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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
Q

What is the first line management for PMD?

A

Exercise, CBT, vitamin B6
COCP
Continuous of luteal (day 15-28) low-dose SSRI

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26
Q

Why use SSRIs only in the luteal phase?

A

May reduce adverse effects of SSRIs themselves e.g. nausea, insomnia, fatigue, low libido

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27
Q

What should be considered in women of reproductive age using SSRIs for PMS alone (absence of depression etc.)?

A

Then PMS will abate in pregnancy and therefore SSRIs should be discontinued prior to/during pregnancy

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28
Q

What is the risk of SSRIs in pregnancy?

A

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

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29
Q

What are the 2nd line management options in PMS?

A

Estradiol patches + micronised progesterone (days 17-25) orally or vaginally, or use of the Mirena
Higher-dose SSRI regime

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30
Q

When using progesterone as part of 2nd line management, what considerations should be made?

A
  • 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
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31
Q

How should SSRIs be discontinued when used continuously?

A

Tapering

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32
Q

How should SSRIs be discontinued when used in the luteal phase only?

A

Immediately, no requirement for tapering

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33
Q

What is 3rd line management for PMS?

A

GnRH analogues and add back HRT

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34
Q

What is 4th line management for PMS?

A

Operative

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35
Q

Who should GnRH analogues as treatment be reserved for?

A

The most severe presentations

36
Q

When should operative management for PMS be considered?

A

When other medical management has failed
When GnRH analogues required for management of symptoms
When there is another operative indication

37
Q

What is a condition of having operative management for PMS?

A

Must have had GnRH analogues and add-back HRT prior to surgery in order to ensure can tolerate

38
Q

When should women ABSOLUTELY have HRT if using GnRH analogues?

A

If they have been using for >6/12

39
Q

What sort of HRT should women using GnRH analogues be on?

A

Continuous combined HRT or tibolone

40
Q

What surveillance should be in place for women using GnRH analogues +/- add-back HRT?

A

Yearly DEXA scanning - treatment should be terminated if there is a significant reduction in BMD

41
Q

Which women whom have operative management for PMS should DEFINITELY have HRT?

A

Those <45 y/o

42
Q

Why should women undergoing operative management for PMS also consider testosterone replacement?

A

Because the ovaries are responsible for 50% of testosterone production - deficiency of this may result in low libido (HSDD)

43
Q

Should progesterone alone be offered as a treatment for PMD?

A

No, good evidence this is not appropriate

44
Q

What should take place if a cyclical pattern of symptoms is not identified?

A

Exclude other causes:
Depression
Hypothyroidism
Anaemia
IBS
Endometriosis

45
Q

What is the mechanism of action of danazol?

A
  • 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
Q

What is the mechanism of action of tamoxifen (may occasionally be prescribed by a specialist int he context of cyclical breast pain)?

A

Selective estrogen receptor modulator (SERM), competitively inhibiting estrogen binding to its receptor

47
Q

What is the mechanism of action of GnRH analogues?

A
  • 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
Q

What is the mechanism of action of SSRIs?

A
  • 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
Q

What are some examples of GnRH analogues?

A

Leuprorelin - “Prostap”
Triptorelin - “Decapeptyl”

50
Q

What proportion of women will develop PN depression?

A

10-15%

51
Q

What proportion of women are affected by postpartum psychosis?

A

1-2/1000

52
Q

In what proportion of postpartum psychosis cases is no risk factor identified?

A

50%

53
Q

What is the background risk of OCD? And in the postnatal period?

A

Background risk - 1 in 100
Postnatal period - 2-3 in 100

54
Q

Olanzapine may be associated with what antenatal complication?

A

Gestation diabetes, which could cause fetal macrosomia

55
Q

Is there an association between sertraline and neurodevelopmental delay?

A

No

56
Q

Section 2 of the MHA allows detainment for compulsory admission for how long?

A

Up to 28 days

57
Q

Section 3 of the MHA allows detainment for compulsory admission for how long?

A

Up to 6 months

58
Q

Section 4 of the MHA allows detainment for compulsory admission for how long?

A

Up to 72 hours (emergency detention)

59
Q

What is a Section 136?

A

Empowers police to transport a patient from a public place to a place of safety for medical assessment

60
Q

What is the strongest risk factor for postpartum psychosis?

A

A personal history of bipolar affective disorder

61
Q

What are the risk factors for development of postpartum psychosis?

A

Bipolar
Family history of BPAD
Previous episode of postpartum psychosis
Primiparity
Insomnia

62
Q

Does a screening tool for postpartum psychosis exist?

A

No, and the EPDS does not assess for symptoms of psychosis

63
Q

What is the risk of suicide in postpartum psychosis?

A

5%

64
Q

What is the risk of infanticide in postpartum psychosis?

A

4%

65
Q

What are the early symptoms of postpartum psychosis?

A

Labile mood
Sleep disturbance
Agitation/irritability

66
Q

What are the established symptoms of postpartum psychosis?

A

Confusion
Delusions
Depersonalisation
Depression/anxiety
Hallucinations
Mania
Suicidal ideation

67
Q

What is the prevalence of bulimia in females?

A

1.5%

68
Q

What proportion of women with pre-existing OCD will have their symptoms exacerbated by pregnancy?

A

A 1/3rd

69
Q

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?

A

Because of the association with withdrawal symptoms in the neonate and/or poor neonatal adaptation syndrome (PNAS)

70
Q

By what degree does the GDM risk increase in pregnancy when taking clozapine?

A

8-fold

71
Q

What is the UK incidence of anorexia?

A

63 per 100 000 women

72
Q

In what age bracket of women is anorexia most common?

A

15–19 year olds

73
Q

What degree of loss of normal body weight may lead to amenorrhoea?

A

10-15% of normal body weight

74
Q

Why my anorexia nervosa result in delayed detection of pregnancy?

A

Due to menstrual irregularity

75
Q

What risks can occur in those whom conceive whilst underweight?

A

Hyperemesis
Anaemia
IUGR
Pre-term birth

76
Q

How does anorexia affect BMD?

A

90% = osteopenia
40% = osteoporosis at one or more skeletal sites

77
Q

How does bulimia affect BMD?

A

Even those with bulimia with normal weight have spinal BMD significantly lower than healthy controls

78
Q

What factors may contribute to reduced BMD in anorexia?

A
  1. Oestrogen deficiency
  2. Low intake of calcium and vit D
  3. Low growth factors such as ILGF-1/dehydroepiandrosterone
79
Q

Does CHC protect against osteoporosis in anorexia patients?

A

No (although it has traditionally been used to try to do so)

80
Q

How may anorexia affect a coil fitting?

A
  • 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
Q

What fetal abnormalities may lithium be associated with?

A

Right ventricular outflow obstruction

Previous evidence has linked Lithium to Epstein’s anomaly, although more recent evidence is conflicting

82
Q

How can Lithium levels fluctuate in pregnancy?

A

Maternal dehydration, e.g. vomiting, can increase serum lithium levels

Increased renal clearance later in pregnancy may reduce levels

83
Q

How often should Lithium be monitored during pregnancy?

A

4-weekly until 36 weeks, and then weekly until delivery

84
Q

Which SSRIs are best in breastfeeding (owing to short half-lives, reduced passage into breast milk)

A

Sertraline and paroxetine

85
Q

Which SSRI has the longest half-life, and therefore could lead ot accumulation, and should ideally be avoided in breastfeeding?

A

Fluoextine

86
Q

For infants being breastfed whilst Mum is using an SSRI, what symptoms should they be monitored for?

A

Drowsiness
Poor feeding
Failure to thrive
GI disturbance
Irritability and restlessness

87
Q

How could methylphenidate effect a pregnancy?

A
  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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