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1
Q

Phases of menstrual cycle=

A

Phases:
day 1: menses→follicular→
day 14: ovulation→luteal to day 30

2
Q

Menstrual Cycle Hormonal Sequence of Events=

A

Sequence of events:

hypothalamus secretes [GnRH] → stimulates anterior pituitary to secrete…

[LH/FSH]→ causes ovarian follicles to mature, secreting…

[estrogen/progesterone]→ ovulation→ if no fertilization→ drop in…

[progesterone]→ menses

3
Q

Name the four primary hormones of the menstrual cycle:

A

[GnRH]
[LH/FSH]
[estrogen/progesterone]
[progesterone]

4
Q

signs of estrogen excess:

A

dysmenorrhea; nausea; edema; enlarged uterus, uterine fibroids; fibrocystic breast changes; menorrhagia

5
Q

signs of estrogen deficiency:

A

scant menses; mid cycle spotting

6
Q

signs of progesterone excess:

A

edema; bloating; headache; depression; weight gain; fatigue; HTN; varicose veins

7
Q

signs of progesterone deficiency:

A

symptoms similar to those with anovulatory cycles, endometriosis, adenomyosis, endometrial hyperplasia; prolonged menses; heavy menses; severe cramps; luteal spotting; BTB

8
Q

normal menstrual cycle:

A

21-35 day cycles

9
Q

normal age of menarche:

A

in US is 12-13yo

10
Q

Amenorrhea=

A

absence or abnormal cessation of the menses for more than 3 months

11
Q

Oligomenorrhea=

A

scanty menstruation; menstrual periods occur at intervals of greater than 35 days, with only 4-9 periods in a year

12
Q

Polymenorrhea=

A

occurrence of menstrual cycles of greater than usual frequency

13
Q

Menorrhagia (hypermenorrhea)-

A

excessively prolonged or profuse menses

14
Q

Metrorrhagia-

A

any irregular, acyclic bleeding from the uterus between periods

15
Q

Menometrorrhagia-

A

irregular or excessive bleeding during menstruation and between menstrual periods

16
Q

Dysmenorrhea-

A

painful menses

17
Q

Mittelschmertz-

A

one-sided lower-abdominal pain that occurs in women at or around the time of ovulation

18
Q

Primary Amenorrhea=

A

-Primary: 0.3% prevalence; no secondary sex characteristics by age 14; no menses by age 16

19
Q

Secondary Amenorrhea=

A

Secondary: 1-3% prevalence; no menses per 3 cycles or 6 months, whichever sooner, in a woman w/ previous menses

20
Q

Primary Amenorrhea Causes=

A

CNS hypothalamic pituitary disorder; membranous blockage of vagina (hymen); drastic weight loss/ malnutrition/ eating disorder; hypoglycemia; extreme obesity; thyroid disease; anemia; congenital abnormalities of genital system

21
Q

Secondary Amenorrhea 4 most common causes=

A
  • normogonadotropic anovulation
  • hypogonadotropic hypogonadism
  • prolactinoma
  • hypergonadotropic hypogonadism
22
Q

hypergonadotropic hypogonadism:

Causes Secondary Amenorrhea

A

high LH/FSH, but unresponsive ovaries; premature ovarian failure

23
Q

prolactinoma:

Causes Secondary Amenorrhea

A

high prolactin; medications, pituitary tumor, hypothyroidism

24
Q

hypogonadotropic hypogonadism:

Causes Secondary Amenorrhea

A

low LH/FSH so lack of stimulation of ovary; psychological and physical stress

25
Q

normogonadotropic anovulation:

Causes Secondary Amenorrhea

A

normal LH/FSH, but cyclic secretion disrupted, therefore, no ovulation and low progesterone; polycystic ovarian syndrome

26
Q

Additional causes of secondary Amenorrhea:

A
  • pregnancy (must rule out)
  • weight reduction/ drastic gain
  • stress/ depression
  • hypothyroidism
  • PCOS (elevated estrogen and testosterone)
  • obesity (elevated estrogen)
  • increased prolactin (inhibits GnRH)
  • premature ovarian failure (early menopause)
27
Q

Amenorrhea Medications=

A
  • hormonal contraception, doesn’t require intervention, may consider change to different contraception
  • antipsychotics
  • antidepressants, inc. tricyclics and MAOIs
  • cardiovascular meds inc Ca-blockers, Aldomet, Reserpine, Digoxin
  • ovarian toxins (cytoxan, fluorouracin, cisplatin)
28
Q

Hypoestrogenic amenorrhea=

A

puts woman at higher risk for bone mineral density loss… osteoporosis

29
Q

Amenorrhea evaluation physical exam=

A

-secondary sex characteristics; imperforate hymen/ normal anatomy; sexual maturity; weight; thyroid, hyperandrogenism signs

30
Q

Amenorrhea evaluation initial labs=

A

-B-hCG; TSH; PRL; progesterone challenge test, rule out estrogen deficiency,

31
Q

What are PCOS (PolyCystic Ovarian Syndrome) associated symptoms?

A

-secondary amenorrhea; metabolic dysfunction; hyperestrogenic/ androgenic state; anovulation

32
Q

PCOS hormonal implications: androgens:

A
  • inc levels of estrone due to conversion of ovarian and adrenal androgens to estrone in body fat
  • suppress pituitary FSH
  • ovary receives constant LH stimulation resulting in:

anovulation, cysts, hyperplasia of theca cells→ more

33
Q

PCOS inc risk for:

A

infertility; DM; CVD; endometrial cancer

34
Q

PCOS Diagnosing:

A

symptoms- hirsutism, anovulation; fasting glucose/ insulin; 2hr postprandial glucose and insulin; free testosterone, DHEA-S;

-PELVIC ULTRASOUND FOR POLYCYSTIC OVARIES NOT NECESSARY

35
Q

PCOS Management=

A

-treat insulin resistance, hyperinsulinemia; address androgen excess problems; address fertility issues; address prevention of long-term PCOS complications

36
Q

Long-term PCOS complications:

A

-diabetes, endometrial hyperplasia/cancer, CVD/dyslipidemia, breast cancer, obesity, fertility issues

37
Q

PCOS Medication Treatments:

A

Medications
-Progesterone: normalize E:P, restore ovulation

- Spironolactone: reduce androgens and reducing abnormal hair growth
- Metformin: regulates blood sugar and dec hirsutism and anovulation
38
Q

PCOS Treatments: Supplements

A
  • Inc SHBG: soy, flax, nettles, green tea
    • Dec androgens: saw palmetto
  • Improve insulin resistance: vit C, chromium, diet
    - Inc ovulation: vitex (chaste tree), rhodiola, tribulus
39
Q

Normal menstrual bleeding=

A

Normal: cycle_ 21-35 days; flow_ up to 7 days (ave 3-5); amount_ up to 80ml/day (1tsp=5ml)

40
Q

Abnormal menstrual bleeding=

A

-Abnormal if: 35 days, >7 days menses, spotting in between menses (BTB of metrorrhagia)

RED FLAG: POST-MENOPAUSAL BLEEDING
41
Q

Abnormal uterine bleeding terms:

A

menorragia; metrorrhagia; menometrorrhagia; polymenorrhea; contact bleeding

42
Q

-Initiators of abnormal bleeding:

A

infection (STI); neoplasms (fibroids, polyps); endocrine/ hormonal (PCOS, thyroid, obesity, hyperprolactinemia, menopause); malignancies (endometrial/cervical); trauma; pregnancy

43
Q

Menorrhagia causes:

A

pregnancy (must rule out); infection (STI screen); intrauterine device; uterine fibroids; endometrial/ cervical polyps; hypothyroidism (TSH, fT4); coagulation disorder (PT/PTT); neoplasms (pap, U/S, EMB); dysfunctional uterine bleeding

44
Q

Menorrhagia symptoms:

A

symptoms: >80-90ml/period; menstrual bleeding> 7d; unusually heavy bleeding, requiring change of protection at night, menstrual flow interfering w/ lifestyle; fatigue, dizziness, and/or SOB

45
Q

Managing Abnormal Bleeding:

A

determine the cause; control bleeding; prevent/treat anemia; restore normal menstrual cycle

46
Q

Work-up of menorrhagia:

A

urine pregnancy; STI screen; endocrine work-up, PRL, TSH/fT4, FSH, E, P; coagulation work-up (PT/PTT); PAP; U/S, pelvic and transvaginal; EMB/hysteroscopy and biopsy

47
Q

Dysfunctional Uterine Bleeding (DUB)=

A
  • If all tests are normal: DUB (diagnosis of exclusion)
  • associated w/ anovulatory cycles; overgrowth of endometrium due to estrogen stimulation w/out adequate (post-ovulatory) progesterone to stabilize growth, unopposed estrogen state; associated w/ long or short cycles
48
Q

Uterine Fibroids aka…

A

leiomyomata, leiomyoma, fibromyoma, myoma

49
Q

Uterine Fibroids=

A
  • most common solid tumor in women; typically benin
  • overgrowth of muscle and connective tissue in the wall of the uterus; most common indication for major surgery in women= 30% of hysterectomies
50
Q

Uterine Fibroids Risk factors:

A

inc w/ age_35-45 yo; race_African American 3x more likely; genetic predisposition; hormones_ estrogen dominance; lifestyle_ nulliparous (no children)

51
Q

Dysfunctional Uterine Bleeding (DUB) Symptoms:

usually asymptomatic

A

Symptoms: enlarged uterus; pressure, bloating; heaviness; constipation; vague feeling of discomfort; P w/ vaginal intercourse; urinary abnormalities: freq, urg, acute or chronic urinary retention, ureteral compression, hydronephrosis; pelvic pain-cramping; backache, esp during menses; abdominal enlargement; infertility, recurrent SAB

52
Q

What is the m/c cause of abnormal bleeding?

A

Dysfunctional Uterine Bleeding (DUB)

53
Q

T/F: pain is NOT a typical symptom with Dysfunctional Uterine Bleeding (DUB).

A

T

majority are asymptomatic (50-80%);

54
Q

Diagnosis of uterine fibroids:

A

ultrasound

55
Q

Diagnosis of Endometrial hyperplasia:

A

U/S (endometrial stripe); endometrial biopsy; D+C; hysteroscopy

56
Q

Endometrial Carcinoma Risk factors:

A

age_ 50-70; hyperplasia; unopposed estrogen; obesity; family history_ breast, colorectal; PCOS/anovulation; nulliparity; extended use of tamoxifen; diabetic; hypertension

57
Q

Protective factors of endometrial cancer:

A

birth control pills; pregnancies; early menopause

58
Q

Endometrial Carcinoma Signs and symptoms:

A

postmenopausal bleeding; postmenopausal pap w/ endometrial cells; premenopausal intermenstrual bleeding

59
Q

Endometrial Carcinoma Stage and 5 year survival rate:

A

Stage I_76%; Stage II_60%; Stage III_ 30%; Stage IV_10%

PATIENTS WITH PERSISTENT SYMPTOMS DESPITE A NORMAL BIOPSY REQUIRE FURTHER EVALUATION!

60
Q

Endometrial Carcinoma Dx imaging:

A

pelvic U/S (abnormal bleeding and large uterus) w/ or w/out endometrial sampling (rule out hyperplasia or carcinoma); laproscopy to evaluate and possibly remove

61
Q

Endometriosis=

A

-progressive; presence of endometrial glands and stroma outside the uterus; etiological theories_ genetics, retrograde menstruation, altered immune function, environmental exposures

62
Q

Endometriosis PREVALENCE AND EPIDEMIOLOGY:

A

M/C in reproductive age 25-30_ 15% of reproductive aged women; one of the leading causes of chronic pelvic P; rare in premenarche or menopausal women

63
Q

Endometriosis Risk factors:

A

fam his; shorter menstrual cycles; longer menstruation flow; inc serum estrogens; obesity (excess estrogen); lack of exercise

64
Q

Endometriosis Clinical Presentation:

A

pelvic P, ovulation before/during menses; dspareunia; infertility; low back/leg P; severe dysmenorrheal; irregular or heavy menstruation

65
Q

Endometriosis Diagnosis:

A
  • Direct visualization of pelvic and abd viscera-dx and treatment
  • visually directed biopsy and removal of implant, dyspareunia, or likelihood of pregnancy following treatment
  • laparoscopy is GOLD STANDARD
  • serum CA-125 levels
  • US or MRI (not highly sensitive)
66
Q

Laparoscopy appearance of blue-grey “powder” burned lesions is found in what dz?

A

Endometriosis

extent of disease on laparoscopy does not correlate well w/ P

67
Q

Endometriosis Treatment:

A

-analgesics (NSAIDS, narcotics)

Endocrine therapy…

progesterone (oral, IUD), OCP’s, GnRh agonists (LUPRON),
Danazol (synth testosterone) dec → antiproliferative effect on endometrium→ amenorrhea, Arimidex (aromatase inhibitor) dec inflammation, growth, P; Surgery

68
Q

Dysmenorrhea Prostaglandin Theory:

A

progesterone dec the release of local PG’s; PG’s inc myometrial contractions, constrict small endometrial blood vessels w/ consequent tissue ischemia, endometrial disintegration, bleeding and pain

69
Q

What is Danazols (synth testosterone) effect on the endometrium?

A

dec → antiproliferative effect on endometrium

70
Q

How does Dysmenorrhea inc levels of PG across the menstrual cycle…

A
  • follicular-luteal has 3x PG inc
  • luteal-menses has 2-7x PG inc
  • prostaglandins inc in luteal phase→ highest levels at the onset of menses
  • higher PG levels→ uterine contractions→ cramps and P
71
Q

DYSMENORRHEIC WOMEN MAKE ______ MORE PG THAN CONTROLS

A

8-13X

72
Q

With Dysmenorrhea, most of the production and release of PG occurs in the first ______ of menstrual flow.

A

48hrs

73
Q

With dysmenorrhea an excess of PG enters bloodstream affecting _______.

A

other smooth muscles→ headaches, dizziness, hot and cold flashes, diarrhea and nausea

74
Q

Conventional management of dysmenorrhea:

A
  • NSAIDS: ibuprofen; Naproxen sodium; ASA; MOA: inhibits arachodonic acid conversion to PG and leukotrienes
  • Hormones: OC’s (hormonal birth control); MOA inhibitors-inhibits ovulation, dec thichness of endometrial lining and thereby fewer PG’s are made; Mirena IUD (progesterone); Depo Provera (progesterone)
75
Q

What dysmenorrhea treatment inhibits arachodonic acid conversion to PG and leukotrienes?

A

NSAIDS

76
Q

What does MOA inhibitor treatment do for dysmenorrhea?

A

MOA inhibitors-inhibits ovulation, dec thichness of endometrial lining and thereby fewer PG’s are made

77
Q

PMS:

A

Monthly recurrence of mood, cognitive, or physical symptoms during the luteal phase

78
Q

PMS symptoms:

A

symptoms peak prior to or w/ onset of flow, symptoms remit w/ menses, symptoms are not an exacerbation of an underlying disorder

79
Q

PMDD:

A

Psychosocial impairment- interferes w/ work, school, relationships or social activities

80
Q

PMDD timing:

A

Not an exacerbation of an underlying disorder, most prominent during last week of luteal phase, begins to remit w/ menses, absent in the week post-menses

81
Q

PMDD Must include 5 of the following and at least one of the symptoms in 1-4:

A
  1. depressed mood, hopelessness, self-deprecation;
  2. Marked anxiety or tension;
  3. Marked affective lability;
  4. Anger or irritability;
  5. Dec interest in usual activities;
  6. Difficulty concentrating;
  7. Dec energy;
  8. Marked change in appitite;
  9. Sleep disturbance;
  10. Sense of being overwhelmed or out of control;
  11. Physical symptoms generally associated w/ changes in the menstrual cycle
82
Q

PMM has distressing physical or affective symptoms during what part of the cycle?

A
  • THROUGHOUT the cycle

- symptoms NEVER completely remit

83
Q

PMM may be an exacerbation of an underlying condition, ie:

A

affective disorder, depression, endometriosis, substance abuse, migraines, seizure disorder, asthma, chronic fatigue, allergies or IBS

84
Q

PMM symptoms worsen during the _____ phase

A

luteal phase

85
Q

Hormonal CAUSES OF PREMENSTRUAL DISORDERS

A

CNS response to normal variations of hormonal changes

86
Q

Nutritional deficiencies CAUSES OF PREMENSTRUAL DISORDERS

A

Vit B6, B3, C, E; Ca2+, Mg, EPO (linoleic acid/GLA); Zn; Lenoleic acid (help to synthesis PGE-1); excessive sugar, caffeine, alcohol

87
Q

Altered PG synthesis CAUSES OF PREMENSTRUAL DISORDERS

A

PGs facilitates shedding of the endometrium and the bursting of the follicle @ ovulation; the withdrawal of progesterone release initiates the synthesis of PGE2-a (pro-inflammatory); dysmenorrheal is due to an imbalance of PGs, 500% inc in pro-inflam PGs (PGE2s) than anti-inflam PGs (PGE1 & 3)

88
Q

Neurotransmitter imbalance CAUSES OF PREMENSTRUAL DISORDERS

A

abnormal serotonergic function and neurotransmission; in PMS pts serotonin levels were found to be lower 10 days prior to menses, while PMDD pts had lower serotonin levels all month long; SSRI shown to reduce PMDD symptoms

89
Q

Are there Psychological factors that cause PREMENSTRUAL DISORDERS?

A

Yes

90
Q

INFERTILITY Definition:

A
  1. No conception after 12 months of intercourse w/out contraception in women 35
91
Q

-FEMALE CAUSES of infertility: Pelvic factors…

A

~35%: infection; surgical history; contraception and pregnancy history; menstrual cycle abnormalities

92
Q

FEMALE CAUSES of infertility: Ovulatory factors…

A

15%: secondary amenorrhea; abnormal uterine bleeding; luteal phase defect (short cycle, low progesterone); premature ovarian failure (early menopause)

-polycystic ovarian syndrome (high androgen); elevated prolactin; hypothyroidism; history of anti-estrogens (lupron)

93
Q

Other causes female infertility:

A

delayed childbearing; overweight (BMI >25), underweight (BMI <18); insulin resistance; depression; substance use; malabsorption (celiac)

94
Q

Male factor infertility causes=

A

~35%: varicocele (42% of cases); unexplained (22%); obstructive azoospermia (14%); undescended testis (3%)

95
Q

Other male factors of infertility=

A

testicular surgeries or injury; genitourinary infection or STI’s; post-pubertal mumps; hypogonadism or other congenital disorder; genital radiation or chemotherapy; testicular cancer; retrograde ejaculation or other dysfunction; exposure to excessive heat, toxic chemicals, pesticides; medications or drug use- nicotine, alcohol, cocaine, steroids, marijuana, prescription meds

96
Q

General Lifestyle affects on infertility=

A
  • Either partner who smoked > 15 cigs/day; Alcohol >20/week; bmi>25; coffee >6cups/day if partners with > than 4 negative risks takes 7x longer, conception fell 60% 7x more likely for drugs
  • Diet , exercise can both be positive and negative depending on intensity and duration, caffeine, weight to low bad to high bad
97
Q

Ovarian masses Functional cyst

3 types=

A
  • Follicular
  • Corpus luteum
  • Theca lutein
98
Q

Follicular functional cysts=

A

most common results from dominant follicles failing to rupture persistent follicle or immature follicles failing the process of atresia usually disappears 1-3 months. Blood can fill the cyst and give a hemorrhagic/ chocolate cyst

99
Q

Corpus luteum functional cysts=

A

less common clinically more important. Normal endocrine and prolonged progesterone secretion. Results from the sac not dissolving after egg is released fluid fills it. Resolves within a few weeks, can get around 4” may bleed or cause torsion 31% chance of recurance

100
Q

Theca lutein functional cysts=

A

rare almost always bilateral and asymptomatic caused by excessive activation of ovaries by endogenous or exogenous gonadotropins

101
Q

Functional cyst symptoms=

A

Sxs often asymptomatic found in pelvic exam, unilateral pain, fullness, pressure in lower abd. Dull ache in low abd. Or thighs. Pain while boning,

102
Q

Functional cyst Sxs requiring immediate referral=

A

Pain with fever vomiting, sudden pain, fainting, dizziness weakness, tachypnea, tachycardia

103
Q

Dermoid cyst aka teratoma Characteristics=

A

Large growth, contain all 3 germ layers, benign or malignant

104
Q

Dermoid cyst aka teratoma Epidemiology:

A
  • Most common in neoplasm in prepuberty girls and teens, 50% occur 25-50age,
  • Postmenapause 20%of ovary tumors benign
  • Accidental discovery most removed because of malignancy though very low.
105
Q

Endometriom mass diagnosis, pain, and recurrence=

A
  • Ultrasound
  • Can be painless of severe pain
  • Frequently recurs if not completely resected
106
Q

Is Ovarian mass Maligancy risk more common pre or postmenopausal?

A

Premenopausal 13%

Post 45%

107
Q

5 leading cause of cancer deaths=

A

Ovarian cancer

108
Q

50 % of all gyn cancer deaths

(Peak age 60-65)=

A

Ovarian cancer

109
Q

How to diagnose Ovarian cancer:

A
  • Labs, CBC, renal/lft, tumor markers-ca125

- Radiographic, Pelvic us, chest xray ,ct scan

110
Q

Stage of Ovarian cancer diagnosis in order of percentage found:

A
  • stage 3 15-50% 5 yr survival rate
  • stage 1 75 -100%
  • stage 4 5%
  • stage 2 45-60%
111
Q

Is CA- 125 a reliable ovarian cancer test?

A

CA -125 is unreliable at best can give false positives with fibroids, benign ovarian tumors, adenomyosis, endometriosis, PID

112
Q

Cervical Dysplasia & cancer Screening Guidelines=

A
  • Reg paps for all women who are sexual active and have a cervix at age 21 or 3 years after first boning which ever comes first.
  • 65 against routine screening if 10 yr history is clean and not high risk
113
Q

HPV Tests=

A

thin prep . sure path transmission sexually, high risk hpv cancer, low risk warts

114
Q

Vocabulary for PAPs:

A

Atypia; variation of normal

Ascus; abnormal squamous cells of undetermined significance watch it.

CIN I; cervical intraepthalial neoplasia mild aka LGSIL low grade intraepithelial lesion

CIN II; moderate aka HGSIL high grade

CIN III; severe AKA hgsil

CIS; carcinoma in situ pre-cancerous

Cervical cancer

115
Q

Ascus=

A

abnormal squamous cells of undetermined significance watch it.

116
Q

CIN I;

A

cervical intraepthalial neoplasia mild aka LGSIL low grade intraepithelial lesion

117
Q

CIN II;

A

moderate aka HGSIL high grade

118
Q

CIS;

A

carcinoma in situ pre-cancerous

119
Q

Management of abnormal paps;

Atypia, ASCUS, CIN I=

A

most go away without treatment paps every 4 months 1 yr every 6 moths 2 yr

120
Q

Management of abnormal paps CIN II=

A

treatment recommended, cryo, LEEP, pap test every 4 months 1 yr 6mths 2 yr

121
Q

Management of abnormal paps CIN II, CIS, Cancer=

A

treatment by gyn oncologist, surgery, LEEP, Conization or laser beam treatment, Hysterectomy in late stages, same pap testing as above

122
Q

Breast Health Upper Outer Quadrant (UOQ) –

A

most common site for fibrous cystic changes (benign) and/or malignancies.

123
Q

Fibrous areas of the breast are of less concern if _______.

A

symmetrical, pain-free & mobile.

124
Q

Mastalgia –

A

breast pain: must differentiate cyclic from non-cyclic

125
Q

Nipple Discharge –

A

most common will be benign, but be concerned if: bloody, associated with mass, unilateral, single duct, spontaneous, post-menopausal, hormone replacement therapy (HRT), prolactinoma

126
Q

Fibrocystic Breast Changes should resolve with _______.

A

menopause

127
Q

Mammogram every ______ after age 40.

A

1-2 years

128
Q

T/F with fibrocystic breast changes 75% of patients have no major risk factors

A

T

129
Q

___% of Pt with Fibrocystic Breast Changes do NOT have a primary family member with breast cancer

A

90%

130
Q

hypothalamus secretes [GnRH] → stimulates anterior pituitary to secrete…

A

[LH/FSH]

131
Q

What dz has the following symptoms: menstrual cycle irregularities and infertility; appearance, weight (obesity), excessive hair growth, acne, hair loss (alopecia); metabolic issues-hypoglycemic, insulin resistant, hyperlipidemia, hypertension?

A

PCOS

132
Q

Complete Gynecological History Taking:

A
 History of Present Illness: 
o	Menstrual History
o      Discharge 
o	Pelvic Pain 
o	Pelvic Relaxation
 OB History 
 Contraceptive History 
 Sexual History 
 ROS 
 FMHx 
 PMHx 
 Psych/Social Hx 
 Medications 
 Supplements 
 Lifestyle
133
Q

LH:
FSH:

A

LH: androgens, progesterone, ovulation
FSH: estrogen

134
Q

Effects of Estrogen:

A
o	Endometrial proliferation
o	Myometrial cell growth 
o	Vaginal cornifcation 
o	Reduced vaginal pH (why important?)
o	Increased cervical mucus pH 
	Other: breast, fat, skin, bone, brain 
 Feed back loop on hypothalamic-pituitary