Intro + menstrual disorders

Question 1

number of pregnancies regardless of outcome

Answer 1

gravidity

Question 2

number of delivered or completed pregnancies

Answer 2

parity

Question 3

what are the four components of parity? (TPAL)

Answer 3

Term deliveries (at or beyond 37 weeks)
Preterm deliveries (having given birth to an infant alive or deceased at or beyond 20 weeks)
Abortions (pregnancies ending prior to 20 weeks, induced or spontaneous, ectopic included)
Living children

Question 4

What is the recommended guideline for pap smears?

Answer 4

every 3 years with cervical cytology alone in women aged 21-29 years

30-65 years = every 3 years with cervical cytology alone, or every 5 years with high-risk HPV testing alone, or every 5 years with hrHPV testing in combo with cytology

women <21 >65, prior hysterecotmy –> do not screen

Question 5

congenital malformation of mullerian ducts, resulting in an absent uterus and variable degrees of hypoplasia of fallopian tubes, cervix, and first 2/3 of vagina

primary amenorrhea
dyspareunia
infertility

Answer 5

mullerian agenesis

Question 6

How do you diagnose and treat mullerian agenesis?

Answer 6

Dx: US -> anatomical abnormalities

Tx: correct anatomical issues with vaginal dilators, surgery

Question 7

infants: horsehoe kidney, bicuspid aortic valve, coarctation, lymphatic defects, cystic hygroma, webbed neck, short stature, low set ears, shield chest (broad cheest), shortened 4th metacarpals, cubitus valgus

miniimal pubic hair, breast + uterine development

ovarian dygenesis, streak ovaries

low estrogen, high FSH and LH
menopause before menarche!

Answer 7

turner syndrome

dx with karotype analysis

treat with grwoth hormone therapy during childhood and sex hormone replacement therapy at puberty onwards!

Question 8

when does an imperforate hymen occur?

Answer 8

when hymen central epitheleal cells fail to degenerate during fetal development

hymenal membrane compltely covers vaginal opening (bulging, bluish hymenal membrane)
- recurring menstraul cramps, abdominal/pelvic pain

Question 9

what are the 2 normal positions of the uterus?

Answer 9

anteflexed and anteverted

Question 10

imperforate hymen dx and tx

Answer 10

dx: US = hemoatocolpos

tx: surgical incision of hymen

Question 11

cryptomenorrhea is

Answer 11

hypomenorrhea, light menstrual flow, sometimes only spotting, that can be from obstruction, Asherman’s, oral contraceptives

Question 12

bleeding that occurs more often than every 21 days

Answer 12

polymenorrhea

Question 13

menstrual periods that occur >35 days apart

Answer 13

oligomenorrhea

from: endocrine (pregnancy, pituitary-hypothalamic, menopause), systemic, estrogen-secreting tumor

Question 14

postcoital bleeding is considered

Answer 14

sign of cervical cancer until proven otherwise

or cervical eversion, polyps, infection, atrophic vaginitis

Question 15

absence by 13 years in absence of normal growth or secondary sexual development OR absence by 15 years in setting of normal growth and secondary sexual development

Answer 15

primary amenorrhea

Question 16

when should you begin an evaluation for primary amenorrhea?

Answer 16

Begin evaluation at 15 years (but do not delay if neuro symptoms or pelvic pain)

Question 17

What are your initial differentials for a primary amenorrhea?

Answer 17

turner syndrome, mullerian agenesis, imperforate hymen, abnormalities

Question 18

All women with primary amenorrhea shoudl have what testing?

Answer 18

beta hCG, FSH, TSH, and prolactin level tested

Question 19

primary amenorrhea + short stature, low set ears, shield chest, shortened 4th metacarpals, cubitus valgus + minimal pubic hair, breast/uterine development

Answer 19

turner syndrome

Question 20

primary amenorrhea + developing normally with secondary sexual characteristics except lack of structures

Answer 20

Mullerian agenesis

Question 21

primary amenorrhea + recurring menstrual cramps, abdominal/pelvic pain

Answer 21

imperforate hymen

Question 22

What does this put someone at risk for: postpartum hemorrhage, D+C, endometrial infection

Answer 22

Asherman’s

Question 23

primary is — while secondary is —

Answer 23

absence of menses, loss of menses

Question 24

low estrogen, high LH and FSH, little to no breast development

and what do you confirm dx with?

Answer 24

turner syndrome

karotype analysis

Question 25

FSH is normal, breast development present → US = absent uterus

Answer 25

mullerian agenesis

Question 26

FSH is normal, breast development is present, “bulging, bluish hymenal membrane” on PE US = hematocolpos, hematometra

Answer 26

imperforate hymen

Question 27

how do you treat turner syndrome?

Answer 27

growth hormone therapy during childhood and sex hormone replacement starting at puberty

Question 28

how do you treat mullerian agenesis?

Answer 28

correcting anatomical issues, vaginal dilators, surgery

Question 29

how do you treat imperforate hymen?

Answer 29

surgical incision of hymen

Question 30

what defines secondary amenorrhea?

Answer 30

Absence of menses for >3 cycles or 6 consecutive months in a previously menstruating women

Question 31

What's the MCC of amenorrhea?

Answer 31

pregnancy

Question 32

What are your differentials for secondary amenorrhea?

Answer 32

hypothalamic – (failure to secrete GnRH) “exercise-induced” - severe caloric restriction, strenuous exercise Hyperprolactinemia (adenoma) Serious physical or emotional stress, androgen disorders, galactorrhea-amenorrhea syndrome, ovarian failure (primary - radiotherapy, chemo, autoimmune, before 30 = chromosome abnormality), uterine dysfunction - Asherman’s (intrauterine adhesions - D+C), Sheehan’s, drug-induced

Question 33

female athlete triad - eating disorder + osteopenia or osteoporosis + amenorrhea

Answer 33

functional hypothalamic

Question 34

before the age of 40 = anovulation, amenorrhea, infertility + early signs of menopause with night sweats, hot flashes, vaginal dryness

Answer 34

primary ovarian insufficiency

Question 35

what's always the first step in secondary amenorrhea?

Answer 35

b-hCG if negative, FSH, prolactin, LH, TSH, estrogen

Question 36

low GnRH, estrogen, LH, VERY low FSH, high cortisol Breast development absent/incomplete

Answer 36

functional hypothalamic

Question 37

low estrogen, high FSH + LH with karyotype screening Breast development absent/incomplete

Answer 37

primary ovarian insufficiency

Question 38

rule OUT with administration of conjugated estrogen (+ = no bleeding), dx with weekly serum progesterone tests (>3 with no menses) US = absence of normal uterine stripe Hysteroscopy

Answer 38

Asherman's syndrome

Question 39

how do you treat funcitonal hypothalamic amenorrhea?

Answer 39

lifestyle changes - weight gain, adequate intake, psychotherapy

Question 40

how do you treat primary ovarian insufficiency?

Answer 40

HRT, virtro fertilization for pregnancy

Question 41

Pain in those that prevents normal activity and requires medication Subjective to patient, generally beginning on day of menses May cause vomiting, nausea, diarrhea, headache

Answer 41

dysmenorrhea

Question 42

Painful menstruation 1 = no organic cause, increased prostaglandins 2 = pathologic cause, such as endometriosis, adenomyosis, PID, cervical stenosis, fibroids, endometrial polyps Membranous = rare due to passage of endometrium through an undilated cervix

Answer 42

dysmenorrhea

Question 43

PE: Normal if primary, secondary may have signs of underlying pathology Transvaginal US in those who secondary is suspected

Answer 43

dysmenorrhea

Question 44

how do you treat dysmenorrhea?

Answer 44

NSAIDs + acetaminophen Codeine for stronger pain Antiprostaglandins Oral contraceptives (if no response to NSAIDs) Surgical treatment, adjunct (topical heat, TENS) Laparoscopy considered if unresponsive to 3 cycles of initial therapy to rule out secondary cause

Question 45

Restriction of symptoms to luteal phase = pathognomic Mood: irritability, mood swings, depression/anxiety Cognitive: confusion, poor concentration Physical: bloating, breast tenderness, insomnia, fatigue, hot flashes, appetite changes, headache Resolves with menses

Answer 45

PMS

Question 46

PMS is MC in

Answer 46

20s-30s

Question 47

Cyclic occurrences of symptoms of sufficient severity to interfere with life and with predictable relationship to menses Etiology unknown

Answer 47

PMS

Question 48

Must rule out other medical conditions that can mimic PMS (thyroid disease, anemia) Chart symptoms during the month Diagnosis if: -1 affective + 1 somatic symptom -During 5 days before menses -In each of 3 prior menstrual cycles

Answer 48

PMS

Question 49

how do you treat PMS?

Answer 49

Change eating habits, stress management, CBT, aerobic exercise Calcium carbonate (bloating, cravings, pain) Magnesium (water retention) NSAIDs Fluoxetine, sertraline Hormonal interventions in those who do not want to take SSRIs → OCPs

Question 50

Irritability, abdominal bloating, fatigue SEVERE form of PMS - following a predictable, cyclic pattern beginning in late luteal phase and end shortly after menstruation begins

Answer 50

premenstrual dysphoric disorder

Question 51

what diagnostic criteria do you use for PDD?

Answer 51

APA DSM 5 - A, B, C, D

Question 52

how do you treat PDD

Answer 52

Mild: exercise, relaxation, NSAIDs Moderate-severe: SSRIs, oral contraceptives, GnRH agonists, surgery

Question 53

Heavy or prolonged menstrual flow Presence of clots = can be normal but signify excessive bleeding >80 mL

Answer 53

menorrhagia

Question 54

intermenstrual bleeding

Answer 54

metrorrhagia

Question 55

Bleeding at irregular intervals with amount and duration varying Sudden onset of episodes = malignancy or pregnancy complications

Answer 55

menometrorrhagia

Question 56

what can cause menorrhagia

Answer 56

Submucosal myomas, pregnancy complications, adenomyosis, IUDs, endometrial hyperplasia, tumors, dysfunctional uterine bleeding

Question 57

What can cause metrorrhagia?

Answer 57

Ovulatory bleeding, endometrial polyps, endometrial/cervical carcinomas, exogenous estrogen

Question 58

What can you generally use for abnormal uterine bleeding?

Answer 58

PALM - polyps, adenomyosis, leiomyoma, malignancy COEIN - coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, none

Question 59

How do you evaluate abnormal uterine bleeding?

Answer 59

Detailed history PE Cytologic examination Pelvic/transvaginal US Blood tests → CBC, hCG, TSH Exclude systemic disease, pregnancy, or trophoblastic disease Further testing → endometrial biopsy, hysteroscopy, D+C In those at risk for hyperplasia or malignancy (all women greater than 45, or <45 with Hx of estrogen exposure such as obesity or PCOS)

Question 60

How do you treat abnormal uterine bleeding?

Answer 60

Combined OCPS NSAIDs/oral tranexamic acid in those unwilling to use hormone therapy Acute hemorrhage = IV high dose equine estrogen or high-dose combined OCPs, or oral progestins Surgery if not responsive or patient preference - endometrial ablation, uterine artery embolization, hysterectomy is definitive