menstrual disorders (15%)

Question 1

normal menstrual cycle

Answer 1

24-38 days w menstruation x4-8 days

Question 2

phases of menstrual cycle

Answer 2

follicular/proliferative (0-14)

luteal (14-28)

Question 3

what occurs in the follicular phase

Answer 3

endometrium thickens under influence of ESTROGEN. dominant follicle in ovaries matures

Question 4

what occurs during days 1-12 of cycle

Answer 4

pulsatile GnRH from hypothalamus releasing more FSH + LH –>

FSH causes follicle + egg maturation in ovary + LH causes follicle to produce estrogen –>

estrogen builds up endometrium + causes NEGATIVE FEEDBACK in HPO –>

inhibits hypothalamic GnRH release to inhibitt LH + FSH release so no more follicles grow at this time.

Question 5

what occurs during days 12-14 of cycle

Answer 5

inc estrogen from follicle switches from negative to POSITIVE FEEDBACK on GnRH –>

inc estrogen, FSH + LH –>

LH surge causes OVULATION.

Question 6

what occurs during the luteal phase

Answer 6

ruptured follicle becomes corpus luteum which secretes progesterone + some estrogen but PROGESTERONE PREDOMINATES) –>

Progesterone maintains endometrium to prep for implantation

Question 7

what happens if pregnancy occurs

Answer 7

blastocyst keeps C.L functional –>

secretes progesterone + estrogen to keep endometrium from sloughing

Question 8

what happens if pregnancy does not occur

Answer 8

C.L degenerates which decreases progesterone + estrogen –>

sloughing of endometrium (menstruation) + negative feedback on GnRH subsides –>

inc pulsatile GnRH –> starts cycle again

Question 9

what are the 2 etiology types of DUB

Answer 9

chronic anovulation (90%)- in teenagers or perimenopausal, unopposed estrogen (PCOS) –> inc endometrial overgrowth –> irregular, unpredictable shedding

ovulatory (10%)- regular cyclical shedding + ovulation w prolonged progesterone secretion –> inc blood loss from endometrial vessel dilation + PGs –> menorrhagia

Question 10

what is cryptomenorrhea

Answer 10

light flow/spotting

Question 11

what is menorrhagia

Answer 11

normal intervals but heavy/prolonged bleeding

Question 12

what is metrorrhagia

Answer 12

irreg bleeding

Question 13

what is menometrorrhagia

Answer 13

irregular, heavy/long bleeding

Question 14

what is oligomenorrhea

Answer 14

infreq periods (cycle length >35 days, <6mo)

Question 15

what is polymenorrhea

Answer 15

freq periods (cycle <21 days)

Question 16

tx of acute severe bleeding

Answer 16

high-dose IV estrogen or high-dose OCPs

D+C if failed

Question 17

tx of DUB

Answer 17

1st OCPs (Combo)- progesterone if estrogen CI
leuprolide (GnRH analog)

Question 18

what is dysmenorrhea

Answer 18

painful menstruation

Question 19

what is primary vs secondary dysmenorrhea

Answer 19

primary- no pelvic pathology but increased PGs –> painful uterine muscle wall activity (usu 1-2yrs after menarche in teenagers)

secondary- pelvic patho, MC >25yo (endometriosis, adenomyosis, leiomyomas, adhesions, PID)

Question 20

tx of dysmenorrhea

Answer 20

nsaids- start before sx + give for 2-3 days
hormonal birth control

laparoscopy if meds fail to R/O 2ry causes (endometriosis if younger, adenomyosis if older)

Question 21

definition of menopause

Answer 21

> 1yr w/o menses d/t loss of ovarian function

Question 22

average age of menopause

Answer 22

50-52yo

Question 23

premature menopause

Answer 23

<40yo

usu DMs, smokers, vegetarians, malnourished

Question 24

complications of menopause

Answer 24

inc CV events
HLD
osteoporosis

Question 25

dx of menopause

Answer 25

FSH assay most sensitive (inc FSH >30) inc LH dec estrogen

Question 26

tx of hot flashes in menopause

Answer 26

estrogen, progesterone, clonidine, SSRIs, gabapentin

Question 27

tx of vaginal atrophy in menopause

Answer 27

estrogen

Question 28

tx of osteoporosis in menopause

Answer 28

``` Ca + Vit D wt bearing exercise bisphosphonates SERM (RAL, TAM) calcitonin estrogen ```

Question 29

estrogen-only HRT pros + cons

Answer 29

pros- most effective sx tx, transdermal or vaginal > PO, no inc breast CA cons- inc endo CA, VTE

Question 30

estrogen-progesterone HRT pros + cons

Answer 30

pros- sx relief, dec heart + stroke risk, dec osteoporosis, protects against endo CA cons- VTE, inc breat CA

Question 31

what differentiates PMS from PMDD

Answer 31

PMDD = anger + irritability + functional impairment

Question 32

when does PMS/PMDD occur

Answer 32

during luteal phase (1-2wks before menses) relieved w.i 2-3 days of menses onset 7+ sx-free days during follicular phase

Question 33

what medication is approved for PMDD

Answer 33

drospirinone

Question 34

what is primary vs secondary amenorrhea

Answer 34

primary- no period by age 15yo (if 2ndary sex characteristics), 13yo (if none) secondary- no period for >3mo in pt w previously normal menses or >6mo in pt w previous oligomenorrhea

Question 35

etiologies of primary amenorrhea if uterus + breasts present

Answer 35

outflow obstruction (transverse vaginal septum, imporforate hymen)

Question 36

etiologies of primary amenorrhea if uterus present+ breasts absent

Answer 36

elevated FSH/LH = ovarian causes - premature ovarian failure (46, XX), gonadal dysgenesis (45, XO) normal/low FSH/LH = hypothalamus-pituitary failure or puberty play (athlete, illness, anorexia)

Question 37

etiologies of primary amenorrhea if uterus absent + breasts present

Answer 37

``` mullerian agenesis (46, XX) androgen insensitivity (46, XY) ```

Question 38

etiologies of primary amenorrhea if uterus + breasts absent

Answer 38

rare- usu defect in testosterone synthesis | will often have intraabdominal testes

Question 39

MC etiology of secondary amenorrhea

Answer 39

pregnancy

Question 40

other etiologies of secondary amenorrhea

Answer 40

``` hypothalamus dysfunction pituitary dysfunction (pituitary adenoma) ovarian disorders uterine disorders (ashermans) ```

Question 41

how does hypothalamus dysfunction cause amenorrhea

Answer 41

disruption of normal pulsatile GnRH secretion --> dec FSH +/or LH

Question 42

causes of hypothalamus dysfunction --> amenorrhea

Answer 42

hypothalamic disorder, anorexia, exercise, stress nutritional deficiency, systemic dz (celiac)

Question 43

diagnosis of hypothalamus dysfunction --> amenorrhea

Answer 43

normal/dec FSH/LH, low estradiol, normal PRL

Question 44

tx of hypothalamus dysfunction --> amenorrhea

Answer 44

clomiphene, menotropin (stimulate GnRH secretion)

Question 45

how does pituitary adenoma cause amenorrhea

Answer 45

prolactin-secreting pituitary adenoma --> suppresses GnRH --> dec FSH/LH

Question 46

dx of pituitary adenoma --> amenorrhea

Answer 46

low FSH/LH inc PRL MRI of pituitary sella

Question 47

tx of pituitary adenoma --> amenorrhea

Answer 47

transsphenoidal surgery

Question 48

what ovarian disorders can cause amenorrhea

Answer 48

PCOS, premature ovarian failure, follicular failure/resistance to LH/FSH, turners syndrome

Question 49

clinical presentation/dx of ovarian disorders --> amenorrhea

Answer 49

sx of estrogen deficiency (hot flashes, sleep + mood disturbances, dyspareunia, dry/thin skin, vaginal atrophy) INC FSH/LH progesterone challenge test- 10mg medroxyprogesterone x10 days --> withdrawal bleeding indicates ovarian issue, no withdrawal bleeding indicates HPO or uterine issue

Question 50

what uterine disorder causes amenorrhea

Answer 50

asherman's syndrome (Scarring of uterine cavity 2ry to PP hemorrhage, s/p D+C or endometritis)

Question 51

how do you dx asherman's syndrome

Answer 51

pelvic US = absence of uterine stripe | hysteroscopy

Question 52

tx of ashram's syndrome

Answer 52

estrogen to stimulate endometrial regeneration