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Women's health > WEEK 1 Menstrual Cycle & Uterine Conditions > Flashcards

WEEK 1 Menstrual Cycle & Uterine Conditions Flashcards

1
Q

What is the process through which sex hormones controlling the menstrual cycle are synthesized from cholesterol?

A

Steroidogenesis

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2
Q

Which part of the brain initially releases the gonadotropin-releasing hormone?

A

Hypothalamus

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3
Q

Which hormones does the pituitary gland produce when stimulated by GNRH?

A

FSH & LH

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4
Q

The withdrawal of which hormone results in menstruation?

A

Progesterone

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5
Q

What is the purpose of the follicular phase of the menstrual cycle?

A

To produce an ovum

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6
Q

In the absence of conception, what process does the unfertilized follicle undergo?

A

Luteinization

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7
Q

During which phase of the menstrual cycle does the endometrial tissue develop?

A

Proliferative phase

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8
Q

Menorrhagia

A

Heavy, prolonged menstrual flow

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9
Q

Oligomenorrhea, hypomenorrhea

A

light bleeding

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10
Q

Polymenorrhea, hypermenorrhea

A

frequent bleeding

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11
Q

Metorrhagia

A

Irregular bleeding patterns

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12
Q

Intermenstrual bleeding

A

Bleeding between periods

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13
Q

Post Coital bleeding

A

after intercourse

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14
Q

what is PALM-COEIN an acronym for? What does the acronym stand for?

A

Standardize causes of abnormal vaginal bleeding

PALM: Anatomical/Structural Etiology **Diagnosed w/imaging**

Polyps

Adenomyosis

Leiomyoma (fibroids)

Malignancy and Hyperplasia

COEIN: Hormonal/Functional Etiologies

Coagulopathy

Ovulatory Dysfunction

Endometrial

Iatrogenic

Not Yet Classified

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15
Q

What are Endocervical Polyps?

Where do they arise from?

What Do they look like? #3

A

Benign growths/Skin Tags

Hyperplastic epithelial cells & Vascular Core Component

Fleshy/Pedunculated lesion (on a stalk)/pear-shaped

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16
Q

Steroidogenesis

A

What is the process through which sex hormones controlling the menstrual cycle are synthesized from cholesterol?

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17
Q

Hypothalamus

A

Which part of the brain initially releases the gonadotropin-releasing hormone?

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18
Q

FSH & LH

A

Which hormones does the pituitary gland produce when stimulated by GNRH?

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19
Q

Progesterone

A

The withdrawal of which hormone results in menstruation?

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20
Q

To produce an ovum

A

What is the purpose of the follicular phase of the menstrual cycle?

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21
Q

Luteinization

A

In the absence of conception, what process does the unfertilized follicle undergo?

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22
Q

Proliferative phase

A

During which phase of the menstrual cycle does the endometrial tissue develop?

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23
Q

Heavy, prolonged menstrual flow

A

Menorrhagia

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24
Q

light bleeding

A

Oligomenorrhea, hypomenorrhea

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25
Q

frequent bleeding

A

Polymenorrhea, hypermenorrhea

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26
Q

Irregular bleeding patterns

A

Metorrhagia

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27
Q

Bleeding between periods

A

Intermenstrual bleeding

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28
Q

after intercourse

A

Post Coital bleeding

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29
Q

Standardize causes of abnormal vaginal bleeding Polyps Adenomyosis Leiomyoma (fibroids) Malignancy and Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified

A

what is PALM-COIN an acronym for? What does the acronym stand for?

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30
Q

What is Adenomyosis?

What are risk factors for Adenomyosis? #5

How to diagnose?

A

Endometrial tissue from uterus deep into uterine muscle in uterine wall

Variant of Endometriosis

Risk Factors:

  1. Multiple pregnancies (even sponanteous abortions)
  2. Uterine surgery
  3. C-section
  4. DNC
  5. Women in 40s - 50s

Diagnosis: TVS or MRI

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31
Q

What are the symptoms of Endocervical Polyps?

When should you remove Endocervical Polyps?

A

Post-Coital Bleeding

Asymptomatic

Remove & send for histology/cytology when:

  1. >3cm
  2. friable,
  3. irregular,
  4. necrotic
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32
Q

Symptoms of Adenomyosis

How do you diagnosis?

A

PALM classification

  • Asymptomatic, often
  • Knifelike, stabbing pain (pretty severe)
  • Dysmenorrhea (painful menstrual cramps)
  • Dyspareunia (pain w/intercourse)

Diagnosis:

  • Ultrasound
  • MRI
  • Histology
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33
Q

What is Leiomyoma?

What does it arise from?

A

PALM Classification

“Uterine Fibroids”

Benign Fibro-muscular tumors

Arises from uterine wall smooth muscle

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34
Q

What is a leading indicator of Hysterectomy?

A

Leiomyoma/Uterine Fibroids

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35
Q

What is a Leiomyoma?

Leiomyoma symptoms

How are Leiomyomas described?

A

Fibroids; benign tumors from smooth muscle cells of myometrium

S/S:

Asymptomatic; usually requires no intervention

Described based on location

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36
Q

Where are subserous fibroids?

Where do you palpate for them?

A

Located outside of uterus

Palpated abdominally

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37
Q

What type of fibroids give the uterus an irregular contour and are located within the organ?

A

Intramural fibroids

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38
Q

Where are submucosal fibroids located?

Are they palpable?

A

Location: Uterine Endometrium (inner lining of uterus/endometrium)

Benign

Palpable as enlarged or irregularly shaped uterus

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39
Q

What type of woman would you see with fibroids?

S/S of fibroids? #4

Diagnosed?

A

usually seen in women transitioning to the menopausal phase

  • Anemia
  • Regular/cyclical bleeding in conjunction with menses
  • Rectal & pelvic pressure
  • Increase urinary frequency

Diagnosed via US

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40
Q

____ is an overgrowth of endometrial glands and occurs in women over ___ years

A

Endometrial hyperplasia & malignancies

50 years

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41
Q

Risk factors of Endometrial Hyperplasia & Malignancy #9

A
  • early menarche/late menopause
  • PCOS
  • anovulatory conditions
  • nulliparity
  • infertility
  • obesity
  • Whites
  • Unopposed exogenous estrogen
  • DM/HTN/gallbladder disease
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42
Q

COEIN Classification: Coagulopathy

A

ABNORMAL UTERINE BLEEDING

Clotting deficiencies EX: Thrombocytopenia, liver disease or plt deficiencies

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43
Q

What should be ruled out for a young woman with heavy bleeding with her menstrual cycle since time of menarche?

A

Von Willebrand disease

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44
Q

Signs of Von Willebrand disease

Labs would you order?

How to diagnose?

A
  • Heavy bleeding
  • Bruising easily (1-2x/month)
  • Prolonged bleeding
  • Epistaxis (1-2x/month)
  • Family hx

LAB:

  • PT
  • PTT
  • PLT

Diagnosis:

  • Hematologic testing
  • Refer to Hematology to make diagnosis
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45
Q

AUB: Ovulatory Dysfunction

Cause

A

Causes:

  • Endocrine disorders
    • Thyroid (Hypothyroidism)
    • Luteal Phase Defect (lack of progesterone)
    • Adrenal Hyperplasia
  • Renal Failure
  • Liver Disease
  • Unopposed estrogen (PCOS)
  • Exessive exercise/Stress

“diagnosis of exclusion when no other organic causes are identifiable”

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46
Q

AUB: Endometrial

S/S #3

Cause #4

A
  • *All child bearing age who present with AUB should be considered pregnant and hcG part of assessment**
  • Means something is wrong with endometrial lining not just endometriosis*

S/S:

  • Longer & Heavy menstrual bleeding
  • Predictive cyclical patterns
  • Intermenstrual bleeding

CAUSE:

  • PID-chlamydia, gonorrhea = endometritis
  • Retained placenta fragments
  • Endometritis
  • Post-abortal issues
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47
Q

AUB: Iatrogenic Conditions

Causes #5

A
  1. Medications:
  • Anticonvulsants (Dilantin)
  • Digoxin
  • Anticoagulants
  • Progestin-containing contraceptives
  1. IUD & complications
  2. PID Complications
  3. Chronic Steroid Use
  4. Opiates
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48
Q

AUB: Not Classified

Causes

A

AV malformations in uterine

anything not diagnosed or fit other categories

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49
Q

What lab work do you order when evaluating abnormal uterine bleeding?

A
  • HcG
  • CBC
  • TSH (or amenorrhea or anovulatory bleeding)
  • Prolactin (or amenorrhea or anovulatory bleeding)
  • PT, PTT (r/o coagulopathy)
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50
Q

Who is required an Endometrial Biopsy? #4

A
  1. Post-menopausal women w/abnormal uterine bleeding
  2. Women on hormone therapy with abnormal bleeding
  3. Unscheduled bleeding on Oral Contraceptives that lasts more than 3 months
  4. Endometrial stripe greater than 5ml on US
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51
Q

A patient is having anovulatory bleeding and there is no response to treatment…What do you order?

A

Pelvic US

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52
Q

You suspect an anatomic defect such as polyps and fibroids…What do you order?

A

saline infusion sonogram

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53
Q

What is considered primary amenorrhea?

A
  1. No Menses by 14yrs in absence of 2ndary sex characteristics

OR

  1. No Menses by 16 yrs regardless of 2ndary sex characteristics
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54
Q

What is secondary amenorrhea?

A

Absence of menses in previously normal menstruating

An interval of at least 3 cycles

OR

an interval of 6 months (after normal menstruation patterns established)

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55
Q

What are 4 causes of Amenorrhea?

A

Genital outflow tract disorder

Ovary disorder

Anterior Pituitary disorder

Hypothalamus or CNS disorder

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56
Q

Asherman Syndrome

A

Intrauterine adhesions

Scar tissue after surgery EX: C-Section

Mechanical obstruction of endometrium, vagina, or cervix

S/S:

  • No pain
  • No bleeding r/t uterine lining becoming obliterated
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57
Q

Cervical Stenosis

A

Cervical scar tissue becomes a plug so blood cannot drain

CAUSE:

Cone biopsy of cervix

LEEP procedure

Cryotherapy

Dilation & curettage

Congenital absence of uterus or vagina

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58
Q

What can cause diseases of the ovary that lead to amenorrhea?

A

Usually before 40 years old or Premature Ovarian Failure

Autoimmune Diseases

  • Thyroid, Addisons, DM, Lupus, RA

Ovarian Destruction

  • Chemo/Radiation, Asherman’s, Mumps, Abscess

Galactosemia

PCOS (alters estrogen levels)

hyperandrogenism/anovulation (interferes w/HPO axis)

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59
Q

Disorders of the Ovary causes

A

HPO Axis intact but hyperadrogen state = Anovulatory Amenorrhea

Hyperadrogen states

  • PCOS
  • Adult-onset congenital adrenal hyperplasia
  • Decreased FSH or LH
  • Lifestyle
  • Hyperprolactinemia

Vascular Infarction

  • Postpartum Hemorrhage “Sheehan Syndrome” (destroys pituitary gland from lack of O2)
  • “Simmonds’ Syndrome” outside of pregnancy (pit destroyed)

Primary Hypothyroidism

  • ^prolactin production
  • Pituitary tumors secrete GH or TSH
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60
Q

Amenorrhea: Disorder of Anterior Pituitary

A

HYPERPROLACTINEMIA

Cause:

  • Prolactin-secreting adenoma tumor (prolactinoma)
  • Hypothyroidism
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61
Q

What are disorders of the Hypothalamus or CNS that cause amenorrhea?

A
  • Lifestyle issues
    • exercise (endorphins inhibit GnRH, LH, & FSH)
    • Anorexia
  • Hypothalamic Lesions (reduce GnRH, FSH & estrogen)
    • Tb
    • Sarcoidosis
    • Encephalitis
  • Medications (effect prolactin levels)
    • antihypertensives
    • psychotropic drugs
    • Contraceptives
    • H2 blockers
  • Chronic diseases
    • DM
    • Crohn’s
    • Celiac’s
    • CF
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62
Q

What drugs can cause amenorrhea? How?

A
  • Antihypertensives
  • Psychotropics
  • Oral contraceptives
  • H2 blockers

Affect Prolactin Levels

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63
Q

How do you “work up” Amenorrhea?

A
  1. R/O pregnancy & menopause
  2. Overall Health Inquiry
  3. Physical Exam (BMI

Labs:

  • HcG
  • TSH
  • Prolactin levels
  • FSH
  • LH

Provera Challenge Test (Progesterone withdrawal test)

*trying to induce withdrawal bleed

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64
Q

What does a Provera Challenge test show?

How long after giving estrogen can we do a Provera Challenge?

A

Progesterone withdrawal = Bleeding

Normal response = period-like bleed = hormone dysfunction

_No Respons_e = Give exogenous estrogen

No response to exogenous estrogen followed by progesterone = Outflow tract problem

Bleeding response after estrogen & progesterone = Limited endogenous or inadequate estrogen >>> check Gonadotropin levels

2 weeks

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65
Q

What is a normal FSH range?

A

5 - 30 IU/L

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66
Q

What is a normal LH range?

A

5 - 20 IU/L

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67
Q

What do high FSH and LH levels mean?

A

Most likely ovarian problem

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68
Q

What do low FSH or low LH mean?

A

Pituitary or CNS problem

69
Q

What labs would you order for someone with heavy menstrual bleeding?

A

HcG

CBC

TSH

LFT

Coags

Cervical Cultures to r/o infection

70
Q

How would you “work up” heavy menstrual bleeding? #5

A
  1. Pregnancy test
  2. Pelvic Exam (masses or pap smear)
  3. Labs
  4. Endometrial biopsy (if indicated)
  5. Pelvic Sonogram (fibroids, polyps, measure endometrial stripe)
71
Q

How thick should the endometrium be during the Follicular phase? Pre-ovulation?

A

Follicular Phase:

1-2 ml

Pre-Ovulation:

3-5 mL

72
Q

An endometrial stripe greater than ___ mL should be evaluated further

A

5 mL

73
Q

How does progestin tx heavy bleeding? Lupron? NSAIDs? Danazol?

A

Progestin:

Keeps Endometrium in secretory phase = limited endometrial growth

Lupron (GnRH agonist)

Ovaries can’t release hormones = menopause state

NSAIDs

Block synthesis of prostaglandins = no cyclical endometrial sloughing

Danazol/ Danoctinre

a synthetic steroid that tx endometriosis

74
Q

Patient Education for Danazol?

A

*not the first choice = refer to OBGYN

Causes Amenorrhea

DC after 6 months

Adrogen side effects (weight gain, acne, seborrhea)

75
Q

Patient education for Lupron (GnRH agonist)

A

Physiologic state similar to menopause

May result in bone loss

76
Q

Differential Diagnosis for Irregular Menses/Metorrhagia #7

A
  1. Pregnancy
  2. Threatened spontaneous abortions
  3. Ectopic Pregnancy
  4. Gestational Trophoblastic Neoplasm
  5. STI
  6. Trauma
  7. Mid cycle bleeding = ovulation?
77
Q

What is the one endocrine disease dysfunction that causes heavy menstrual bleeding?

A

Hypothyroidism

78
Q

What should you suspect if you see poor endometrial build up and irregular bleeding? Commonly seen in?

What is the treatment?

A
  • Low levels of cyclic endogenous estrogen
  • High levels of progestin

Commonly seen: in Depo-Provera implants or OCP

Treatment:

-Estrogen therapy for 7 to 10 days then Progesterone to initiate withdrawal bleed & protect against hyperplasia

79
Q

What would you see in someone that has PCOS?

signs

Labs

Menses

A

Hirsutism, acne, obesity, alopecia, seborrhea, & acanthosis nigricans

Normal Estrogen

High Androgen

Anovulation

Chronic oligo or amenorrhea

Insulin resistant

80
Q

What is the diagnostic criteria for PCOS?

A
  1. Irregular or No periods
  2. Androgen excess symptoms
  3. Multiple early mid-follicular stage cysts 10 mm

*Diagnosis of exclusion

*Only diagnosed in the absence of other conditions

81
Q

Women suspected of PCOS with menstrual dysfunction and hyperandrogenism should be screened for? #5

A
  1. Pregnancy (HcG)
  2. Hypothyroidism (TSH)
  3. Hyperprolactinemia (prolactin level)
  4. Glucose intolerance (OGTT)
  5. Dyslipidemia (lipid profile)
82
Q

What are causes of hyperadrogenism?

A
  1. Androgen secreting tumors
  2. Adrenal Gland tumors
  3. Adult onset congenital adrenal hyperplasia
  4. Cushing’s syndrome
83
Q

How to diagnose Androgen-secreting tumors

A

Testosterone >200ng/mL

Pelvic US

Palpation on physical exam

84
Q

How to assess for adrenal gland tumor?

A

DHEAS level

85
Q

How to assess for adult-onset non-classical congenital adrenal hyperplasia?

accompanying symptoms?

Labs?

A

Usually accompanied by primary or secondary amenorrhea

Hypertension in childhood or family history

More common in Hispanics, Italians, Slavics, Jew, & Inuit

Draw 17-hydroxyprogesterone fasting levels, >2ng/mL = PCOS

86
Q

What 17-hydroxyprogesterone fasting level would be suspicious for PCOS?

A

>2ng/mL

87
Q

Hwo to test for Cushing’s syndrome?

A

24 hour urine for cortisol

88
Q

How to OCPs treat PCOS?

A
  1. Supress enlarged ovaries
  2. Inhibit LH & androgen production
  3. Protect endometrium from unopposed estrogen
  4. Binds up free testosterone (relieved acne & hirsutism)
89
Q

How long does it take to see a reduction of hair growth with combined oral contraceptives?

A

9 to 12 months

90
Q

Which progesterones have low adrogen effects?

A

Desogestrel

Norgestimate

Drospirenone

91
Q

What would you give to manage PCOS if contraception is not required?

A

Medroxyprogesterone acetate

5-10mg daily for first 14 days of each month

Progestin only Does not treat hirsutism

92
Q

How to treat hirsutism with PCOS?

A

Antiandrogens used in combination with contraception because they are teratogenetic

Spironolactone (Aldactone): inhibits testosterone (hirsutism & alopecia)

Finasteride (Proscar, Propecia): blocks conversion of testosterone DHT

93
Q

How to manage metabolic syndrome associated with PCOS

A

Insulin sensitizing agents

Metformin

Not 1st line or to be given solely for weight loss & hirsutism

Decreases androgen levels, BP, LDL, fasting insulin

**Can induce ovulation with clomiphene (Clomid)

94
Q

What is Lupron used to treat? How does it work? Why is this not a great option?

A

PCOS hirsutism

MOA:

inhibits gonadotropin secretion & ovarian hormone section = slows hair growth & severe estrogen deficiency

Expensive & requires estrogen therapy & injections

95
Q

What do you want to monitor and follow up for in PCOS patients?

A

Diabetes - glucose tolerance Qannualy

Lipids -Q 2 years

Hypertension

Smoking cessation

96
Q

Primary dysmenorrhea

Onset?

Cause?

A

Onset:

  • 6-12 months menses onset

Cause:

  • Increased prostaglandin production
  • Reduction in uterine blood flow = uterine contractions (angina of vagina)
  • Assoc w/ anxiety and depression
  • No anatomic issues
97
Q

Secondary dysmenorrhea

Cause?

Associated symptoms?

A

Less common

Cause:

  • Pelvic Pathology
  • Pelvic floor weakness
  • IBS
  • Interstitial cystitis/UTI
  • Endometritis
  • Fibroids/Polyps/Cancer

Associated Symptoms

  • dyspareunia
  • post coital bleeding
  • abnormal uterine bleeding
98
Q

How is secondary dysmenorrhea different from primary dysmenorrhea?

A

Secondary occurs before, during or after menstrual period

Pathologic & not caused by prostaglandins

Occurs later in life

99
Q

How to meet the diagnostic requirements of PMDD

A
  1. Symptoms during majority of menstrual cycles
  2. Decreased interest in usual activities
100
Q

What are differential diagnosis for PMDD?

What are the goals of PMDD treatment?

A
  1. Endocrine
  2. Psychiatric
  3. Chronic pelvic pain, IBS, Crohn’s, hypothyroidism, endometriosis, ovarian cysts, fibromyalgia, arthritis

Goals of Tx

  1. Stabilize hormone levels
  2. Suppress ovulation
  3. Antidepressants/antianxiety
  4. Lifestyle changes
  5. Calcium supplementation
  6. SSRIs
101
Q

What is the difference between adenomyosis & uterine fibroids?

A

Uterine fibroids are benign tumors in wall of uterus

Adenomyosis is when the inner lining of the uterus grows into the muscle wall of uterus causing heavy painful periods

102
Q

How often does the hypothalamus release GnRH?

A

60-90mins

103
Q

What is the role of FSH?

A

plays a dominant role in promotion of ovarian follicular growth

104
Q

What is the role of LH?

A

stimulates androgen production in the theca cells

105
Q

It is the preliminary role of ____ to stimulate the production of androgens by the granulosa cells

A

LH

106
Q

What happens during days 1-5 during the follicular phase?

A

Main purpose of follicular phase is the development of follicles in ovary

Days 1 -5

Follicle are recruited and begin to grow

Increasing estradiol levels to induce more FSH receptors on largest follicle thus producing a greater amounts of estradiol

107
Q

What happens during days 5- 7 of the follicular phase?

What happens after day 7?

What happens at the end of the follicular phase?

A

Days 5-7

1 follicle becomes more dominant& produces most estradiol and has the most receptors

Day 7

The dominant follicle is selected

At the end: LH surge

108
Q
A
109
Q

When does positive feedback occur during the menstrual cycle?

Describe the positive feedback loop during this phase

A

Ovulation phase

  1. Estradiol reaches critical level (usually 24 hours before ovulation) =
  2. positive feedback in pituitary =
  3. causes LH & FSH surge
  4. LH causes progesterone production
110
Q

What is the hallmark of the luteal phase?

A

shift from estrogen dominant-follicular phase to Progesterone dominance

111
Q

When is peak progesterone production?

A

7-8 days after the LH surge (at the approximate time of implantation if fertilization has occurred)

112
Q

A patient has a uterus that is slightly enlarged, boggy and tender on exam. What might the working diagnosis be?

A

Adenomyosis

113
Q

What are the 3 subcategories of AUB-Ovulatory Dysfunction?

What do they look like?

What are their causes?

A
  • Anovulatory Uterine Bleeding
    • Abnormal cycle intervals, usually heavy bleeding
    • Cause: Hormone imbalance (PCOS, obesity
  • Amenorrhea
    • No Menses
    • Cause: Disorder of genital outflow tract, ovary, anterior pituitary, or hypothalamus/CNS
  • Ovulatory AUB
    • Cyclic & regular, Heavy bleeding
    • Cause: polyps, fibroids
114
Q

What labs would you order for someone with Amenorrhea?

A

Urine hcG

FSH/LH

Prolactin

TSH, T3, T4

115
Q

What labs would you order for someone that you suspect has Von Willebrand Disease?

A

Ristocetin cofactor assay

PT/PTT

Platelets

116
Q

When is the best time in the menstrual cycle to perform a transvaginal scan?

A

Days 4-6

117
Q

When would you do an endometrial biopsy?

A
  1. History of AUB-Ovulatory Dysfunction AND Ages 45+
  2. 30-45 not responding to medical Tx,
  3. Hx unopposed estrogen and persistent AUB
  4. Endometrial thickness >5 mm
118
Q

What is Asherman’s?

Cause

Symptoms

A

Disorder of the genital outflow tract

Severe inflammation of the uterus from bands of scar tissue that join parts of the walls of the uterus to one another reducing the volume of the uterine cavity

Cause: uterine instrumentation, endometrium infection

119
Q

Following the rupture of the follicle, the ___ and ____ cells take up ____ and ____ to give the corpus luteum (yellow body) a yellow appearance

A

Following the rupture of the follicle, the granulosa and theca cells take up steroids and lutein pigment to give the corpus luteum (yellow body) a yellow appearance.

120
Q

The proliferative phase of the uterine cycle is under the influence of….progesterone or estrogen?

What days of the cycle are the proliferative phase?

A

estrogen

Proliferative phase is Days 7-14

121
Q

Estrogen increases the thickness of the endometrium by increasing the number and ____ of _____ cells

A

Estrogen increases the thickness of the endometrium by increasing the number and size of endometrial cells

122
Q
  1. false
  2. true
  3. true
  4. f
A
123
Q

What hormone is responsible for the LH surge and ovulation?

A

Estrogen

124
Q

What is considered a frequent period?

A

Less than 24 days between cycles

125
Q

What is considered an infrequent period?

A

More than 38 days between cycles

126
Q
A
127
Q

What is the normal duration of a period?

A

8 days or fewer

128
Q

What is a normal variation in cycle length?

A

Shortest to longest shouldn’t vary more than 7-9 days

129
Q

What is an irregular cycle variation length?

A

Any variation more than 8 to 10 days

130
Q

metro menorrhagia define

A

irregular AND heavy menstrual bleeding

131
Q

How does adenomyosis feel on exam?

A

Tender (especially during menses)

Enlarged/Heavy feeling

Boggy

132
Q

How to evaluate AUB?

A
  1. R/O pregnancy
  2. Where is the bleeding coming from? (r/o bladder, rectum)
  3. Is it anovulatory
  4. bleeding regular or irregular?
  5. Associated symptoms EX bruising
133
Q

What labs are important to order if someone is having amenorrhea or anovulatory bleeding?

A

TSH

Prolactin

134
Q
A
135
Q

3 Examples of functional hypothalamic amenorrhea

What will their labs look like?

A
  1. Weight loss below certain level
  2. Female athlete: amenorrhea, disordered eating & osteoporosis
  3. emotional stress

not enough GnRH produced therefore no FSH/LH = no estrogen production

Low estrogen

136
Q

What is the most common cause for amenorrhea with an anterior pituitary disorder?

What would your order if you were suspicious of an anterior pituitary disorder?

A
  • Hyperprolactinemia caused by a “prolactinoma” prolactin-secreting adenoma tumor
  • Hypothyroidism = hyperprolactinemia

Orders include

  • Prolactin level
  • MRI/CT pituitary
137
Q

What are some labs you would order for amenorrhea?

A
  • TSH & Prolactin
  • FSH & LH
  • Provera challenge
138
Q

What does it mean if your patient with amenorrhea has normal TSH, Prolactin, FSH, & LH?

What would you order next? why?

A

Functional Hypothalamic Amenorrhea

Progestin challenge test

  • to r/o outflow concerns & see if uterus is being primed with estrogen
139
Q

Progesterone Challenge 10 mg daily for 7-10 days

  1. Bleeding >>>
  2. No bleeding with Progesterone >>>
  3. Bleeding after estrogen >>>>
  4. No bleeding with progesterone or estrogen >>>>
A
  1. Bleeding >>> anovulatory (PCOS) *not ovulating and getting into that luteal phase for the progesterone…unopposed estrogen*
  2. No bleeding with Progesterone >>> Give estrogen for 21 days followed by progesterone
  3. Bleeding after estrogen >>>> HPOA issue
  4. No bleeding with progesterone or estrogen >>>> endometrial lesion or outflow tract obstruction TX hysterosalpingography or hystroscopy
140
Q

True or False: A positive progesterone challenge test means no outflow concerns and the FNP should look at higher-up components as causes of amenorrhea?

A

True

141
Q

True or False:

A negative progesterone challenge test is concerning for outflow tract abnormalities?

A

True

142
Q

True or False:

Low BF and excessive stress/exercise are common causes of functional hypothalamic amenorrhea which affects the HPO axis leading to hypo estrogen states

A

True

143
Q

How to treat acute vaginal bleeding

A

Estrogen therapy IV (stops the shedding and regrows the uterine lining)

Once stable, Monophasic COC

or

Progestin therapy if endometrium is thick

144
Q

What is the treatment of choice for chronic anovulation bleeding?

A

Progestin

145
Q

What is Lupron/Synarel used for? How does it work?

A

Treats heavy bleeding r/t endometriosis

GnRH agonist

puts the person in menopause by shutting down the whole cycle

146
Q

What are some causes of Menorrhagia?

A

Heavy menstrual flow/cramping

  1. Miscarriage
  2. Mid Cycle Ovulation
  3. STI - Cervicitis
  4. Trauma
  5. Oral contraceptives
147
Q

What is primary dysmenorrhea?

Cause?

A

Painful cramps *most common cause dysmenorrhea

  • Begins 6-12 months after onset menses

Cause:

  • Increased prostaglandin production causing uterine contractions

Symptoms

  • Ischemic pain “angina of vagina”
  • Recurrent symptoms w/ each cycle and resolution with end of menses
  • NOT PSYCHOSOMATIC
148
Q

What is a key component of primary dysmenorrhea?

A

Recurrent symptoms with each cycle and resolution with the end of menses

149
Q

What are the common causes of secondary dysmenorrhea?

A

usually ages 30-40; less common than primary dysmenorrhea

Causes:

1st - Endometriosis

2nd - Adenomyosis

fibroids, polyps, cysts, cancer, PID/STI, pelvic floor weakness, IBS, Interstitial cystis, UTI

150
Q

What is the gold standard of diagnosis endometriosis?

A

Laproscope

151
Q

Multiple symptoms of Premenstrual disorder occurs only during…

A

Luteal phase: <7 days prior to menses & resolve with menses (days 2-13)

Charted during at least 2 cycles

152
Q

What criteria do you need to be diagnosed with PMD

A
  • 1+ affective symptoms: emotional lability, anger, feelings of hopelessness, anxious
  • 5 PMS symptoms: poor concentration, appetite changes, decreased interest in activities, fatigue, breast tenderness, bloating, weight gain, joint aches, insomnia or hypersomnia
153
Q

PMD Management

A
  • COC: Yaz approved for PMD, diuretic effect
  • SSRI if symptoms emotional: Day 14 of cycle for 2 weeks
  • Anxiolytics last resort
154
Q

What are herbal supplements to treat PMD?

A
  • Vitex agnus-castus (Chasteberry)
  • Evening primrose oil
  • tumeric
  • Calcium supplements
155
Q

True or False

Progestin pills or a progesterone IUD are good options for the treatment of PMDD?

A

False

We want to suppress ovulation. Progestin does not suppress ovulation

156
Q

What underlying disorders are you ruling out for PCOS? What diagnostic studies would you order?

A
  1. hCG - pregnancy
  2. TSH - hypothyroidism
  3. Prolactin - hyperprolactinemia
  4. OGTT, FBS or HbA1C - Glucose Intolerance
  5. Lipids - Dyslipidemia
  6. Testosterone - hyperadrogenism
157
Q

When working up PCOS, what are other causes of hyperandrogenism?

A
  • Androgen-secreting tumor
  • Adrenal gland tumor
  • Adult-onset non-classical congenital adrenal hyperplasia
  • Cushing’s syndrome

For excessive or rapid onset androgen symptoms

158
Q

What would you prescribe someone with PCOS that does not want contraception?

A

Medroxyprogesterone acetate 5-10mg po daily for the 1st 14 days of each month

**progesterone alone will not treat hirsutism

159
Q

What is the follow up for PCOS?

A
  1. Treat DM, dyslipidemia & hypertension
  2. Smoking cessation
  3. Lipid profile Q2 years
  4. GTT for DM annually or every 2 years if normal
160
Q

True or False:

PCOS can put individuals at higher risk for breast cancer?

A

False

puts them at higher risk for endometrial or uterine cancer

161
Q

What are the 3 most common signs of TSS?

A

Rapid onset Fever

Hypotension

Sunburn like rash

Multiorgan system dysfunction

162
Q

How do you diagnose TSS?

A
  1. Involves at least 3 organ systems

usually staph aureas

163
Q

What are the benefits of OCPs for dysmenorrhea?

A
  1. Contraception
  2. Rapid Relief
  3. Cycle Control
164
Q

How does OCPs work for dysmenorrhea?

A
  1. Suppress ovulation & endometrial tissue overgrowth
  2. Decrease prostaglandin production & lower menses volume
  3. Lower intrauterine pressure & cramping
165
Q

How is TSS treated?

A

ED & infectious disease specialist

IV hydration

Supportive care

Sources of bacteria removed and cultured

166
Q

What are causes of anovulatory bleeding?

A

· Estrogen Withdrawal

· Estrogen breakthrough EX: PCOS (from chronic anovulation from high androgen production), perimenopausal

· Progesterone breakthrough EX: Progestin only pills

167
Q

What is the characteristic US sign of PCOS?

A

Thickened, glistening, white, enlarged multicystic ovary

20+ follicles and/or ovarian volume over 10ml

168
Q

What is the treatment for PCOS when conception is desired?

A

Weight loss

Metformin

Referral

169
Q

When is an endometrial evaluation necessary? What does it involve?

A

Post menopausal with uterine vaginal bleeding

Ovulatory dysfunction and older than 45

OR

<45yrs, unopposed estrogen exposure, failed medical management & persistent abnormal uterine bleeding

Women's health (10 decks)

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