Lecture 11: Menstrual and Uterine Disorders Flashcards
1
Q
Primary amenorrhea in classified by absence of menses by age () with impaired sexual development, or by age () with normal sexual development.
A
- Age 13 if impaired development.
- Age 15 if development was normal.
2
Q
The MCC of primary amenorrhea is…
A
Abnormal chromosomes leading to gonadal dysgenesis.
Ovarian insufficiency
3
Q
Absence of menses for > 3 cycles or 6 consecutive months in a previously menstruating patient is known as…
A
Secondary amenorrhea
4
Q
The MCC of secondary amenorrhea is…
A
Pregnancy
5
Q
Postpastum pituitary necrosis due to hypovolemia and leading to hypothalamic-pituitary dysfunction/amenorrhea is known as…
A
Sheehan’s syndrome
6
Q
Premature ovarian failure occurs prior to the age of…
A
40
Menopause prior to 40.
7
Q
T/F: PCOS can cause amenorrhea
A
True
8
Q
Mullerian dysgensis is congenital absence of the () and the upper 2/3 of the ()
A
- Uterus
- Upper 2/3 of vagina
However, can still ovluate and have normal 2ndary sex characteristics
9
Q
Uterine adhesions are usually due to …
A
Dilation and curettage
Asherman’s syndrome
10
Q
In a patient showing primary amenorrhea with Positive 2deg sex characteristics, the labs you would order are… (1)
A
Pregnancy test
11
Q
In a patient showing primary amenorrhea with negative 2deg sex characteristics, the labs you would order are… (4)
A
- Prolactin
- TSH
- LH
- FSH
12
Q
In a patient showing primary amenorrhea with negative 2deg sex characteristics, and elevated LH/FSH, you would expect their ovaries to ()
A
Not produce estrogen!
Ovarian failure
13
Q
In a patient showing primary amenorrhea with negative 2deg sex characteristics, and low LH/FSH, the next step in workup is…
A
MRI of the brain
14
Q
The 3 labs you would order initially for workup of secondary amenorrhea are….
A
- Pregnancy test (MCC!)
- TSH
- Prolactin
Abnormal TSH = thyroid dz
Abnormal prolactin = pituitary imaging
15
Q
A progesterone challenge test that shows bleeding means the () is intact but progesterone is lacking.
Workup of secondary amenorrhea
A
Endometrium
16
Q
In an estrogen + progesterone challenge test, lack of bleeding suggests that the endometrium is either () or ()
A
Unresponsive or blocked.
Bleeding = suspect hypogonadism
17
Q
The presence of high FSH/LH with amenorrhea pretty much means…
A
Primary ovarian failure
The ovaries are not responding properly.
18
Q
The presence of low FSH/LH with amenorrhea usually means () ovarian failure
A
Secondary
Pituitary is not releasing a proper amt
19
Q
A patient with secondary amenorrhea has a negative pregnancy test, Normal TSH/Prolactin, and a Progesterone challenge test with no bleed. The next test to run is… ()
A
Estrogen Progesterone challenge test
20
Q
The main hormone responsible for growing the endometrium is..
A
Estrogen
I think? Im p sure? I hope?
21
Q
In a patient suffering from amenorrhea that desires to get pregnant, the two pharmacologics we could suggest are…
A
- Letrozole/Femara (aromatase inhibitor)
- Clomiphene citrate/clomid (SERM)
22
Q
A woman with amenorrhea that does not desire to get pregnant should be put on… ()
A
OCPs
Combination to maintain bones, reduce atrophy, menopausal s/s
23
Q
The MC type of dysmenorrhea is…
A
Primary dysmenorrhea (idiopathic)
24
Q
Painful menstruation that inhibits normal activity and requires medication is known as..
A
Dysmenorrhea
25
The primary hormone? associated with dysmenorrhea is...
Prostaglandins during ovulation
26
The hallmark symptom of dysmenorrhea is...
PAIN
27
Generally, dysmenorrhea pain begins () relative to menses onset and recurs with () menstrual cycles
* Begins at onset/1-2 days prior
* Recurs with most/all menstrual cycles
28
Physical pelvic exam of dysmenorrhea will usually show...
No significant pelvic disease.
29
First line pharm treatment for dysmenorrhea
NSAIDs (Naproxen/Advil)
| Reduce prostaglandins.
## Footnote
Take prior or at onset of S/S.
30
The first line NON-pharm tx for dysmenorrhea is...
Continuous heat to abdomen
| Same efficacy as advil, better than tylenol
31
Erythema ab igne can occur in dysmenorrhea because...
Chronic use of heat pads
| Toasted skin syndrome
32
A patient suffering from dysmenorrhea tries NSAIDs and heat, which both don't work. You should now suggest...
Contraceptives (oral or IUDs)
33
The highest incidence of PMS and PMDD occurs between the ages of...
late 20s to early 30s
34
PMS becomes PMDD when there is clear...
Functional impairment
35
The primary non-pharm tx for mild-mod PMS/PMDD include changing (), () therapy, and supplements, specifically ()
* Changing eating habits (complex carbs, avoid caffeine/chocolate/alcohol/salt)
* CBT
* Chasteberry
36
Cyclic edema in PMS/PMDD can be treated with...
Spironolactone
37
The primary use of bromocriptine, a dopamine agonist, in PMS/PMDD is for...
Breast pain
38
For more severe PMS/PMDD, the first-line treatment is...
SSRIs
39
Second-line tx for more severe PMS/PMDD is...
Hormonal contraceptives containing drospirenone
| Yaz, Yasmin, Beyaz
40
For PMS/PMDD that is severe and refractory to SSRIs and hormones, our last resort is to use (meds) or definitive (surgery)
* GnRH agonists (medical menopause)
* Definitive: Bilateral oophorectomy +/- hysterectomy
41
You would expect endometrial cells in a postmenopausal patient to be an **abnormal finding** unless they were currently taking...
MHT
42
Generally, contact bleeding/postcoital bleeding is suggestive of ()
Cervical cancer
43
A **transvaginal US** needs be performed with a () bladder
Empty bladder
44
Typically, the **initial imaging for evaluating dysfunctional uterine bleeding** would be a....
Pelvic US
45
The **gold standard** for evaluating dysfunctional uterine bleeding is...
Hysteroscopy
46
In a pre-menopausal patient with dysfunctional uterine bleeding, no serious pathology, and no impact of QOL, we would recommend either () or ()
* Observation
* Hormone therapy
47
In a premenopausal patient with an active uterine hemorrhage, the TOC is...
IV estrogen
48
Definitive tx of dysfunctional uterine bleeding in a premenopausal woman is...
Hysterectomy
49
T/F: A postmenopausal patient with 12 months of amenorrhea that now presents with dysfunctional uterine bleeding needs investigation.
True
50
The MCC of postmenopausal uterine bleeds is...
Exogenous hormones
51
The MCC of a **lower GU tract** postmenopausal bleed is...
Vaginal atrophy
52
The primary differences between first and 2nd gen endometrial ablations is that 2nd gen does not require () and takes () time
* 2nd gen **does not require direct hysteroscopic guidance**
* Also 2nd gen is **faster**
53
A majority of patients will experience () menstrual flow after an endometrial ablation
Decreased menstrual flow
54
The primary contraindication to endometrial ablation is...
Patient wants kiddos later
| Very dangerous to have kids after this
## Footnote
Also you cant do this if theyre currently pregnant lol
55
T/F: you need pre-op abx before an endometrial ablation
False
56
The first tool used for 1st gen endometrial ablation is...
Nd-YAG laser
57
The main caveat of using rollerball ablation is that it cannot reach () lesions
| 1st gen endometrial ablation
Intracavitary
58
The 1st gen endometrial ablation technique with the highest rates of perforation is...
Endometrial resection
59
What is the primary advantage and disadvantage of Hysteroscopic thermal ablation?
| 2nd gen endometrial ablation
* Pro: Can use with anatomically abnormal uterus
* Con: Higher burn risk
| Its like boiling your uterus
60
The primary advantage of using radiofrequency thermal ablation is...
| 2nd gen endometrial ablation
No endometrial prep required
61
Thermal + RF Thermal ablation, aka Minerva, shows () rates of normal or no menstrual flow post procedure
Higher rates
62
Cryoablation of the endometrium typically causes () pain
Less pain
63
The MC GYN diagnosis that leads to hospitalization in women aged 15-44 is...
Endometriosis
64
The 6 RFs for endometriosis are...
* (+) FHx
* Early Menarche
* Nulliparity
* Long flows
* Heavy flows
* Short cycles
65
The MC symptom of endometriosis is...
Dysmenorrhea
| Pelvic pain, dyspareunia, infertility
66
T/F: Symptom severity does not correlate with endometriosis extent
True
67
The constant pelvic pain in endometriosis is usually worse () menses
Just before menses
68
Classically, a patient with endometriosis will have () nodules in their posterior vaginal fornix, or they will have ()
* Tender nodules
* They could also just have nothing
69
The initial imaging for endometriosis is...
TVUS
| Checking for rectum or rectovaginal septa
70
Definitive dx of endometriosis is done via
Surgery w/ biopsy
71
**Power burn** and **chocolate cysts** are most commonly associated with what condition?
Endometriosis
72
The primary goal in treating endometriosis is...
Symptom relief
| Plus restoring fertility
73
In a patient with endometriosis presenting with minimal symptoms, we would first suggest (meds)
NSAIDs/Hormones
| Combo or progestin only
74
In a patient with mild endometriosis and is not responding well to hormones, the next hormonal tx options are (3)
* GnRH agonists/antagonists
* Danazol
* Aromatase inhibitors
75
What is Danazol's MOA?
Inhibit gonadotropin release and enzymes that produce estrogen
| Testosterone derivative that acts like progestin.
## Footnote
Relieves pain!
76
Leuprolife is a GnRH (agonist/antagonist), whereas Orilissa is a GnRH (agonist/antagonist)
* Leuprolide = Agonist
* Orilissa = Antagonist
| Both should only be used up to 6 months. Orilissa low dose = 24 m
77
The two STDs MC associated with PID are...
Gonorrhea and chlamydia
| Usually polymicrobial
78
Overall, the highest risk patient for PID is..
Young, nulliparous, sexually active woman with multiple partners
79
The leading cause of infertility and ectopic pregnancy is...
PID
80
The cardinal symptom of PID is...
Lower abd pain
81
Specifically, RUQ pain associated with PID is most suggestive of () syndrome
Fitz-Hugh-Curtis Syndrome
82
The classic sign of PID is known as ...
Chandelier's sign (Cervical motion tenderness
83
T/F: A patient with PID has an elevated temp.
True, often PO temp is > 38.3C/101F
84
T/F: Labs and imaging will always show if someone has PID
False
85
Initial imaging for PID suspicion is a ...
TVUS
| Can also add on laparoscopy
86
Per CDC guidelines, a Dx of PID is treated empirically. The Dx requires () and one or more of ()
* Pelvic/lower abd pain with NO OTHER CAUSE
* Either cervical motion/uterine/adnexal tenderness
87
A pregnant patient presenting with PID needs empiric tx. You would choose (PO/IV) abx and tx her (IP/OP)
**Admit her** and tx with IV/PO abx (see below for details)
| Pregnancy is an admit condition.
88
The 3 drugs used in empiric tx of PID are...
* Rocephin
* Doxy
* Metro
| All 14d!
89
The classic patient for a tubo-ovarian abscess is a...
Young, low-parity, hx of pelvix infection
90
The method of choice to search for a tubo-ovarian abscess is...
US
91
Tubo-ovarian abscesses that are **unruptured** are treated with...
* Rocephin
* Doxy
* Metro
| Similar to inpt PID but **4-6 weeks!**
92
A patient presenting with a ruptured tubo-ovarian abscess needs immediate (surgery)
Total abdominal hysterectomy + Bilateral salpingo-oophorectomy
| and some fluids and abx
93
In a **postmenopausal pt with a tubo-ovarian abscess** we suspect that they may also have a concurrent ()
Malignancy
94
Cystocele is also known as...
Anterior vaginal prolapse
95
A patient presents to your office with a feeling of discomfort down there. She describes it like **something is falling out** or **its like im sitting on a ball**. She is also coughing a lot and says she needs to strain hard when poopin. She probably has a ()
Pelvic organ prolapse
96
What does it mean to splint your bladder or vagina/perineum?
Gotta push their fingers against that organ so they can pee/poop
97
Dx of pelvic organ prolapse is usually done...
Clinically.
| Only need imaging if you suspect something else
98
Generally, the conservative tx for pelvic organ prolapse is...
Pessary
| Requires provider to fit and check.
## Footnote
Can also do Kegels or topical estrogen
99
T/F: After surgical mesh/repair of a pelvic organ prolapse, it will not recur again.
False
100
Adenomyosis is (symmetrical/asymmetrical) enlargement of the endometrium
Symmetrical
101
The top two RFs for adenomyosis is...
* Parity
* Age (40-50)
102
Adenomyosis is characterized by growths within what layer of the endometrium?
Myometrium
103
The preferred imaging modality for adenomyosis is...
TVUS
| Focal thickening, heterogenous texture
104
Symptomatic relief of adenomyosis is achieved with (OTC meds), OCPs, and (procedure)
* NSAIDs for pain
* Endometrial ablation/resection somewhat helpful
105
Definitive tx of adenomyosis is with
Hysterectomy
106
The MC benign neoplasm of the female genital tract is....
Leiomyomas
| Myomas, fibroids, fibroid tumors
107
Although most leiomyomas are asymptomatic, the MC presenting S/S are (2)
* Abnormal uterine bleeding
* Pelvic pressure/pain
108
Presence of a leiomyoma is confirmed via () and its location is confirmed via ()
* US to confirm presence.
* Hysterography/hysteroscopy to confirm if its cervical vs submucous
109
For a patient presenting **asymptomatic** with a leiomyoma, the preferred management is...
Observation with annual exams.
110
If a leiomyoma is symptomatic, the pharm therapy for it is (2)
* NSAIDs
* Hormonal therapy (contraceptives, GnRH agonists)
111
The 3 surgical treatments for leiomyomas are....
* Myomectomy
* Hysterectomy
* Uterine artery embolization
112
Your 45 year old patient presents with a new onset leiomyoma with no symptoms. She seems like she is about to go through menopause. You should counsel her that her leiomyoma will () after menopause.
It will usually regress sponatenously.
113
The MC GYN malignancy is...
| MC in white woman, but they also have higher survival rates
Endometrial cancer
114
Although endometrial cancer can occur as young as 20-30, it typically has a peak onset at (age)
70s
115
The primary underlying etiology for endometrial cancer is...
Endometrial hyperplasia.
| Long-term estrogen, which stimulates the endometrium!
116
The MCC of **endogenous overproduction** of estrogen is...
Obesity
| Metabolic syndrome
## Footnote
PCOS = no progesterone to counteract
117
What drug can cause abnormally high levels of estrogen/increase risk of endometrial cancer?
Tamoxifen
118
Generally, estrogen enhances the endometrium. In order to counteract it, the mainstay of therapy is...
Progesterone
119
The primary medication we use to reduce risk of endometrial cancer is...
Combo OCPs!
| We need that progesterone
120
Lifestyle modifications to reduce endometrial cancer are primarily (2)
* Smoking (NOT CESSATION)
* lower animal fat diet
| Smoking reduces estrogen, so it actually reduces risk
121
The MC symptom of endometrial hyperplasia is...
Abnormal uterine bleeding
122
Simple hyperplasia without atypia of the endometrium is expected to regress (spontaneously/with progestin) 80% of the time
Spontaneously
123
T/F: Endometrial hyperplasia with atypia is considered cancer
False, it is premalignant
| It could become caner
124
If endometrial hyperplasia with atypia undergoes () but it **fails/relapses**, the next step in management is ()
* Progestin therapy
* Hysterectomy
125
The **majority** of endometrial ccancers are seen in **younger patients**, have **favorable** prognoses, and are usually **low-grade** mean they are (type 1/2) endometrial caner
Type 1 endometrial cancer
126
Type 2 endometrial cancer is unique in that estrogen ()
Estrogen has no effect.
127
The classic patient with endometrial cancer is...
Obese, nulliparous, infertile, HTN, DM, white woman
128
The MC cell type of endometrial cancer is...
Adenocarcinoma
129
The endometrial cancer cell type that is rarest and NOT associated with hyperestrogenic states is...
Clear cell carcinoma
130
The mainstays of preventing endometrial cancer include:
* Reduce exposure to exogenous (1)
* Using (2)
* Avoiding any syndrome that induces (3)
* Wt control/exercise
* Control of (2 chronic conditions)
* Prophylactic TAH/TVH +/- BSO
1. Exogenous estrogen
2. Using progesterone
3. Anovulation (think PCOS)
131
The MC symptom of endometrial cancer is..
| Also often the most important and earliest!
Abnormal bleeding
| **Always workup any postmenopausal bleed**
132
Cervical os stenosis leading to blood/detritus build-up is known as...
Hematometra
133
Generally, a physical exam of endometrical cancer early on will show...
Probably nothing
134
In a post-menopausal pt with abnormal bleeding, your initial imaging choice would be... ()
Pelvic US
135
What endometrial thickness is highly suspicious of endometrial cancer in a postmenopausal patient?
> 4 mm
136
In order to definitively diagnose endometrial cancer, you need a ()
Biopsy of endometrial tissue
137
The extra definitive diagnostic procedure for endometrial cancer is (), which must be done inpatient with anesthesia.
D&C
| Bigger sample.
138
The mainstay of treating endometrial cancer is...
Surgery
| Gotta take it all out ):
139
The 2 adjunct chemo agents used for endometrial cancer are...
* Doxorubicin
* Cisplatin
