitamin B6 Vitamin E Herbal remedies Natural progesterone creams ```

Question 33

What is the difference between PMS and PMDD?

Answer 33

Sx of PMDD are similar to those of PMS, but they are generally more severe and debilitating

Question 34

Timeline of PMDD

Answer 34

Sx occur during the 7-10 days just before menstrual bleeding and usually improve within a few days after the period starts

Question 35

Diagnostic criteria for PMDD

Answer 35

Five or more of the following sx must be present: - Disinterest in daily activities and relationships - Fatigue or low energy - Feeling of sadness or hopelessness, possible suicidal thoughts - Feelings of tension or anxiety - Feeling out of control - Food cravings or binge eating - Mood swings marked by periods of teariness - Panic attack - Persistent irritability or anger that affects other ppl - Trouble concentrating - Physical sx, such as bloating, breast tenderness, HAs, and joint or muscle pain - Sleep disturbances

Question 36

Tx for PMDD

Answer 36

Balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol and caffeine) Adequate rest Regular exercise 3-5 times per week Diary or calendar to record the type, severity, and duration of sx SSRIs, nutritional supplements, and OTC meds for symptomatic relief

Question 37

Primary amenorrhea

Answer 37

The absence of menstrual bleeding and secondary sexual characteristics in a girl by age 14 yrs OR The absence of menstrual bleeding with normal development of secondary sexual characteristics in a girl by age 16 yrs

Question 38

Secondary amenorrhea

Answer 38

The absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for 6 or more mos

Question 39

Reasons for amenorrhea

Answer 39

An abnormality in the hypothalamic-pituitary-ovarian axis Anatomical abnormalities of the genital tract Functional causes

Question 40

Hypothalamic causes of amenorrhea

Answer 40

``` Craniopharyngioma Teratoma Sarcoidosis Kallman syndrome Nutritional deficiency/eating disorders Low body weight Constitutional delay ```

Question 41

Pituitary causes of amenorrhea

Answer 41

``` Prolactinemia Other pituitary tumors Postpartum pituitary necrosis Autoimmune hypophysitis Pituitary radiation Sarcoidosis ```

Question 42

Ovarian causes of amenorrhea

Answer 42

``` Anovulation Hyperandrogenemia PCOS Premature ovarian failure Turner syndrome-primary Pure gonadal dysgenesis Autoimmune oophoritis Fragile X premutation Radiation or chemo ```

Question 43

Other causes of amenorrhea

Answer 43

Galactosemia Anatomical abnormalities of the genital tract -Intrauterine adhesions -Mullerian defects --Imperforate hymen --Transverse vaginal septum --Aplasia of the vagina, the cervix, or the uterus

Question 44

Functional causes of amenorrhea

Answer 44

``` Anorexia/bulemia Chronic diseases Excessive wt gain or wt loss Malnutrition Depression or other psychiatric disorders and/or their therapeutic tx Recreational drug abuse Excessive stress or excessive exercise Cycle suppression with systemic birth control methods ```

Question 45

Work up secondary amenorrhea

Answer 45

If 3 consecutive menses have been missed, work up is indicated Pregnancy test Hormone levels (FSH, LH, estradiol, free and total testosterone, androstenedione), thyroid funciton, serium prolactin CT or MRI of head Pelvic exam to r/o physical cause U/s or other evaluation of the uterus Tx is dependent on cause

Question 46

Causes of oligomenorrhea

Answer 46

``` Prolactinomas Systemic contraceptives PCOS Thyrotoxicosis Hormonal changes in perimenopause Graves disease ```

Question 47

Workup for oligomenorrhea

Answer 47

``` PCOS labs Thyroid panel FSH LH Estradiol levels ```

Question 48

Reasons for abnormal uterine bleeding

Answer 48

``` Polyps Adenomyosis Leiomyomata Malignancy or hyperplasia Coagulopathy Ovarian dysfunction Endometrial Iatrogenic Not yet classified ```

Question 49

When are irregular menses common in premenopausal pts?

Answer 49

For up to 2 yrs after menarche

Question 50

What is the most likely dx of AUB in premenopausal women with nl findings on PE?

Answer 50

AUB secondary to anovulation | Check for PCOS or thyroid dz

Question 51

Other differentials of AUB in premenopausal women

Answer 51

Pregnancy Infection Coagulopathy

Question 52

DDx of perimenopausal AUB

Answer 52

``` Fibroids Polyps Anovulatory bleed d/t declining ovarian function Adenomyosis Endometrial hyperplasia or neoplasm ```

Question 53

What must be considered early in the investigation of AUB in perimenopausal women?

Answer 53

Endometrial bx and other methods of detecting endometrial hyperplasia or carcinoma

Question 54

What is commonly seen with AUB in postmenopausal women?

Answer 54

Uterine pathology, particularly endometrial carcinoma

Question 55

What is included in the intial investigation of AUB in postmenopausal women?

Answer 55

Endometrial bx and/or transvaginal u/s

Question 56

What is considered CA until it is ruled out?

Answer 56

Postmenopausal bleeding

Question 57

Tx of premenopausal AUB

Answer 57

May respond to oral contraceptives, cyclic medroxyprogesterone therapy or cyclic clomiphene

Question 58

Tx of perimenopausal AUB

Answer 58

Low-dose oral contraceptives if they don't smoke or medroxyprogesterone or a progesterone IUD

Question 59

Primary dysmenorrhea

Answer 59

Dysmenorrhea that has no cause

Question 60

Tx of primary dysmenorrhea

Answer 60

``` Primary cause is believed to be related to prostaglandin secretion Based on symptomatic relief: -NSAIDs at a therpeutic dose (ALWAYS first line) -OCPs -Progestin only pills -Progesterone IUDs -Heating pads/hot showers -Exercise ```

Question 61

When does primary dysmenorrhea start?

Answer 61

Once ovulatory cycles begin

Question 62

Causes of secondary dysmenorrhea

Answer 62

``` Endometriosis PID Myomata Uterine adenomyosis Endometrial polyps Ovarian cysts Retroverted uterus Cervical stenosis Pelvic adhesions Congenital uterine anomalies IUD ```

Question 63

Hx questions to ask in regards to secondary dysmenorrhea

Answer 63

``` How painful? What changed? Is it getting worse? What other sx are you having? Any FHx? What meds (including BC) are you on? STD exposure ```

Question 64

Tx of secondary dysmenorrhea

Answer 64

Based upon cause Any existing pathology must be addressed Pain control Cycle control if indicated