UWise - Objectives 45-49 Flashcards
Describe the pathophysiology leading to anovulatory bleeding/mechanism by which MPA controls irregular bleeding.
Unopposed estrogen stimulation leads to a predominantly proliferative endometrium. Progestins inhibit further endometrial growth, converting the proliferative to secretory endometrium. Withdrawal of the progestin then mimics the effect of the involution of the corpus luteum, creating a normal sloughing of the endometrium.
Disorders of clotting may present with menstrual symptoms in young women, with ___ disease being most common.
Von Willebrand
How is endometrial polyp managed in various settings?
- Observation (not recommended if the polyp is >1.5 cm)
- Polypectomy (TOC in infertility)
- Endometrial ablation (contraindicated in patients desiring fertility)
- Medical management with progestin
- Curretage
- Hysterectomy
Patients with PCOS have ___ levels at the upper limits of normal or slightly increased. Why?
Testosterone; free (biologically active) testosterone is elevated often because SHBG is decreased by elevated androgens
What are the components of a complete workup for abnormal uterine bleeding?
TSH, Prl, pelvic U/S, endometrial biopsy
What causes mid-cycle bleeding at the time of ovulation?
Drop in estrogen
What is a common side effect from the etonogestrel implant (Nexplanon)?
Irregular spotting or bleeding
What is the mechanism by which combined OC’s treat dysmenorrhea?
The progestin in OC’s causes endometrial atrophy -> less endometrium = less prostaglandins produced -> less pain
What are some causes of secondary dysmenorrhea?
Endometriosis STIs Adhesions from PID Ovarian cysts Adenomyosis Uterine fibroids
True or false - an endometrial biopsy should be performed on all women over age 40 with irregular bleeding to rule out endometrial carcinoma.
True
What pathologic findings confirm the diagnosis of fibroids?
Well-circumscribed, non-encapsulated myometrium
What pathologic findings are consistent with endometrial polyps?
Hyperplastic overgrowth of endometrial glands/stroma
When is the decidual effect on the endometrium seen?
During pregnancy
What pathologic findings are consistent with adenomyosis?
Endometrial glands invading into the myometrium
Presentation of endometrial polyps?
Common in women ages 40-50, cause increased menstrual flow, frequently accompanied by increased cramping and intermenstrual spotting
Fibroids can cause dysmenorrhea, but ___ fibroids do not cause increased pain with menstruation.
Subserosal
What is first-line therapy for painful menses?
NSAIDs
What must be done prior to initiating hormone therapy?
Tissue diagnosis consistent with normal endometrium or a pelvic U/S with an endometrial stripe of 4 or less mm
Why does calcium absorption decrease with age?
Because of a decrease in biologically active vitamin D
___ supplementation reduces bone loss and decreases fractures in individuals with low dietary intakes. In order to remain in zero ___ balance, postmenopausal women require a total of ___mg per day (diet + supplements).
Calcium; 1200
True or false - patients who have had an osteoporotic fracture may be treated on this basis alone.
True
Prior to beginning treatment with bisphosphonates, what must be done?
BMD documented and repeated at 2 year intervals to monitor treatment (DEXA - test of choice)
How is a nuclear medicine bone scan used in evaluating bone pathology?
Ruling out a pathologic fracture from metastatic disease
What are the ACOG recommendations regarding HRT?
HRT is the most effective treatment for severe menopausal symptoms that include hot flashes, night sweats, and vaginal dryness. The physician should counsel the woman about the risk and benefits before initiating treatment. ACOG recommends the smallest effective dose for the shortest possible time and annual reviews of the decision to take hormones. A woman with an intact uterus should not use estrogen-only therapy because of the increased risk of endometrial cancer.
Why may surgical removal of postmenopausal ovaries result in the resurgence of menopausal symptoms?
Estrogen production by the ovaries does not continue beyond menopause. However, estrogen levels in postmenopausal women can be significant due to the extraglandular conversion of androstenedione and testosterone to estrogen. This conversion occurs in peripheral fat cells. Because menopausal ovaries are known to continue production of androgens, surgical removal of postmenopausal ovaries may result in the resurgence of menopausal symptoms from the abrupt drop inc circulating androgens.
Discuss the effect of HRT on cancer risk.
Increased risk of BC
Reduced risk of colon cancer
No change in risk of endometrial cancer
What are the effects of hormone therapy on serum lipid profiles?
Reduced LDL and increased HDL
How does hormone therapy reduce LDL?
Estrogen increases triglycerides and increases LDL catabolism, as well as lipoprotein receptor numbers and activity, therefore causing decreased LDL levels.
How does hormone therapy increase HDL?
Hormones inhibit hepatic lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing HDL levels
What is the ACOG recommendation for management of postmenopausal women in their 50s with T scores in the osteopenia range with and without risk factors?
Counseling on calcium and vitamin D intake and risk factor reduction to delay initiation of pharmacologic intervention
What are some of the risk factors for fracture?
Prior fracture, family hx of osteoporosis, white or Asian race, dementia, history of falls, poor nutrition, smoking, low BMI, estrogen deficiency, alcoholism, and insufficient physical activity
After one month, ___% of couples will conceive. After three months, ___%. After 6 months, ___%. After 12 months, ___%.
20; 50; 75; 90
How is primary infertility defined?
Inability to conceive for one year without contraception
What is the best way to assess adhesions and blockage of the fallopian tubes?
Hysterosalpingogram
Discuss the LH and FSH levels seen in PCOS patients.
Increased LH/FSH ratio; each test separately will not aid in the diagnosis
What are the characteristic lab findings in exercise-induced hypothalamic amenorrhea?
Normal FSH
Low estrogen
What are anti-mullerian hormone levels used to determine?
Ovarian reserve
The male factor plays a role in about ___% of infertility cases.
30
What are the first-line treatment for ovulatory dysfunction in patients with PCOS?
Metformin and ovulation induction agents
Symptoms of ___ can mimic typical symptoms of PMS, but symptoms occur more constantly throughout the cycle.
Hypothyroidism
What is a last resort treatment for women with severe PMDD refractory to other treatment options?
Bilateral oophorectomy
To ensure that surgical menopause will have satisfactory results for treatment of PMDD, what is best practice?
Administer a course of GnRH agonist to initiate a menopause-like state; resolution of PMDD symptoms with this treatment is likely to predict improvement with oophorectomy
Why might exercise decrease symptoms of PMS?
Increased circulating endorphins in the brain
List risk factors for PMS.
- Family hx of PMS
- Vitamin B6, Calcium, or Magnesium deficiency
- Age (increases as women age through their 30s)
- PMDD - previous anxiety, depression, or other mental health problems
The typical symptoms of premenstrual changes are best treated with ___.
OTC remedies such as NSAIDs and nutritional supplements
Multicenter randomized trial have demonstrated that supplementation with at least 1,200 mg of ___ improves both physical and emotional symptoms of PMS.
Calcium
