Clinical: Menstruation and ART Flashcards Preview

Block I: Reproduction & Sexuality > Clinical: Menstruation and ART > Flashcards

Flashcards in Clinical: Menstruation and ART Deck (93):
1

Define the follicular phase

Begins with the onset of menses and ends on the day of the luteinizing hormone (LH) surge

2

Hormone levels in late luteal phase

Withdrawal of estrogen and progesterone

3

Phase in which the ovary is least hormonally active

Early follicular phase (low serum estradiol and progesterone)

4

GnRH and FSH levels during the early follicular phase

Release from negative feedback effects of estrogen and progesterone = increased GnRH pulse frequency --> 30% increase in serum [FSH]

5

Number of primordial follicles stimulated by FSH release from pituitary during the follicular phase

5 - 15

6

When is a single dominant follicle selected?

By late follicular phase

7

Describe the 2-cell process by which the developing dominant follicle produces estrogen

  • Theca interna cells produce androstenedione in response to LH stimulation
  • Granulosa cells conert androstenedione --> estradiol when stimulated by FSH

8

Effects of estrogen on the uterine lining during the follicular phase

Thicken/proliferate

9

GnRH and LH levels during the follicular phase

GnRH pulse frequency increases --> rise in LH

10

Effect of raised LH levels during the follicular phase

Stimulation of androgen synthesis --> androgens converted to estrogens

11

Peak of serum estradiol concentrations

Approx 1 day before ovulation

12

Midcycle LH levels (~day 14)

LH spike in response to estrogen surge

13

Why does ovulation occur?

Increase in LH level causes the follicle to rupture and release mature ovum

14

Describe the effect of rising estradiol levels at the end of the follicular phase on LH concentration

10-fold increase (positive feedback switch from negative feedback; poorly-understood phenomenon)

15

When does the oocyte in the dominant follicle complete the 1st meiotic division

In response to the LH surge

16

When is the oocyte released from follicle at ovarian surface?

~36 hours after LH surge

17

Even before the oocyte is released, what do the granulosa 

18

When does the luteal phase begin?

After ovulation

19

What does the remnants of the follicle become after ovulation

Corpus luteum

20

Time it takes for the ovum to travel down the tube to the uterus

3 -4 days

21

When must fertilization occur and what is the consequence of it not occuring?

Must occur within 24 hours of ovulation or ovum degenerates

22

What forms the corpus luteum cyst and when

Granulosa and theca interna cells lining the wall of the follicle after ovulation

23

Function of corpus luteum

Synthesize estrogen and large amounts of progesterone

24

Effect of progesterone on endometrium

Stimulate endometrium to become more glandular/secretory in preparation for implantation of fertilized ovum

25

Substance synthesized by trophoblast if fertilization occurs

Human chorionic gonadotropin (hcg)

26

Function of HCG

Maintain the corpus luteum so it may continue producing estrogen and progesterone to support the endometrium

27

When is the placenta developed and what function does it take over?

8-10 weeks gestation

Takes over production of estrogen and progesterone

28

8 events occuring in the luteal phase if fertilization does not occur

  • Corpus luteum is not maintained by HCG
  • Corpus luteum degenerates after ~14 days
  • Estrogen and progesterone levels fall
  • Increased prostaglandins and leucocytes in endometrium
  • Constriction of spiral arteries
  • Desquamation and ischemia of endometrium
  • Arteriolar relaxation, bleeding and tissue breakdown
  • FSH levels slowly rise again in absence of negative feedback

29

2 types of dysfunctional uterine bleeding (DUB)

Anovulatory

Ovulatory

30

4 types of organic disease linked to abnorma uterine bleeding

  • Systemic
  • Reproductive disease
  • Pregnancy-related
  • Iatrogenic

31

6 common terminologies for abnormal uterine bleeding

  • Menorrhagia
  • Metrorrhagia
  • Menometorrhagia
  • Hypermenorrhea
  • Polymenorrhea
  • Oligomenorrhea

32

Bleeding cycle of menorrhagia

Regular cycles, prolonged duration, excessive flow

33

Bleeding pattern of metrorrhagia

Irregular cycles

34

Bleeding pattern of menometorrhagia

Irregular, prolonged, excessive

35

Bleeding pattern of hypermenorrhea

Regular, normal duration, excessive flow

36

Bleeding pattern of polymenorrhea

Frequent cycles

37

Bleeding pattern of oligomenorrhea

Infrequent cycles

38

When can anovulatory bleeding occur?

First year after menarche

Perimenopause

39

6 conditions where anovulatory bleeding can occur

  • Polycystic Ovary Syndrome (15% all women)
  • Adult-onset Congenital Adrenal Hyperplasia
  • Androgen producing tumors
  • Hypothalamic dysfunction
  • Hyperprolactinemia
  • Pituitary disease

40

Typical bleeding pattern of anovulatory bleeding

Irregular, heavy, and-or prolonged

41

4 identifiable causes of abnormal ovulatory bleeding

  • Fibroids
  • Adenomyosis
  • Polyps
  • Infection

42

5 risk factors for fibroids

  • Nulliparity
  • Obesity
  • Fam Hx
  • HTN
  • African-American

43

Bleeding pattern associated with fibroids

Heavier periods

44

Define adenomyosis

Endometrial glands within the myometrium

45

Symptoms and bleeding patterns of adenomyosis

  • Usually asymptomatic (symptoms usually occur after age 35- 45)
  • Potential heavy or prolonged bleeding
  • Often dysmenorrhea (painful periods) up to one week before menstruation

46

3 bleeding patterns of endometrial polyps

  • Intermenstrual bleeding
  • Irregular bleeding
  • Menorrhagia

47

2 bleeding patterns of cervical polyps

  • Intermenstrual spotting
  • Postcoital spotting

48

3 infectious causes of abnormal uterine bleeding

  • Pelvic Inflammatory Disease (PID)
  • Chronic endometritis
  • Endocervicitis

49

3 usual symptoms of PID

  • Fever
  • Discomfort
  • Adnexal tenderness

NOTE: Can present atypically

50

2 bleeding patterns associated with PID

Menorrhagia or metrorrhagia

51

When does PID most commonly occur?

During menstruation and with bacterial vaginosis

52

3 reasons why oral contraceptice pills may cause contraceptive bleeding

  • Lower dose contraceptives
  • Skipped pills
  • Altered absorption/metabolism (i.e. upset GI)

53

3 causes of contraceptive bleeding

  • Oral Contraceptive Pills
  • Intra-uterine device (IUD)
  • Depo Provera

54

5 prescriptions medications that may cause abnormal uterine bleeding

  • Anticoagulants
  • SSRI's
  • Antipsychotics
  • Corticosteroids
  • Tamoxifen

55

4 OTC medications that may cause abnormal uterine bleeding

  • Soy supplements
  • Gingkgo
  • Ginseng
  • St. John's Wort

56

Why might ginseng cause abnormal uterine bleeding?

Estrogenic properties

57

Why might St. John's Wort cause abnormal uterine bleeding

Interaction with oral contraceptive --> breakthrough bleeding

58

2 endocrine abnormalities that may cause abnormal uterine bleeding

  • Hyperthyroidism
  • Hypothyroidism

59

4 bleeding patterns associated with hyperthyroidism

  • Amenorrhea
  • Oligomenorrhea (most common)
  • Hypermenorrhea
  • Polymenorrhea

60

4 bleeding patterns associated with hypothyroidism

  • Amenorrhea
  • Oligomenorrhea
  • Polymenorrhea
  • Menorrhagia

NOTE: Occurs more frequently with severe hypothyroidism

61

Two most common bleeding disorders that may cause abnormal uterine bleeding

  • Von Willebrand's disease
  • Thrombocytopenia

62

First step of homeostasis during menstruation

Formation of a platelet plug

63

When may abnormal uterine bleeding due to a bleeding disorder may be particularly severe and why

At menarche due to the dominant estrogen stimulation causing increased vascularity

64

5 lab studies for abnormal uterine bleeding

  • CBC
  • Urine or serum pregnancy test
  • TSH
  • PT, PTT, and bleeding time
  • PCOS/adult-onset CAH investigations

65

5 substance levels tested for PCOS/Adult-onset CAH

  • LH
  • FSH
  • Testosterone
  • Androstenedione
  • Basal 17-hydroxyprogesterone (17-HP)

66

3 things to evaluate in ultrasound to investigate abnormal uterine bleeding

  • Ovaries for PCOS
  • Fibroids
  • Endometrial stripe

67

Define PMS

Recurrent psychological or physical symptoms during the luteal phase of menstrual cycle, resolves by the end of menstruation, and interferes with some aspect of function

68

Define Premenstrual Dysphoric DIsorder (PMDD)

More severe form of PMS meeting DSM-IV criteria

69

4 general UCSD criteria for diagnosing PMS

  • >1 somatic and affective symptom 5 days prior to menses x 3 cycles
  • Resolve within 4 days onset of menses and symptom free until day 12 of cycle
  • Not due to meds, drugs, or EtOH use
  • Causes dysfunction

70

6 somatic symptoms that can be used to diagnose PMS

  • Depression
  • Anger
  • Irritability
  • Confusion
  • Social withdrawal
  • Fatigue

71

4 affective symptoms that can be used to diagnose PMS

  • Breast tenderness
  • Bloating
  • Headache
  • Swelling

72

5 DSM-IV criteria to diagnose PMDD

  • >5 symptoms of PMS 1 week prior to and resolve during menses
  • >1 psychological symptom x 1 year during most cycles
  • Interferes with social, occupation, sexual or school functioning
  • symptoms discretely related to menstrual cycle and not a worsening of a psychiatric or medication condition
  • Documented symptoms meeting criteria for at least 3 cycles

73

4 psychological symptoms that can be used to diagnose PMDD

  • Depressed mood
  • Increased sensitivity
  • Anxiety
  • Irritability

74

7 differential diagnoses for PMS

Menstrual exacerbation of

  • Psychiatric disorder
  • Medical condition:
    • Dysmenorrhea
    • Hyper- or hypo- thyroidism
    • Peri-menopause
    • Migraine
    • Chronic fatigue syndrome
    • Irritable bowel syndrome

75

4 prescriptions for mild to moderate PMS with at least some evidence

  • Vit B6 during luteal phase
  • Calcium
  • Evening primrose oil
  • Magnesium

76

7 Rx of mild to moderate PMS with unknown benefits

  • Exercise
  • Relaxation
  • Chiropractic manipulation
  • CBT
  • Light therapy
  • Eliminating caffeine
  • Reducing sugar and salt

77

Beneficial treatment for moderate to severe PMs

Spirolactone 500-200 mg OD during luteal phase

78

Contraindication for spirolactone as treatment for PMS

Pregnancy

79

6 treatments for moderate to severe PMS that are likely beneficial

  • Alprazolam 0.25-1 mg TID in luteal phase
  • Buspirone 5 - 10 mg TID
  • GnRH analogues
  • Metolazone
  • NSAIDs in luteal phase
  • OCP

80

3 PMS symptoms improved by spirolactone

  • Breast tenderness
  • Weight gain
  • Mood

81

Risk of using alprazolam as PMS treatment

Dependence

82

Benefit of buspirone

Global symptoms improvement

83

When is GnRH analogue considered as treatment for PMS

Patients not responding to other therapies (short term Rx only)

84

5 disadvantages of using GnRH analogues as treatment for PMS

  • 11% bone loss with continuous treatment (should not exceed 6 months without add-back hormone therapy)
  • Hot flashes
  • Nausea
  • Night sweats
  • Headaches

85

Advantage of using GnRH analogue as treatment for PMS

Given in luteal phase = improved breast tenderness

86

3 benefits of Metolazone as treatment for PMS

Improved

  • Weight gain
  • Mood
  • Swelling

87

3 improved PMs symptoms by OCP

  • Acne
  • Appetite
  • Food cravings

88

4 treatments for PMS that have a trade-off between benefit and harm

  • Clompramine
  • Danazol 200 mg OD
  • SSRI's
  • Progesterone

89

Benefits/harm of clompramine as PMS treatment

  • Benefit = improve psychological symptoms only
  • Harm = significant drowsiness, nausea, vertigo, headache

90

Benefits/harm of danazol 200 mg as treatment for PMS

Effective but masculinization

91

Benefits/harm of SSRI's as treatment for PMS

Effective but may increase risk of suicide (warnings about use in children and adolescents)

92

5 potential adverse effects of progesterone as treatment for PMS

  • Bleeding
  • Dysmenorrhea
  • Abdo pain
  • Nausea
  • Headache

93

4 lab tests for PMS

  • CBC
  • -lytes
  • TSH
  • +/- menopause workup