Contraception, prolactin, ectopic pregnancy, amenorrhea

Question 1

Main hormone producing contraceptive effect

Answer 1

Progesterone

Question 2

How do OCPs decrease androgenic signs?

Answer 2

Estrogen increases SHBG, which binds more free testosterone

Question 3

Age cut off for not giving a smoker OCPs

Answer 3

35 y/o

Question 4

How long to wait for combined methods after delivery?

Answer 4

21 days (or longer if breastfeeding)

Question 5

Meds that stimulate hepatic metabolism of sex hormones (and thus can make OCPs fail)

Answer 5

Rifampin, phenobarbital, phenytoin, cabamazepine, primidone

Question 6

Mean time of return to menses after stopping OCPs

Answer 6

32 days

Question 7

Time frame for emergency contraception

Answer 7

3 days for levonorgestrel (Plan B)

5 days for ulipristal (Ella) or IUD

Question 8

Site of prolactin production

Answer 8

Anterior pituitary

Question 9

Effect of dopamine on prolactin

Answer 9

Decreases

Question 10

Ddx for galactorrhea

Answer 10

1. Medications
2. Pituitary tumors
3. Hypothalamic lesions, stalk lesions, compression
4. Estrogen (from OCPs, rare)
5. Prolonged suckling
6. Stress
7. Non-pituitary sources of prolactin (lung or renal tumor)

Question 11

What meds can cause galactorrhea?

Answer 11

Dopamine receptor blockers: antipsychotics, metoclopramide, SSRIs, TCAs
Dopamine depleting agents: methyldopa, reserpine
Dopamine release inhibitors: opiates, cimetidine

Question 12

Effect of hyperprolactinemia on the menstrual cycle

Answer 12

Inhibits pulsatile secretion of GnRH -> often amenorrhea, low estrogen (and its complications like osteoporosis)

Question 13

Micro vs macroadenoma

Answer 13

1 cm

Question 14

Treatment for hyperprolactinemia

Answer 14

Dopamine agonists: bromocriptine (safe in pregnancy if symptomatic) or cabergoline

Question 15

Discriminatory zone

Answer 15

Beta hcg 3500

Question 16

Progesterone levels and use in PUL

Answer 16

< 5 almost always nonviable

> 20 almost always normal IUP

Question 17

Relative contraindications to MTX

Answer 17

GS > 3.5 cm
Embryonic cardiac activity
Beta hcg > 5000

Question 18

Primary amenorrhea definition

Answer 18

No menstruation…
By 15 y/o with normal secondary sex characteristics
By 13 y/o without normal secondary sex characteristics

Question 19

Secondary amenorrhea

Answer 19

At least 3 months / cycles without menses

Question 20

Mullerian agenesis vs androgen sensitivity on exam

Answer 20

Pubic hair

Question 21

What does a positive progestin challenge (bleeding within 2-7 days) prove?

Answer 21

Estrogen and functional outflow tract

Question 22

What FSH tells you about amenorrhea

Answer 22

> 20 suggests ovarian failure
< 5 suggests hypogonadotrophic state
Low-normal with low estradiol suggests hypothalamic dysfunction

Question 23

High FSH and low estradiol

Answer 23

Hypergonadotrophic hypogonadism - ovarian failure (gonadal dysgenesis if primary)

Question 24

Low FSH and low estradiol

Answer 24

Hypogonadotrophic hypogonadism - hypothalamic amenorrhea, pituitary or CNS tumor

Question 25

Normal FSH and estradiol

Answer 25

Anovulation (PCOS), anatomic defect (Asherman)

Question 26

Causes of primary ovarian insufficiency

Answer 26

Chromosomal, autoimmune, radiation, chemotherapy

Question 27

Autoimmune associations with POI

Answer 27

Adrenal disease (test for anti-CYP21 antibodies), thyroid disease (test for thyroid peroxidase and anti-thyroglobulin)

Question 28

Chemo most associated with POI

Answer 28

Alkylating agents and procarbazine

Question 29

Treatment for POI

Answer 29

HRT, include progesterone if has a uterus

Question 30

How to achieve pregnancy with hypothalamic dysfunction

Answer 30

May try ovulation induction agents, may need LH + FSH

Question 31

Anosmia plus delayed puberty and sexual development, normal pubic hair

Answer 31

Kallman syndrome (congenital GnRH deficiency)

Question 32

DHEAS is produced exclusively by...

Answer 32

Adrenals

Question 33

DHEA is made mostly by, and also by...

Answer 33

Adrenals (90%) and ovary (10%)

Question 34

Criteria for PCOS

Answer 34

2 of 3: - Hyperandrogenism - Ovarian dysfunction - Polycystic ovaries on ultrasound

Question 35

Molecular cause of hirsutism

Answer 35

DHT (converted from testosterone by 5 alpha reductase)

Question 36

Definition of polycystic ovary on ultrasound

Answer 36

20 more follicles 2-9 mm | Ovarian volume > 10 mL

Question 37

Hirsutism causes in pregnancy

Answer 37

``` Pregnancy luteoma (can cause female infants to be virilized), rapidly regresses after delivery Theca-lutein cysts (can cause maternal but not fetal virilization) ```

Question 38

Ovulation induction in PCOS

Answer 38

Letrozole

Question 39

Mechanism of spironolactone

Answer 39

Aldosterone antagonist diuretic, inhibits androgen synthesis, competes for androgen receptor, inhibits 5 alpha reductase

Question 40

Treatment for hirsutism

Answer 40

Flutamide - nonsteroidal anti-androgen Finasteride - 5 alpha reductase inhibitor Eflonithine cream - blocks ornithine decarboxylase

Question 41

What is ovarian drilling?

Answer 41

Destroys theca cells and lowers androgen production, can help restore ovulatory cycles but not clearly supported by evidence

Question 42

Enzyme most commonly deficient in congenital adrenal hyperplasia

Answer 42

21-hydroxylase (95% of cases)

Question 43

Lab findings for 21-hydroxylase deficiency

Answer 43

Low aldosterone, low cortisol, [most important] elevated 17OHP (which leads to higher androgens)

Question 44

Treatment for congenital adrenal hyperplasia

Answer 44

Supply deficient cortisol and aldosterone

Question 45

Treatment prenatally for suspected congenital adrenal hyperplasia

Answer 45

Diagnosed by CVS or amnio | High-dose steroids

Question 46

Non-classical CAH presentation

Answer 46

Puberty or later, similar to PCOS

Question 47

Differential diagnosis for hirsutism

Answer 47

``` PCOS Idiopathic hirsutism CAH HAIR-AN syndrome Androgen-secreting neoplasm Androgen use Cushing syndrome (rarely) ```

Question 48

Initial work-up for hirsutism

Answer 48

Total testosterone, SHBG, DHEAS, 17-OH progesterone