Menstrual disorders

Question 1

What is the MCC of amenorrhea

Answer 1

Unrecognized pregnancy

beta HCG should be the first test always!!

Question 2

What treatment is indicated for hypoestrogenic conditions associated with primary and secondary amenorrhea

Answer 2

Estrogen (with progestin)

Question 3

Causes of menorrhagia include

Answer 3

systemic disorders or specific uterine abnormalities

-Uterine fibroids, adenomyosis, endometrial polyps. gynecologic disorders

Question 4

What is anovulatory bleeding

Answer 4

Bleeding form endometrium as a result of a dysfunctional menstrual system
Must exclude anatomic lesion of the uterus

Question 5

PCOS is characterized by

Answer 5

Amenorrhea
Menorrhagia
Anovulatory bleeding
(an androgenic disorder)

Question 6

What medication can be given in PCOS to improve glucose tolerance

Answer 6

Metformin (off label use)

Question 7

What conditions can cause amenorrhea

Answer 7

congenital uterine abnormalities
premature ovarian failure
meds (antipsychotics, verapamil)
anovulation/PCOS

Question 8

What conditions can cause anovulatory bleeding

Answer 8

adolescence 
perimenopause 
hyperandrogenic anovulation (PCOS) 
hyperprolactinemia 
hypothyroidism 
premature ovarian failure

Question 9

Because PCOS is an androgenic disorder, treatment should include

Answer 9

an anti-androgenic progesterone (3 or 4 gen)

Question 10

If pregnancy is an immediate goal for a woman with PCOS, treatment should include

Answer 10

weight loss
Clomiphene citrate
+/- metformin (if with reduced insulin sensitivity)

Question 11

If amenorrhea is 2/2 anorexia or excessive exercise, and increasing weight/decreasing exercise/psychotherapy are not effective, try

Answer 11

Estrogen (oral contraceptives or the patch)

Question 12

Primary/Secondary amenorrhea treatments include

Answer 12

CEE (conjugated estrogen equine): Premarin
Ethinyl estradiol patch: Alora, Estraderm
Combination OC

Question 13

Secondary amenorrhea treatments include

Answer 13

Oral MPA (medroxyprogesterone acetate): Provera
Progesterone vaginal gel
Norethindrone
Micronized progesterone

Question 14

Treatment for amenorrhea related to hyperprolactinemia includes

Answer 14

Bromocriptine*

Cabergoline

Question 15

Treatment for anovulatory bleeding includes

Answer 15

Combination OC (Desogen, Yaz, etc.)

Question 16

How do Bromocriptine and cabergoline work

Answer 16

Dopamine agonists; they suppress prolactin production from pituitary tumors so normal FSH and LH production occurs

Question 17

ADE of dopamine agonists include

Answer 17

hypotension 
nausea 
constipation 
anorexia
Raynaud's
fatigue
HA

Question 18

How do combination OC’s work

Answer 18

exogenous estrogen and progesterone suppresses FSH and LH, and inhibits ovulation
Reduces menstrual flow
controls menstrual cycle

Question 19

ADE of COC’s include

Answer 19

VTE 
breast enlargement 
breast tenderness 
bloating 
nausea
upset stomach 
HA
peripheral edema

Question 20

What drugs can interact with COC’s

Answer 20

St John’s Wort: contributes to altered menstrual bleeding
Rifampin: induce estrogen metabolism, causing Tx to fail
Sulfa drugs: Increased photosensitivity

Question 21

How do CEE work

Answer 21

Estrogen replacement for hypoestrogen states

Causes anovulatory bleeding

Question 22

How MPA work

Answer 22

Suppresses FSH and LH= suppress estrogen and progesterone

Inhibit usual growth of endometrium

Question 23

ADE of MPA include

Answer 23

Edema 
anorexia 
depression 
weight gain 
insomnia 
increased total cholesterol and LDL 
reduce HDL

Question 24

Good treatments for women with dysmenorrhea include

Answer 24

Mirena: decrease contractility and effect of fibroids

NSAIDS as prophylaxis

Question 25

Treatment options for dysmenorrhea include

Answer 25

``` COC's Depo-Provera LNG-IUD NSAIDS Celecoxib ```

Question 26

How does LNG-IUD work

Answer 26

Suppresses FSH and LH= suppress estrogen and progesterone | Inhibit usual growth of endometrium

Question 27

Why do NSAIDs work in treating dysmenorrhea

Answer 27

Inhibit prostaglandin release= reduce inflammatory response that contributes to dysmenorrhea

Question 28

ADE of NSAIDs include

Answer 28

``` GI upset stomach ulcer nausea vomiting heartburn indigestion rash dizziness ```

Question 29

What treatments can you use for Menorrhagia

Answer 29

COC's LNG-IUD Oral MPA Tranexamic acid

Question 30

What is tranexamic acid

Answer 30

Reversibly blocks lysine binding sites on plasminogen= prevents fibrin degredation= reduced menstrual blood loss AKA: anti-fibrinolytic Should be noticeable in the first month of therapy, with improved H&H after 3 months

Question 31

ADE of Tranexamic acid are

Answer 31

nausea vomiting diarrhea dyspepsia

Question 32

How do you dose Tranexamic acid

Answer 32

1300 mg TID up to 5 days during monthly menses

Question 33

PCOS treatments include

Answer 33

Injectable MPA COC's Oral MPA Metformin

Question 34

How does metformin work in treating PCOS

Answer 34

Inhibits hepatic glucose production increases insulin sensitivity= reduced insulin resistance *Start low (500 mg) and titrate up slowly!

Question 35

Metformin is contraindicated in

Answer 35

``` CrCl <30, can cause lactic acidosis IV contrast (dye can increase risk of lactic acidosis): stop metformin 1 day prior to IV contrast ```

Question 36

What treatments can be used for PMDD

Answer 36

``` Clomipramine (mechanism unknown) Drospirenone Leuprolide SSRI's (ONLY during luteal phase) SNRI's ```

Question 37

How does Drospirenone work in treating PMDD

Answer 37

Progesterone with anti-androgen properties (fourth gen) = decreased emotional lability

Question 38

How does Leuprolide treat PMDD

Answer 38

GnRH agonist= suppress FSH/LH= decrease estrogen and progesterone Inhibit normal menstrual cycle (ned 1-2 months of therapy to see improvement)