Exam 1 Flashcards
(41 cards)
1
Q
What is included in the workup of abnormal uterine bleeding (AUB)?
A
- R/O pregnancy with urine HCG
- CBC for H&H and platelet count to r/o anemia
- TSH and prolactin if amenorrhea or anovulatory bleeding
- PT, PTT, fibrinogen if coagulopathy suspected
2
Q
When is endometrial biopsy indicated in the workup of AUB?
A
- premenopausal women: prolonged irregular bleeding, unexplained post-coital bleeding, intermenstrual bleeding; endometrial cells or glandular on pap smear, anovulatory abnormal bleeding
- Postmenopausal: abnormal uterine bleeding, hormone therapy with abnormal bleeding; unscheduled bleeding that lasts more than 3 months after starting COC; endometrial stripe greater than 5mm on ultrasound
3
Q
When is pelvic US indicated in the workup of AUB?
A
anovulatory bleeding w/o response to tx, anatomic defect suspected
4
Q
PALM-COEIN classification: what is included in the PALM portion of this classification?
A
Structural abnormalities
- Polyps: endocervical or endometrial
- Adenomyosis
- Leiomyoma
- Malignancy & hyperplasia
5
Q
PALM-COEIN classification: what is included in the COEIN portion of this classification?
A
Hormonal abnormalities
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
6
Q
What are some abnormal causes of amenorrhea?
A
- PCOS
- anatomic factors
- abnormalities related to the HPO axis
- ovarian failure
- CNS disorders
7
Q
What is primary vs. secondary amenorrhea?
A
- Primary
- no menses by 14 in absence of secondary sexual characteristics
- No menses by 16 regardless of presence of secondary sexual characteristics
- Secondary: no menses in previously normal menstruating female for an interval of at least 3 cycles or none if they are irregular in 6 months
8
Q
What are the categories of causes of amenorrhea?
A
- dx of the genital outflow tract
- disorders of the ovary
- disorders of the anterior pituitary
- disorders of the hypothalamus or CNS
9
Q
What is the most common cause of pituitary associated abnormal bleeding?
A
hyperprolactinemia
10
Q
What is included in the workup for amenorrhea?
A
- TSH and prolactin
- Progesterone (Provera) challenge
11
Q
What is the effectiveness of the nonhormonal forms of contraception?
A
- withdrawal: 20-60% effective
- lactational amenorrhea: 98-99.5% effective
- diaphragm: 88%
- cervical cap: 77%, 86% for nulliparous women
- male condoms: 85%
- copper IUD: 99%
12
Q
What are the timeframes for placement for the diaphragm and cervical cap? - think how far in advance can it be placed and how long after intercourse should it remain in place?
A
- Diaphragm: can be inserted up to 6 hours before intercourse and should remain in place for at least 6 hours following intercourse but no longer than 24 hours
- Cap: Can be inserted 48 hours prior and stay in place for at least 6 hours after
13
Q
What is the MOA of the copper IUD?
A
Copper components fx tubal and endometrial fluids and incapacitates sperm; toxic fx on ovum; creates localized reaction in endometrial tissue which makes it unsuitable for implantation
14
Q
What are the side fx of the copper IUD?
A
menstrual changes (heavier, longer menses/bleeding) , increased dysmenorrhea, increased blood loss, copper allx
15
Q
How do COCs prevent pregnancy? How effective are they with typical use?
A
- Inhibits LH to suppress ovulation
- Progesterone only works but estrogen used to decrease abnormal bleeding fx of progesterone only methods - 91% effective
16
Q
What are contraindications to COC use? (11)
A
- pregnancy
- estrogen dependent cancers
- undiagnosed dysfunctional uterine bleeding
- clotting disorders hx of stroke/MI/CAD, DVT, PE
- major surgery
- severe hepatic disease
- uncontrolled HTN
- over 35 yo and smoking
- active gallbladder disease
- migraine with aura
- under 21 days postpartum
17
Q
What are special considerations for the ortho-evra patch and the NuvaRing?
A
- Patch: avoid in women >90kg (198lbs); can reapply if off for less than 24 hours, change if out for more than 24 hours
- Ring: no decrease in fx if out for less than 3 hours
18
Q
What are the major side fx that should be reported with COCs?
A
- A: abdominal pain: hepatic mass or tenderness
- C: chest pain: cough or SOB
- H: headache
- E: eye problems: visual changes, speech changes
- S: severe leg pain
19
Q
What are some non-contraceptive benefits of COCs?
A
- Reduce risk of endometrial cancer
- Reduce ovarian cancer risk
- Reduce colon cancer risk
- Reduce anemia and blood loss
- May reduce PMS/PMDD
- Reduce PID
- Fewer ectopic pregnancies
- Reduce benign breast conditions/fibrocystic breast
- May reduce ovarian cysts
- Treat endometriosis
- Less dysmenorrhea
- Some improve acne and hirsutism (ortho tri-cyclen, yaz, estrostep FDA approved)
- Improved bone mineral density
20
Q
What are some drugs that may decrease the effectiveness of COCs?
What allergy is most common in COCs?
A
Drugs
- Rifampin
- Anticonvulsants (depo is a better option)
- HIV meds
- TB meds
- Griseofulvin
- St. John’s wort
Allergy: most common is to lactose component
21
Q
What are the instructions for 1 vs. 2+ missed pills with COCs?
A
- 1: take late or missed pill as soon as possible and take remaining pill one time; no backup method needed
- 2+: take most recent missed pill as soon as possible and continue remaining pills at the usual time, discard other missed pills; use back up BC for 7 days
22
Q
What population are POPs (progestin only pills) good for?
A
good for those with a CI to estrogen; niche for breastfeeding moms
23
Q
What are some benefits of POPs?
A
- May reduce painful crises in pts with sickle cell disease
- May reduce pelvic pain w/ endometriosis
- May reduce frequency and severity of migraines
- May reduce amt of menstrual blood loss
- Preferred to COCs if 21 days or less postpartum and for lactating women
24
Q
How is Depo-Provera administered and what are important considerations?
A
- Administration: Every 12 weeks, r/o pregnancy if more than 13 weeks
-
Considerations
- Potent inhibitor of HPO axis: return to fertility may be delayed than other methods (15-18 mo)
- BBW: reduction in bone density if use longer than 2 years
25
How effective is the Nexplanon implant and for how long can it be used? Side fx?
* 99.5% effective up to 3 years
* Side fx: irregular bleeding, BP, user satisfaction
26
How effective are the hormonal IUDs (Mirena, Skyla, Liletta, Kyleena) and how long can they be used for? MOA?
* 99.8% effective 3-5 years (Skyla is for 3 years)
* MOA: thicken cervical mucus, endometrial changes, some ovulation suppression
27
What are some noncontraceptive benefits of hormonal IUDs?
* Reduces menstrual blood loss
* Reduces dysmenorrhea
* Can be used to tx endometriosis, adenomyosis, menorrhagia
* Can be used as progestin during hormone therapy
* Decreased risk for PID (and if PID develops, do not need to remove IUD
* Reduced r/f endometrial and cervical cancer
28
How do emergency contraceptives work? What is not a part of the function of the emergency contraceptives that is important to include in counseling?
* MOA: delays ovulation; copper IUD creates an inhabitable environment for a fertilized ovum to implant
* Do not interfere with an implanted egg and presents no risk to embryo that has been implanted
29
When can emergency contraceptives be used?
* Plan B, next step: up to 72 hours
* Ella (Ulipristal): up to 5 days
* Copper IUD: up to 5 days
30
How is dysmenorrhea defined?
Painful abdominal or pelvic cramps or back pain associated with menstrual cycle
31
What are the normal time frames in the menstrual cycle? full cycle, duration of bleeding, regularity
* Full cycle
* Frequent: fewer than 24 days
* Normal: 24-38 days
* Infrequent: 38 days +
* Absent = none (amenorrhea)
* Duration of bleeding
* Prolonged: 8 days +
* Normal: 8 days or fewer
* Regularity: depends on age
* cycle to cycle variation generally +/- 20 days
32
What hormones are involved in the menstrual cycle and what organ releases them?
* Hypothalamus
* GnRH
* prolactin inhibiting factor
* Follicle releasing factor
* luteinizing releasing factor
* Pituitary
* FSH
* LH
* Ovaries
* estrogen
* progesterone
* Corpus luteum
* progesterone
33
What are the phases of the ovarian cycle vs. uterine/endometrial?
* Ovarian
* Follicular phase: Days 1-14
* Ovulation: Day 14
* Luteal phase: days 15-28
* Uterine/endometrial
* Menstruation: days 1-7
* Proliferative phase: days 7-14
* Secretory phase: days 14-28
34
What is the Rotterdam diagnostic criteria for PCOS?
**Exclusion of other etiologies and 2-3 of the following**
* Oligo or anovulation
* Clinical and/or biochemical signs of hyperandrogenism
* Polycystic ovaries
35
What is the androgen excess and PCOS society diagnostic criteria for PCOS?
* Hyperandrogenism: hirsutism and/or hyperandrogenemia
* Ovarian dysfunction: oligo or anovulation and/or polycystic ovaries
* Exclusion of other androgen excess or related dx
36
What are the diagnostic criteria for PMDD?
* One or more of the following sx: emotional lability, anger, feelings of hopelessness, anxious
* One or more sx present for a total of 5 or more sx: poor concentration, appetite changes, decreased interest in activities, fatigue, overwhelmed, breast tenderness, bloating, weight gain, aching joints, insomnia or hypersomnia
37
What is the diagnostic criteria for PMS?
* Sx must occur in the majority of menstrual cycles in the past year (at least 2 cycles)
* Not exacerbations of underlying conditions, not from other dx
* Sx significant enough to interfere with ADLs
* Sx can be moderate to severe (PMS to PMDD)
38
What are some possible pharmacologic interventions for PMS/PMDD?
COC, SSRI, anxiolytics
39
How can an HCP be reasonably certain a woman is not pregnant?
**no symptoms or signs of pregnancy and meets any one of the following criteria:**
* is ≤7 days after the start of normal menses
* has not had sexual intercourse since the start of last normal menses.
* has been correctly and consistently using a reliable method of contraception
* is ≤7 days after spontaneous or induced abortion
* is within 4 weeks postpartum
* is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority [≥85%] of feeds are breastfeeds), amenorrheic, and 6 months or less PP
40
What options are available for pregnancy termination?
* Surgical abortion
* D&C
* dilatation and evacuation
* mifepristone + misoprostol
41
What is the clinical presentation of Toxic Shock Syndrome and what is the usual causative organism?
* Clinical presentation
* Fever/chills
* Hypotension
* Skin manifestations (sunburn like rash) especially on palms and soles
* Typically caused by staph aureus
