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Part 1 MFSRH 2024 > Reproductive Mental Health & Mood Disorders > Flashcards

Reproductive Mental Health & Mood Disorders Flashcards

1
Q

For how long should a symptom diary be kept prospectively to make a diagnosis of PMS?

A

2-3 cycles

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2
Q

What proportion of women experience symptoms of PMS?

A

40%

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3
Q

What proportion of women experience severe symptoms of PMS?

A

5-8%

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4
Q

How many American Psychiatric Association’s DSM-5 diagnostic criteria must be present to make a PMDD diagnosis?

A

5/11

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5
Q

What is core PMD?

A

Cyclical physiological and/or physical symptoms that cease following menstruation

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6
Q

Which type of CHC preparation is best for controlling PMS symptoms?

A

Drospirenone containing COC preparations - should be given continuously rather than cyclically

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7
Q

What is thought to be mechanism behind PMS?

A
  • Progesterone is released by the corpus luteum during the luteal phase of the menstrual cycle
  • Allopregnanolone is a metabolite of Progesterone and is a positive allosteric modulator of the GABA receptor
  • This normally has an anxiolytic effect
  • In PMS, low levels of Allopregnanolone and dysregulated GABA activity is seen
  • This results in symptoms such a labile mood, anxiety, depression and sleep disturbance
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8
Q

How does ethinylestradiol cause bloating and breast pain?

A

Potent activator of the renin-angiotensin system causing water retention, responsible for side effects such as bloating and breast pain

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9
Q

How does drospirenone counteract the water retention caused by ethinyestradiol?

A

Anti-mineralocorticoid and anti-androgenic activity

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10
Q

What formalised questionnaire can be used to record a patients symptom diary?

A

Daily record of severity of problems (DRSP)

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11
Q

What can be done if the clinical picture is inconclusive despite a 3/12 symptom diary?

A

3/12 use on GnRH analogues ?symptom resolution

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12
Q

What are the possible risk factors for PMS?

A
  1. Ovulatory menstrual cycles (biggest single biggest risk factor)
  2. FHx
  3. Other mood disorders
  4. Smoking
  5. Alcohol XS
  6. Sexual abuse/trauma
  7. Weight gain
  8. Stress
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13
Q

What is an alternative explanation re: the cause of PMS?

A

‘Sensitivity’ to progesterone
(unclear as to whether this, or lack of allopregnanolone, or alternative explanation altogether)

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14
Q

What proportion of women experience cyclical breast pain?

A

Up to 2/3rds

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15
Q

What proportion of women experience moderate-severe cyclical breast pain?

A

1 in 10

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16
Q

What is thought to be the cause of cyclical breast pain?

A
  1. ?Hyperprolactinaemia
  2. ?Oestrogenic overstimulation
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17
Q

When a woman presents with (cyclical) breast pain, what should you also consider/examine for?

A
  1. Pregnancy
  2. Malignancy
  3. Infection
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18
Q

What information may be required for a diagnosis of cyclical breast pain?

A

Breast pain diary, taken over at least 3 cycles

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19
Q

When is the luteal phase of the menstrual cycle?

A

Ovulation to menstruation

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20
Q

What proportion of women experience PMDD?

A

1-10%

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21
Q

Cyclical symptoms, relieved by menstruation, with a symptom free week, not affecting QoL, describes what Dx?

A

Physiological (mild) PMD

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22
Q

Cyclical symptoms, relieved by menstruation, with a symptom free week, affecting QoL, describes what Dx?

A

Core PMD

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23
Q

Cyclical symptoms, relieved by menstruation, no symptom free week, affecting QoL, describes what Dx?

A

Premenstrual exacerbation of underlying physical/psychological condition

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24
Q

Cyclical symptoms, relieved by menstruation, with a symptom free week, affecting QoL, on progesterone treatment describes what Dx?

A

Progestogen-induced PMD (consider alternative progesterone treatment)

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25
What is the first line management for PMD?
Exercise, CBT, vitamin B6 COCP Continuous of luteal (day 15-28) low-dose SSRI
26
Why use SSRIs only in the luteal phase?
May reduce adverse effects of SSRIs themselves e.g. nausea, insomnia, fatigue, low libido
27
What should be considered in women of reproductive age using SSRIs for PMS alone (absence of depression etc.)?
Then PMS will abate in pregnancy and therefore SSRIs should be discontinued prior to/during pregnancy
28
What is the risk of SSRIs in pregnancy?
May be associated with a small increased in congenital abnormalities. but may be due to other confounding features. Concern mainly re: cardiac malformations. There is a small increased risk of PPH and neonatal withdrawal syndrome
29
What are the 2nd line management options in PMS?
Estradiol patches + micronised progesterone (days 17-25) orally or vaginally, or use of the Mirena Higher-dose SSRI regime
30
When using progesterone as part of 2nd line management, what considerations should be made?
- Consider use of micronised progesterone - fewer androgenic and unwanted S/Es - S/Es may be reduced further by using vaginally - avoiding first-pass hepatic metabolism and the creation of metabolites that ?some may be sensitive to - Use lowest dose possible to provide endometrial protection - The IUS is not micronised progesterone, but may avoid S/Es due to avoidance of systemic absorption
31
How should SSRIs be discontinued when used continuously?
Tapering
32
How should SSRIs be discontinued when used in the luteal phase only?
Immediately, no requirement for tapering
33
What is 3rd line management for PMS?
GnRH analogues and add back HRT
34
What is 4th line management for PMS?
Operative
35
Who should GnRH analogues as treatment be reserved for?
The most severe presentations
36
When should operative management for PMS be considered?
When other medical management has failed When GnRH analogues required for management of symptoms When there is another operative indication
37
What is a condition of having operative management for PMS?
Must have had GnRH analogues and add-back HRT prior to surgery in order to ensure can tolerate
38
When should women ABSOLUTELY have HRT if using GnRH analogues?
If they have been using for >6/12
39
What sort of HRT should women using GnRH analogues be on?
Continuous combined HRT or tibolone
40
What surveillance should be in place for women using GnRH analogues +/- add-back HRT?
Yearly DEXA scanning - treatment should be terminated if there is a significant reduction in BMD
41
Which women whom have operative management for PMS should DEFINITELY have HRT?
Those <45 y/o
42
Why should women undergoing operative management for PMS also consider testosterone replacement?
Because the ovaries are responsible for 50% of testosterone production - deficiency of this may result in low libido (HSDD)
43
Should progesterone alone be offered as a treatment for PMD?
No, good evidence this is not appropriate
44
What should take place if a cyclical pattern of symptoms is not identified?
Exclude other causes: Depression Hypothyroidism Anaemia IBS Endometriosis
45
What is the mechanism of action of danazol?
- A synthetic steroid with anti-gonadotrophic and anti-estrogenic activity - Causes suppression of the anterior pituitary, inhibiting the output of gonadotropins LH and FSH and so suppresses oestrogen production - In breast tissue its exact mechanism is unknown, but may have a direct effect on steroid receptors in breast tissue
46
What is the mechanism of action of tamoxifen (may occasionally be prescribed by a specialist int he context of cyclical breast pain)?
Selective estrogen receptor modulator (SERM), competitively inhibiting estrogen binding to its receptor
47
What is the mechanism of action of GnRH analogues?
- Acts as agonist to the GnRH receptors on the ant pit, this initially causes it to produce MORE LH and FSH - a FLAIR, with subsequent temporary worsening of symptoms - Then with continuous stimulation, the ant pit becomes desensitised and so shuts down production of LH and FSH, resulting in a state of hypogonadotrophic hypogonadism
48
What is the mechanism of action of SSRIs?
- Serotonin is a neurotransmitter, carrying messages from the pre-synaptic to the post-synaptic neurone - SSRIs prevent re-uptake into the pre-synaptic neurone and therefore there is more 'free' serotonin, potentiating serotonergic activity in the CNS
49
What are some examples of GnRH analogues?
Leuprorelin - "Prostap" Triptorelin - "Decapeptyl"
50
What proportion of women will develop PN depression?
10-15%
51
What proportion of women are affected by postpartum psychosis?
1-2/1000
52
In what proportion of postpartum psychosis cases is no risk factor identified?
50%
53
What is the background risk of OCD? And in the postnatal period?
Background risk - 1 in 100 Postnatal period - 2-3 in 100
54
Olanzapine may be associated with what antenatal complication?
Gestation diabetes, which could cause fetal macrosomia
55
Is there an association between sertraline and neurodevelopmental delay?
No
56
Section 2 of the MHA allows detainment for compulsory admission for how long?
Up to 28 days
57
Section 3 of the MHA allows detainment for compulsory admission for how long?
Up to 6 months
58
Section 4 of the MHA allows detainment for compulsory admission for how long?
Up to 72 hours (emergency detention)
59
What is a Section 136?
Empowers police to transport a patient from a public place to a place of safety for medical assessment
60
What is the strongest risk factor for postpartum psychosis?
A personal history of bipolar affective disorder
61
What are the risk factors for development of postpartum psychosis?
Bipolar Family history of BPAD Previous episode of postpartum psychosis Primiparity Insomnia
62
Does a screening tool for postpartum psychosis exist?
No, and the EPDS does not assess for symptoms of psychosis
63
What is the risk of suicide in postpartum psychosis?
5%
64
What is the risk of infanticide in postpartum psychosis?
4%
65
What are the early symptoms of postpartum psychosis?
Labile mood Sleep disturbance Agitation/irritability
66
What are the established symptoms of postpartum psychosis?
Confusion Delusions Depersonalisation Depression/anxiety Hallucinations Mania Suicidal ideation
67
What is the prevalence of bulimia in females?
1.5%
68
What proportion of women with pre-existing OCD will have their symptoms exacerbated by pregnancy?
A 1/3rd
69
When a woman has been using olanzapine/aripriprazole/clozapine/other anti-psychotics in pregnancy, why should delivery be planned on a unit with NICU facilities?
Because of the association with withdrawal symptoms in the neonate and/or poor neonatal adaptation syndrome (PNAS)
70
By what degree does the GDM risk increase in pregnancy when taking clozapine?
8-fold
71
What is the UK incidence of anorexia?
63 per 100 000 women
72
In what age bracket of women is anorexia most common?
15–19 year olds
73
What degree of loss of normal body weight may lead to amenorrhoea?
10-15% of normal body weight
74
Why my anorexia nervosa result in delayed detection of pregnancy?
Due to menstrual irregularity
75
What risks can occur in those whom conceive whilst underweight?
Hyperemesis Anaemia IUGR Pre-term birth
76
How does anorexia affect BMD?
90% = osteopenia 40% = osteoporosis at one or more skeletal sites
77
How does bulimia affect BMD?
Even those with bulimia with normal weight have spinal BMD significantly lower than healthy controls
78
What factors may contribute to reduced BMD in anorexia?
1. Oestrogen deficiency 2. Low intake of calcium and vit D 3. Low growth factors such as ILGF-1/dehydroepiandrosterone
79
Does CHC protect against osteoporosis in anorexia patients?
No (although it has traditionally been used to try to do so)
80
How may anorexia affect a coil fitting?
- If there is amenorrhoea, there may be an atrophic uterus, with short uterine cavity - Cardiac abnormalities, e.g. bradycardia, low blood pressure and long QT are more common. Long QT requires discussion with cardiologist, Pre-existing bradycardia/low pulse increases the chance of a fitting-associated vasovagal
81
What fetal abnormalities may lithium be associated with?
Right ventricular outflow obstruction Previous evidence has linked Lithium to Epstein’s anomaly, although more recent evidence is conflicting
82
How can Lithium levels fluctuate in pregnancy?
Maternal dehydration, e.g. vomiting, can increase serum lithium levels Increased renal clearance later in pregnancy may reduce levels
83
How often should Lithium be monitored during pregnancy?
4-weekly until 36 weeks, and then weekly until delivery
84
Which SSRIs are best in breastfeeding (owing to short half-lives, reduced passage into breast milk)
Sertraline and paroxetine
85
Which SSRI has the longest half-life, and therefore could lead ot accumulation, and should ideally be avoided in breastfeeding?
Fluoextine
86
For infants being breastfed whilst Mum is using an SSRI, what symptoms should they be monitored for?
Drowsiness Poor feeding Failure to thrive GI disturbance Irritability and restlessness
87
How could methylphenidate effect a pregnancy?
1. 2-fold increased risk of miscarriage when used in early pregnancy 2. Low APGARs later in pregnancy has been identified 3. Use in early pregnancy also a prognostic RF for cardiac malformation - consider fetal echo at 13-22 weeks

Part 1 MFSRH 2024 (20 decks)

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