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NURS 871: NP Role in Illness > Week 01.Women's Health.AUB > Flashcards

Week 01.Women's Health.AUB Flashcards

(76 cards)

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1
Q

downside of depo provera

A

long return to fertility; d/n use in women who hope to have a baby w/in a year

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2
Q

how long does it take to become amenhorreic after starting on depo proverb?

A

4 cycles = 1 year

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3
Q

For whom is Depo Provera used?

A

for those who prefer to avoid estrogen

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4
Q

For what is LNG-IDU (Levonorgestrel IUD) used? What cautions should you consider?

A

NOT AUB-O –> d/n result in regular bleeding
used for AUB in women who don’t want pregnancy (1st line); reduces blood loss

consider:
expulsion rate
long adjustment period w/ adenomyosis, endometriosis

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5
Q

Name an infectious cause of AUB

A

chlamydia

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6
Q

Iatrogenic causes of AUB (AUB-I)

A 
medical interventions
medical devices
IUD
pharmacologic agents
--gonadal steroids
--those impacting endometrium
--those interfering with coagulation
--those interfering w/ systemic control of ovulation
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7
Q

When is AUB often caused by a disorder of the endometrium?

A

predictable/cyclic menstrual bleeding

typical ovulatory cycles

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8
Q

Name some disorders of the endometrium that can cause AUB

A

endometrial inflammation
endometrial infection
abnormalities in local inflammatory response
abnormalities in endometrial vasculogenesis

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9
Q

Name some causes for the inhibition of ovulation

A

inadequate progesterone d/t lack of LH surge (From alteration of GnRH release from hypothalamus)
–typical w/ stress, weight loss, increased exercise

hyperprolactinemia
hypothryoidism
iron deficiency anemia
excess androgen & cortisol production
extremes of age:  adolescence & menopause
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10
Q

When and why does heavy menstrual bleeding (HMB) need to be treated?

A

when interfering with QOL

  • -stains bedding and clothes
  • -avoidance of activities
  • -frequent changes of pads and tampons

can cause anemia

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11
Q

Define intermenstrual bleeding; what is the goal?

A

occurs b/w regular menses
if no etiology, goal is sx relief
evaluation goal is to ID etiology and r/o malignancy
if etiology can be ID’ed and tx’ed, then tx; otherwise, tx symptoms

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12
Q

name some possible causes of intermenstrual bleeding

A 
endometrial polyp
chronic endometriosis
fibroids
cancer
improper use of contraceptives
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13
Q

Define ovulatory dysfunction

A

AUB-O = abnormal uterine bleeding - ovulatory dysfunction

irregular NONCYCLIC bleeding (in the absence of an anatomic lesion)
may be infrequent
can be prolonged/heavy

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14
Q

name goals of tx of ovulatory dysfunction; what to keep in mind regarding treatment?

A

goal: est regular bleeding pattern
prevent heavy bleeding
prevent ENDOMETRIAL HYPERPLASIA
often requires fertility treatments to conceive

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15
Q

name some causes of ovulatory dysfunction

A

hypothyroidism

PCOS

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16
Q

What is the risk of progesterone levels being too low?

A

unopposed estrogen –> endometrial hyperplasia

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17
Q

Symptoms of PCOS

A 
lifelong h/o irregular menses or amenorrhea
infertility
hirsutism
obesity
acne
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18
Q

Risks of PCOS

A

hyperinsulinemia –> increased CV risk

unopposed endometrial estrogen stimulation =–> hyperplasia, atypical cells, endometrial carcinoma

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19
Q

What is the leading cause of AUB-O anovulatory bleeding?

A

PCOS

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20
Q

What clotting disorder is commonly associated w/ heavy menstrual bleeding?

A

von Willebrand disease

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21
Q

What is PALM-COEIN, and for what is it used?

A

Polyp
Adenomyosis = endometrial tissue grows into uterine wall
Leimyoma (fiobroid = benign smooth muscle tumor)
Malignancy & Hyperplasia

Coagulopathy
Ovulatory Dysfunction
Endometrial Dysfunction
Iatrogenic
Not Yet Classified

PALM-COEIN guides the clinicians to think about differential diagnoses of PREMENOPAUSAL AUB by structure vs funciton

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22
Q

What is an endocervical polyp and is it concerning?

A

endothelial proliferation
small minority have malignant potential
often asymptomatic

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23
Q

What is adneomyosis?

A

endometriosis in muscle layer of uterus

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24
Q

What is a leiomyoma and is it concerning?

A

fibroid
asymptomatic
presence d/n typically cause AUB
widely variable growth

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25
Discuss malignancy and hyperplasia r/t AUB in the premenopausal woman
rare, but still a possibility must be considered in all reproductive age women associated w/ AUB
26
Name some drugs/substances that reduce circulating levels of estrogens/progestin
``` TCAs anticonvulsants anticoagulants antibiotics smoking phenothiazines anything interfering w/ the metabolism of dopamine ```
27
normal menstrual cycle length
24-35 days
28
normal menstrual period length
2-7 days
29
define heavy menstrual bleeding, as defined by the International Federation of Gynecology and Obstetrics (IFGO)
ovulatory bleeding that exceeds 8 days' duration or heavy enough to interfere w/ daily activity
30
What happens w/ fibroids at menopause?
they shrink and symptoms regress
31
What happens if a fibroid continues to grow through menopause?
is the fibroid actually a sarcoma?
32
How common are fibroids?
very common; may coexist w/ another cause of abnormal vaginal bleeding
33
When are polyps more of a concern?
most are benign | bleeding polys and those in postmenopausal women are associated w/ higher risk of malignancy
34
With what is postcoital bleeding associated?
carcinoma of the cervix (when there is a surface ulceration)
35
For whom is endometrial carcinoma more typical?
postmenopausal women experiencing AUB
36
What is typically the cause of anovulatory bleeding?
alteration in the hypothalamic-pituitary-ovarian axis
37
Name a common cause of irregular menstrual bleeding?
age extremes: adolescence and perimenopause | irregular menstrual bleeding typical of perimenopause = anovulatory estrogen w/d phenomenon
38
What is the most common gynecologic cancer in the U.S.?
endometrial cancer
39
risk factors for endometrial cancer
early menarche late menopause nulliparity
40
Describe the relationship of ectopic pregnancy w/ abnormal vaginal bleeding
delay of regular period | vaginal blood spotting, often in conjunction w/ unilateral pelvic pain
41
What is the risk of an ectopic pregnancy?
RISK: intraperitoneal hemorrhage if tubal rupture (< 5%)
42
Name the initial tasks to address AUB in women of reproductive age
r/o pregnancy | determine whether the bleeding is ovulatory or anovulatory
43
What could be the cause of rapid onset of hirsutism and virilization?
androgen-producing adrenal or ovarian tumor
44
When in the cycle is the best time to do an U/S to visualize the endometrium?
ASAP after cessation of bleeding
45
What is the gold standard test if bleeding persists despite negative evaluation?
hysteroscopy
46
What helps confirm suspected perimenopausal bleeding? What results confirm it? Why this test?
serum FSH if greater than 40 IU/mL, ovarian failure is imminent FSN levels rise as estrogen levels begin to fall
47
What test helps confirm the diagnosis of PCOS? What level is indicative of PCOS?
serum testosterone level > 60ng/dL
48
What is the treatment for acute anovulatory bleeding? Why and how does this work?
course of oral medroxyprogesterone (Provera, 10mg/d for 10 days) OR norethindrone (5-10 mg/d for 5-10d) OR progesterone 100mg IM x 1 OR oral contraceptive containing 30-35 micrograms of estrogen; 1 tablet q4-6h for 2-3d **converts proliferative endometrium into a secretory one; bleeding should stop w/in 24-48h; menstrual flow should stop on completion of progestin therapy
49
What should be done if pharmacological treatment of acute anovulatory bleeding does not stop the bleeding?
refer for D&C + hysteroscopy
50
What is the most effective treatment for chronic anovulatory bleeding in those who do not desire pregnancy?
Levonorgestrel-releasing IUDs (reduce both ovulatory and anovulatory bleeding by decreasing endometrial proliferation) more effective than oral contraceptives in reducing blood loss
51
What pharmacological treatment can be used for women who do not require contraception? What does it do?
monthly administration of progesterone --> triggers endometrial shedding
52
What benefit does progesterone therapy give to women with AUB?
reduces risk of endometrial cancer d/t long-term unopposed estrogen stimulation
53
What progesterone medication can be used for progesterone therapy for anovulatory AUB? What to keep in mind for high doses?
medroxyprogesterone (Provera, 10-12 days each month) high doses can have lots of side effects (bloating, dysphoria, increased appetite)
54
What should be done if further AUB happens when a patient is on progestin therapy?
further evaluation
55
When can progestin therapy for anovulatory AUB be halted/paused and why?
periodically for 2-3 months to observe for return of normal cycles, as ovulation may resume
56
What needs to be done for a patient with anovulatory bleeding who desires pregnancy?
refer for consideration of medical ovulation induction
57
What pain medication can decrease both ovulatory and anovulatory bleeding? What is the mechanism of action? What other benefits can they provide?
NSAIDs: interference w/ prostaglandin synthesis: - -causes vasoconstriction in endometrium - -can also relieve dysmenorrheal symptoms
58
What antifibrinolytic can be used for bleeding associated with ovulatory cycles? What are the downsides?
``` tranexamic acid (TXA), 1300mg TID up to 5D during menstrual bleeding **expensive, theoretical concerns for thrombogenic effects ```
59
Irregular perimenopausal bleeding: normal or abnormal? Are there any concerns?
NORMAL if the result of anovulatory periods | irregular pattern can indicate intrauterine disease
60
What to do for AUB that is suspected to be perimenopausal?
first, rule out structural lesion then, monthly medroxypregesterone (10mg/d for 10-12d) to correct irregular bleeding; continue monthly until w/d bleeding stops (indicates ovarian failure and menopause)
61
What can happen with progesterone therapy that is given for AUB that is suspected to be r/t perimenopause? And how does this impact bleeding?
ovulation, causing bleeding
62
When would one want to use combined oral contraceptives for perimenopausal irregular bleeding? Who should not receive combined oral contraceptives?
To regulate ovulatory bleeding that might occur with progesterone therapy alone, as well as provide contraception who should not use: * *nonsmokers * *uncontrolled HTN
63
What should be done for breakthrough bleeding on low-dose estrogen oral contraceptives?
make sure the patient is adhering to the regimen; if so, switch to something with a higher dose of estrogen
64
In a patient with AUB, who should be admitted to the hospital?
* those with signs of intravascular volume depletion | * if ectopic pregnancy is suspected (life-threatening hemorrhage is a slight risk)
65
Who needs an emergency OB consult?
bleeding in pregnancy
66
Who needs a referral to gynecology?
* woman w/ risk factors for carcinoma of cervix or endometrium * mass lesion detected on pelvic exam * abnormal-appearing cervix * abnormal Pap test * postmenopausal woman w/ new-onset vaginal staining, especially those w/ thickened endometrium (> 4mm) or focal endometrial lesion
67
At what age does risk of cancer begin to increase?
35 years
68
What are the options for a woman who has AUB when initial medical therapy fails to control bleeding? (especially for bleeding that interferes with daily activities or results in symptomatic anemia)
``` levonorgestrel-releasing IUS endometrial ablation fibroid embolization myomectomy (surgery to remove fibroids while preserving uterus) hysterectomy ```
69
Why would you want to preserve the uterus?
Loss can compromise pelvic support --> bladder and bowel dysfunction
70
Are fibroids worrisome?
generally not unless they cause difficulty or there is evidence of lesion growth after menopause
71
When should NSAIDs be taken to address AUB?
a few days prior to menses and continued through menses
72
A patient w/ h/o myomectomy is pregnant; what does she need to know?
will likely need a C/S
73
If a patient has an endometrial ablation, what is required and why?
pregnancy is 100% contraindicated | need contraception
74
Why is it common for adolescents to experience AUB?
1st year of menses, 50% of cycles are anovulatory endometrium lacks stabilizing effects of progesterone --> endometrium becomes thickened and proliferates beyond ability of estrogen to maintain integrity
75
Causes of adolescent AUB?
``` anovulatory cycles pregnancy! bleeding disorders PCOS thyroid dysfunction hypothalamic dysfunction: exercise, stress, eating disorder, acute weight loss, obesity infection endometriosis ```
76
What risk factors cause excessive estrogen?
``` obesity (BMI > 35) PCOS anovulatory menstrual cycles tamoxifen any unopposed estrogen ```

NURS 871: NP Role in Illness (10 decks)

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