Other Gyn Problems

Question 1

What happens if no ovulation occurs?

Answer 1

Estrogen continues to be produced and the endometrium continues to proliferate so that periods will not occur normally until the endometrial architecture cannot be sustained any longer leading to sporadic breakthrough bleeding or menorrhagia

NOTE: Oral birth control can help normalize periods!

Question 2

What is another possible consequence of not ovulating?

Answer 2

endometrial proliferation can turn neoplastic due to unopposed estrogen

Question 3

How common is dysmenorrhea?

Answer 3

About 50% of menstruating women have dysmenorrhea and 10% require treatment, and is most common between the ages of 20-24

The likelihood of having serious symptoms related to dysmenorrhea is like most common within 2 yrs of menarche

Question 4

What causes dysmenorrhea?

Answer 4

This is primarily related to levels of prostaglandins, with women who experience dysmenorrhea with menstruation having higher levels of PGF2a and PGE2 (Infusions of PG have been known to cause uterine contractions and pain).

Question 5

T or F. Women who do not ovulate have no dysmenorrhea and low levels of PGs

Answer 5

T

Question 6

Note about suggested natural initator of labor

Answer 6

Progesterone levels are high throughout pregnancy and typically progesterone suppresses prostaglandin receptors and the arachadonic acid cascade. When labor nears, progesterone levels drop and prostaglandins can promote muscle contraction and labor

Question 7

So why would pain occur with menses and not other times of the menstrual cycle?

Answer 7

During the luteal phase progesterone levels are very high and suppress prostaglandin action, but when progesterone levels drop due to the degeneration of the corpus luteum, prostaglandins can act can cause pain

Question 8

What is primary dysmenorrhea?

Answer 8

No known cause- i.e. most likely due to the hormonal rises and drops of progesterone

Question 9

How would primary dysmenorrhea be treated?

Answer 9

NSAIDs- want to start taking NSAIDs as soon as progesterone levels begin to fall (i.e. when you feel like your period is about a day away from starting) OR

Hormonal contraceptive agents because they prevent ovulation due to a steady state of progesterone

Question 10

What are some causes of secondary dysmenorrhea?

Answer 10

pelvic inflammatory disease

Endometriosis

Ovarian cysts

Tx: Treat cause

Question 11

Notes about Endometriosis

Answer 11

This is a benign condition that is often found incidentally but can cause symptoms, and typically becomes clinically apparent in the 30’s

Question 12

What is endometriosis?

Answer 12

Endometrial tissue found outside the endometrial cavity that still responds to estrogen and progesterone and thus can cause cyclic symptoms of even chronic symptoms

This is most often found on the ovary or fallopian tubes

Question 13

Question 14

How does endometriosis occur?

Answer 14

These are just theories:

1) Retrograde menses (Support: pts. with imperforate hyman often get endometriosis)
2) Totipotential cells differentiate into endometrial tissue (Support: Can see endometrial tissue in the lung)
3) Heme spread

Question 15

What are the symptoms of endometriosis?

Answer 15

Dysmenorrhea BUT pain typically begins a couple days BEFORE menses and is some better on Day 1 or 2

Question 16

How can endometriosis be treated?

Answer 16

Harder to treat but OCPs/Depo-provera usually work (stop ovulations) as well as neoadjuvant NSAIDs which inhibit PG production

If no relief, go to a lapraoscopy for a diagnosis. Biopsy required

Question 17

Question 18

T or F. Biopsy should be done for dx. of endometriosis

Answer 18

T. Diagnosis is laparoscopy and biopsy

Question 19

What are some other symptoms of endometriosis?

Answer 19

pelvic pain (means its pretty extensive) or mass,

dyspareunia, and

infertility (in 30-40% of infertile couples, the pts. presents with sigsn of endometriosis)- an embryo gets confused about where to implant

Question 20

T or F. There is not much correlation between the stage of endometriosis and infertility

Answer 20

T. Even a little scarring can cause infertility

Question 21

Can also give a continuous GnRH agonist that essentially places a women in a menopausal state (but long term use is assoicated with bone density loss- may want to add some estrogen)

Question 22

What is Premenstrual syndrome?

Answer 22

Mood swings around menses-

• Very common to have some physical manifestations
• 5-10% of women have severe enough symptoms that they interfere with daily life

Question 23

T or F. PMS worsens with age

Answer 23

T. But only occurs in women who are ovulatory!!

Question 24

What are some common symptoms of PMS?

Answer 24

• Bloating and Weight gain
• Irritability and Difficulty concentrating
• Tiredness and Moodiness

Nobody knows whta causes PMS

Question 25

What is a good way to diagnose PMS?

Answer 25

Menstrual and symptom diary to ask the question: Are these symptoms really associated with menses or are they more constitutional (or getting worse at a certain time)?

Question 26

What are some Tx options for PMS?

Answer 26

* NSAIDs * Short course of diuretics- if bloated * Oral contraceptives * Diet- reduce salt or respond to cravings if you're having them * SSRIs around menses

Question 27

What is adenomyosis?

Answer 27

Endometrial implants in the endometrial wall of the uterus into the myometrium that typically cause dysmenorrhea **and an enlarged and tender uterus (boggy)** Not uncommon- NSAIDs and OCP do work, but sometimes hysterectomy is needed **Does not lead to infertility**

Question 28

What is Premenstrual Dysphoric Disorder?

Answer 28

* An extreme form of PMS marked by extreme mood shifts that interfere with work and personal relationships * Likely that underlying behavioral health issue is present * During the premenstrual time period, the symptoms worsen

Question 29

What are the symptoms of PMDD?

Answer 29

* The PMS symptoms of bloating and dysmenorrhea are there, but at least one of these other symptoms must be present: * Sadness or hopelessness * Anxiety or tension * Extreme moodiness * Marked irritability or anger

Question 30

What are the Tx options for PMDD?

Answer 30

* SSRIs either all month or only in the interval between ovulation and the start of your period. Depends if underlying mental health disorder is diagnosed * OCPs * Regular exercise and proper diet * Nutritional supplements: 1,200 milligrams of calcium daily, vitamin B-6, magnesium and **L-tryptophan** * Avoid stressors, look for ways to avoid triggers or cope