WEEK 1 Menstrual Cycle & Uterine Conditions Flashcards
(169 cards)
1
Q
What is the process through which sex hormones controlling the menstrual cycle are synthesized from cholesterol?
A
Steroidogenesis
2
Q
Which part of the brain initially releases the gonadotropin-releasing hormone?
A
Hypothalamus
3
Q
Which hormones does the pituitary gland produce when stimulated by GNRH?
A
FSH & LH
4
Q
The withdrawal of which hormone results in menstruation?
A
Progesterone
5
Q
What is the purpose of the follicular phase of the menstrual cycle?
A
To produce an ovum
6
Q
In the absence of conception, what process does the unfertilized follicle undergo?
A
Luteinization
7
Q
During which phase of the menstrual cycle does the endometrial tissue develop?
A
Proliferative phase
8
Q
Menorrhagia
A
Heavy, prolonged menstrual flow
9
Q
Oligomenorrhea, hypomenorrhea
A
light bleeding
10
Q
Polymenorrhea, hypermenorrhea
A
frequent bleeding
11
Q
Metorrhagia
A
Irregular bleeding patterns
12
Q
Intermenstrual bleeding
A
Bleeding between periods
13
Q
Post Coital bleeding
A
after intercourse
14
Q
what is PALM-COEIN an acronym for? What does the acronym stand for?
A
Standardize causes of abnormal vaginal bleeding
PALM: Anatomical/Structural Etiology **Diagnosed w/imaging**
Polyps
Adenomyosis
Leiomyoma (fibroids)
Malignancy and Hyperplasia
COEIN: Hormonal/Functional Etiologies
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
15
Q
What are Endocervical Polyps?
Where do they arise from?
What Do they look like? #3
A
Benign growths/Skin Tags
Hyperplastic epithelial cells & Vascular Core Component
Fleshy/Pedunculated lesion (on a stalk)/pear-shaped
16
Q
Steroidogenesis
A
What is the process through which sex hormones controlling the menstrual cycle are synthesized from cholesterol?
17
Q
Hypothalamus
A
Which part of the brain initially releases the gonadotropin-releasing hormone?
18
Q
FSH & LH
A
Which hormones does the pituitary gland produce when stimulated by GNRH?
19
Q
Progesterone
A
The withdrawal of which hormone results in menstruation?
20
Q
To produce an ovum
A
What is the purpose of the follicular phase of the menstrual cycle?
21
Q
Luteinization
A
In the absence of conception, what process does the unfertilized follicle undergo?
22
Q
Proliferative phase
A
During which phase of the menstrual cycle does the endometrial tissue develop?
23
Q
Heavy, prolonged menstrual flow
A
Menorrhagia
24
Q
light bleeding
A
Oligomenorrhea, hypomenorrhea
25
frequent bleeding
Polymenorrhea, hypermenorrhea
26
Irregular bleeding patterns
Metorrhagia
27
Bleeding between periods
Intermenstrual bleeding
28
after intercourse
Post Coital bleeding
29
Standardize causes of abnormal vaginal bleeding Polyps Adenomyosis Leiomyoma (fibroids) Malignancy and Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified
what is PALM-COIN an acronym for? What does the acronym stand for?
30
What is Adenomyosis?
What are risk factors for Adenomyosis? #5
How to diagnose?
Endometrial tissue from uterus deep into uterine muscle in uterine wall
Variant of Endometriosis
Risk Factors:
1. Multiple pregnancies (even sponanteous abortions)
2. Uterine surgery
3. C-section
4. DNC
5. Women in 40s - 50s
Diagnosis: TVS or MRI
31
What are the symptoms of Endocervical Polyps?
When should you remove Endocervical Polyps?
Post-Coital Bleeding
Asymptomatic
*Remove & send for histology/cytology when:*
1. \>3cm
2. friable,
3. irregular,
4. necrotic
32
Symptoms of Adenomyosis
How do you diagnosis?
PALM classification
* Asymptomatic, often
* Knifelike, stabbing pain (pretty severe)
* Dysmenorrhea (painful menstrual cramps)
* Dyspareunia (pain w/intercourse)
Diagnosis:
* Ultrasound
* MRI
* Histology
33
What is Leiomyoma?
What does it arise from?
PALM Classification
"Uterine Fibroids"
Benign Fibro-muscular tumors
Arises from *uterine wall smooth muscle*
34
What is a leading indicator of Hysterectomy?
Leiomyoma/Uterine Fibroids
35
What is a Leiomyoma?
Leiomyoma symptoms
How are Leiomyomas described?
Fibroids; benign tumors from smooth muscle cells of myometrium
S/S:
Asymptomatic; usually requires no intervention
Described based on location
36
Where are subserous fibroids?
Where do you palpate for them?
Located outside of uterus
Palpated abdominally
37
What type of fibroids give the uterus an irregular contour and are located within the organ?
Intramural fibroids
38
Where are submucosal fibroids located?
Are they palpable?
**Location**: Uterine Endometrium (inner lining of uterus/endometrium)
Benign
Palpable as enlarged or irregularly shaped uterus
39
What type of woman would you see with fibroids?
S/S of fibroids? #4
Diagnosed?
usually seen in women transitioning to the menopausal phase
* Anemia
* Regular/cyclical bleeding in conjunction with menses
* Rectal & pelvic pressure
* Increase urinary frequency
Diagnosed via US
40
\_\_\_\_ is an overgrowth of endometrial glands and occurs in women over ___ years
Endometrial hyperplasia & malignancies
50 years
41
Risk factors of Endometrial Hyperplasia & Malignancy #9
* early menarche/late menopause
* PCOS
* anovulatory conditions
* nulliparity
* infertility
* obesity
* Whites
* Unopposed exogenous estrogen
* DM/HTN/gallbladder disease
42
COEIN Classification: Coagulopathy
ABNORMAL UTERINE BLEEDING
Clotting deficiencies EX: Thrombocytopenia, liver disease or plt deficiencies
43
What should be ruled out for a young woman with heavy bleeding with her menstrual cycle since time of menarche?
Von Willebrand disease
44
Signs of Von Willebrand disease
Labs would you order?
How to diagnose?
* Heavy bleeding
* Bruising easily (1-2x/month)
* Prolonged bleeding
* Epistaxis (1-2x/month)
* Family hx
LAB:
* PT
* PTT
* PLT
Diagnosis:
* Hematologic testing
* Refer to Hematology to make diagnosis
45
AUB: Ovulatory Dysfunction
Cause
**Causes**:
* _Endocrine disorders_
* _Thyroid (Hypothyroidism)_
* Luteal Phase Defect (lack of progesterone)
* Adrenal Hyperplasia
* _Renal Failure_
* _Liver Disease_
* _Unopposed estrogen (PCOS)_
* _Exessive exercise/Stress_
*"diagnosis of exclusion when no other organic causes are identifiable"*
46
AUB: Endometrial
S/S #3
Cause #4
* \*All child bearing age who present with AUB should be considered pregnant and hcG part of assessment\**
* Means something is wrong with endometrial lining not just endometriosis*
**S/S:**
* Longer & Heavy menstrual bleeding
* Predictive cyclical patterns
* Intermenstrual bleeding
**CAUSE**:
* PID-chlamydia, gonorrhea = endometritis
* Retained placenta fragments
* Endometritis
* Post-abortal issues
47
AUB: Iatrogenic Conditions
Causes #5
1. **Medications:**
* Anticonvulsants (Dilantin)
* Digoxin
* Anticoagulants
* Progestin-containing contraceptives
1. **IUD & complications**
2. **PID Complications**
3. **Chronic Steroid Use**
4. **Opiates**
48
AUB: Not Classified
Causes
AV malformations in uterine
anything not diagnosed or fit other categories
49
What lab work do you order when evaluating abnormal uterine bleeding?
* HcG
* CBC
* TSH (or amenorrhea or anovulatory bleeding)
* Prolactin (or amenorrhea or anovulatory bleeding)
* PT, PTT (r/o coagulopathy)
50
Who is required an Endometrial Biopsy? #4
1. Post-menopausal women w/abnormal uterine bleeding
2. Women on hormone therapy with abnormal bleeding
3. Unscheduled bleeding on Oral Contraceptives that lasts more than 3 months
4. Endometrial stripe greater than 5ml on US
51
A patient is having anovulatory bleeding and there is no response to treatment...What do you order?
Pelvic US
52
You suspect an anatomic defect such as polyps and fibroids...What do you order?
saline infusion sonogram
53
What is considered primary amenorrhea?
1. No Menses by 14yrs in **absence** of 2ndary sex characteristics
OR
2. No Menses by 16 yrs **regardless** of 2ndary sex characteristics
54
What is secondary amenorrhea?
Absence of menses in previously normal menstruating
An interval of at least 3 cycles
OR
an interval of 6 months (after normal menstruation patterns established)
55
What are 4 causes of Amenorrhea?
Genital outflow tract disorder
Ovary disorder
Anterior Pituitary disorder
Hypothalamus or CNS disorder
56
Asherman Syndrome
Intrauterine adhesions
Scar tissue after surgery EX: C-Section
Mechanical obstruction of endometrium, vagina, or cervix
S/S:
* No pain
* No bleeding r/t uterine lining becoming obliterated
57
Cervical Stenosis
Cervical scar tissue becomes a plug so blood cannot drain
## Footnote
CAUSE:
Cone biopsy of cervix
LEEP procedure
Cryotherapy
Dilation & curettage
Congenital absence of uterus or vagina
58
What can cause diseases of the ovary that lead to amenorrhea?
Usually before 40 years old or Premature Ovarian Failure
**Autoimmune Diseases**
* Thyroid, Addisons, DM, Lupus, RA
**Ovarian Destruction**
* Chemo/Radiation, Asherman's, Mumps, Abscess
**Galactosemia**
**PCOS (alters estrogen levels)**
**hyperandrogenism/anovulation (interferes w/HPO axis)**
59
Disorders of the Ovary causes
HPO Axis intact but hyperadrogen state = **Anovulatory Amenorrhea**
**Hyperadrogen states**
* PCOS
* Adult-onset congenital adrenal hyperplasia
* Decreased FSH or LH
* Lifestyle
* Hyperprolactinemia
**Vascular Infarction**
* Postpartum Hemorrhage "Sheehan Syndrome" (destroys pituitary gland from lack of O2)
* "Simmonds' Syndrome" outside of pregnancy (pit destroyed)
**Primary Hypothyroidism**
* **^**prolactin production
* Pituitary tumors secrete GH or TSH
60
Amenorrhea: Disorder of Anterior Pituitary
**HYPERPROLACTINEMIA**
**Cause**:
* Prolactin-secreting adenoma tumor (prolactinoma)
* Hypothyroidism
61
What are disorders of the Hypothalamus or CNS that cause amenorrhea?
* **Lifestyle issues**
* exercise (endorphins inhibit GnRH, LH, & FSH)
* Anorexia
* **Hypothalamic Lesions (reduce GnRH, FSH & estrogen)**
* Tb
* Sarcoidosis
* Encephalitis
* **Medications** (effect _prolactin_ levels)
* antihypertensives
* psychotropic drugs
* Contraceptives
* H2 blockers
* **Chronic diseases**
* DM
* Crohn's
* Celiac's
* CF
62
What drugs can cause amenorrhea? How?
* Antihypertensives
* Psychotropics
* Oral contraceptives
* H2 blockers
Affect Prolactin Levels
63
How do you "work up" Amenorrhea?
1. R/O pregnancy & menopause
2. Overall Health Inquiry
3. Physical Exam (BMI
Labs:
* HcG
* TSH
* Prolactin levels
* FSH
* LH
Provera Challenge Test (Progesterone withdrawal test)
\*trying to induce withdrawal bleed
64
What does a Provera Challenge test show?
How long after giving estrogen can we do a Provera Challenge?
Progesterone withdrawal = Bleeding
_Normal response_ = period-like bleed = hormone dysfunction
_No Respons_e = Give exogenous estrogen
_No response to exogenous estrogen followed by progesterone_ = Outflow tract problem
_Bleeding response after estrogen & progesterone_ = Limited endogenous or inadequate estrogen \>\>\> check Gonadotropin levels
**2 weeks**
65
What is a normal FSH range?
5 - 30 IU/L
66
What is a normal LH range?
5 - 20 IU/L
67
What do high FSH and LH levels mean?
Most likely ovarian problem
68
What do low FSH or low LH mean?
Pituitary or CNS problem
69
What labs would you order for someone with heavy menstrual bleeding?
HcG
CBC
TSH
LFT
Coags
Cervical Cultures to r/o infection
70
How would you "work up" heavy menstrual bleeding? #5
1. Pregnancy test
2. Pelvic Exam (masses or pap smear)
3. Labs
4. Endometrial biopsy (if indicated)
5. Pelvic Sonogram (fibroids, polyps, measure endometrial stripe)
71
How thick should the endometrium be during the Follicular phase? Pre-ovulation?
Follicular Phase:
1-2 ml
Pre-Ovulation:
3-5 mL
72
An endometrial stripe greater than ___ mL should be evaluated further
5 mL
73
How does progestin tx heavy bleeding? Lupron? NSAIDs? Danazol?
**Progestin:**
Keeps Endometrium in secretory phase = limited endometrial growth
**Lupron (GnRH agonist)**
Ovaries can't release hormones = menopause state
**NSAIDs**
Block synthesis of prostaglandins = no cyclical endometrial sloughing
**Danazol/ Danoctinre**
a synthetic steroid that tx endometriosis
74
Patient Education for Danazol?
\*not the first choice = refer to OBGYN
Causes Amenorrhea
DC after 6 months
Adrogen side effects (weight gain, acne, seborrhea)
75
Patient education for Lupron (GnRH agonist)
Physiologic state similar to menopause
May result in bone loss
76
Differential Diagnosis for Irregular Menses/Metorrhagia #7
1. Pregnancy
2. Threatened spontaneous abortions
3. Ectopic Pregnancy
4. Gestational Trophoblastic Neoplasm
5. STI
6. Trauma
7. Mid cycle bleeding = ovulation?
77
What is the one endocrine disease dysfunction that causes heavy menstrual bleeding?
Hypothyroidism
78
What should you suspect if you see poor endometrial build up and irregular bleeding? Commonly seen in?
What is the treatment?
* Low levels of cyclic endogenous estrogen
* High levels of progestin
**Commonly seen:** in Depo-Provera implants or OCP
**Treatment**:
-Estrogen therapy for 7 to 10 days then Progesterone to initiate withdrawal bleed & protect against hyperplasia
79
What would you see in someone that has PCOS?
signs
Labs
Menses
Hirsutism, acne, obesity, alopecia, seborrhea, & acanthosis nigricans
Normal Estrogen
High Androgen
Anovulation
Chronic oligo or amenorrhea
Insulin resistant
80
What is the diagnostic criteria for PCOS?
1. Irregular or No periods
2. Androgen excess symptoms
3. Multiple early mid-follicular stage cysts 10 mm
\*Diagnosis of exclusion
\*Only diagnosed in the absence of other conditions
81
Women suspected of PCOS with menstrual dysfunction and hyperandrogenism should be screened for? #5
1. Pregnancy (HcG)
2. Hypothyroidism (TSH)
3. Hyperprolactinemia (prolactin level)
4. Glucose intolerance (OGTT)
5. Dyslipidemia (lipid profile)
82
What are causes of hyperadrogenism?
1. Androgen secreting tumors
2. Adrenal Gland tumors
3. Adult onset congenital adrenal hyperplasia
4. Cushing's syndrome
83
How to diagnose Androgen-secreting tumors
Testosterone \>200ng/mL
Pelvic US
Palpation on physical exam
84
How to assess for adrenal gland tumor?
DHEAS level
85
How to assess for adult-onset non-classical congenital adrenal hyperplasia?
accompanying symptoms?
Labs?
Usually accompanied by primary or secondary amenorrhea
Hypertension in childhood or family history
More common in Hispanics, Italians, Slavics, Jew, & Inuit
Draw 17-hydroxyprogesterone fasting levels, \>2ng/mL = PCOS
86
What 17-hydroxyprogesterone fasting level would be suspicious for PCOS?
\>2ng/mL
87
Hwo to test for Cushing's syndrome?
24 hour urine for cortisol
88
How to OCPs treat PCOS?
1. Supress enlarged ovaries
2. Inhibit LH & androgen production
3. Protect endometrium from unopposed estrogen
4. Binds up free testosterone (relieved acne & hirsutism)
89
How long does it take to see a reduction of hair growth with combined oral contraceptives?
9 to 12 months
90
Which progesterones have low adrogen effects?
Desogestrel
Norgestimate
Drospirenone
91
What would you give to manage PCOS if contraception is not required?
Medroxyprogesterone acetate
5-10mg daily for first 14 days of each month
Progestin only Does not treat hirsutism
92
How to treat hirsutism with PCOS?
**Antiandrogens used in combination with contraception because they are teratogenetic**
## Footnote
**Spironolactone (Aldactone):** inhibits testosterone (hirsutism & alopecia)
**Finasteride (Proscar, Propecia):** blocks conversion of testosterone DHT
93
How to manage metabolic syndrome associated with PCOS
**Insulin sensitizing agents**
## Footnote
**Metformin**
Not 1st line or to be given solely for weight loss & hirsutism
Decreases androgen levels, BP, LDL, fasting insulin
\*\*Can induce ovulation with clomiphene (Clomid)
94
What is Lupron used to treat? How does it work? Why is this not a great option?
PCOS hirsutism
MOA:
inhibits gonadotropin secretion & ovarian hormone section = slows hair growth & _severe_ estrogen deficiency
Expensive & requires estrogen therapy & injections
95
What do you want to monitor and follow up for in PCOS patients?
Diabetes - glucose tolerance Qannualy
Lipids -Q 2 years
Hypertension
Smoking cessation
96
Primary dysmenorrhea
Onset?
Cause?
Onset:
* 6-12 months menses onset
Cause:
* Increased prostaglandin production
* Reduction in uterine blood flow = uterine contractions (angina of vagina)
* Assoc w/ anxiety and depression
* No anatomic issues
97
Secondary dysmenorrhea
Cause?
Associated symptoms?
Less common
Cause:
* Pelvic Pathology
* Pelvic floor weakness
* IBS
* Interstitial cystitis/UTI
* Endometritis
* Fibroids/Polyps/Cancer
Associated Symptoms
* dyspareunia
* post coital bleeding
* abnormal uterine bleeding
98
How is secondary dysmenorrhea different from primary dysmenorrhea?
Secondary occurs before, during or after menstrual period
Pathologic & not caused by prostaglandins
Occurs later in life
99
How to meet the diagnostic requirements of PMDD
1. Symptoms during majority of menstrual cycles
2. Decreased interest in usual activities
100
What are differential diagnosis for PMDD?
What are the goals of PMDD treatment?
1. Endocrine
2. Psychiatric
3. Chronic pelvic pain, IBS, Crohn's, hypothyroidism, endometriosis, ovarian cysts, fibromyalgia, arthritis
Goals of Tx
1. Stabilize hormone levels
2. Suppress ovulation
3. Antidepressants/antianxiety
4. Lifestyle changes
5. Calcium supplementation
6. SSRIs
101
What is the difference between adenomyosis & uterine fibroids?
_Uterine fibroids_ are benign tumors in wall of uterus
_Adenomyosis_ is when the inner lining of the uterus grows into the muscle wall of uterus causing heavy painful periods
102
How often does the hypothalamus release GnRH?
60-90mins
103
What is the role of FSH?
plays a dominant role in promotion of ovarian follicular growth
104
What is the role of LH?
stimulates androgen production in the theca cells
105
It is the preliminary role of ____ to stimulate the production of androgens by the granulosa cells
LH
106
What happens during days 1-5 during the follicular phase?
Main purpose of follicular phase is the development of follicles in ovary
## Footnote
Days 1 -5
Follicle are recruited and begin to grow
Increasing estradiol levels to induce more FSH receptors on largest follicle thus producing a greater amounts of estradiol
107
What happens during days 5- 7 of the follicular phase?
What happens after day 7?
What happens at the end of the follicular phase?
Days 5-7
1 follicle becomes more dominant& produces most estradiol and has the most receptors
Day 7
The dominant follicle is selected
At the end: **LH surge**
108
109
When does positive feedback occur during the menstrual cycle?
Describe the positive feedback loop during this phase
Ovulation phase
1. Estradiol reaches critical level (usually 24 hours before ovulation) =
2. positive feedback in pituitary =
3. causes LH & FSH surge
4. LH causes progesterone production
110
What is the hallmark of the luteal phase?
shift from estrogen dominant-follicular phase to **Progesterone dominance**
111
When is peak progesterone production?
7-8 days after the LH surge (at the approximate time of implantation if fertilization has occurred)
112
A patient has a uterus that is slightly enlarged, boggy and tender on exam. What might the working diagnosis be?
Adenomyosis
113
What are the 3 subcategories of AUB-Ovulatory Dysfunction?
What do they look like?
What are their causes?
* **Anovulatory Uterine Bleeding**
* Abnormal cycle intervals, usually heavy bleeding
* _Cause_: Hormone imbalance (PCOS, obesity
* **Amenorrhea**
* No Menses
* _Cause_: Disorder of genital outflow tract, ovary, anterior pituitary, or hypothalamus/CNS
* **Ovulatory AUB**
* Cyclic & regular, Heavy bleeding
* _Cause_: polyps, fibroids
114
What labs would you order for someone with Amenorrhea?
Urine hcG
FSH/LH
Prolactin
TSH, T3, T4
115
What labs would you order for someone that you suspect has Von Willebrand Disease?
Ristocetin cofactor assay
PT/PTT
Platelets
116
When is the best time in the menstrual cycle to perform a transvaginal scan?
Days 4-6
117
When would you do an endometrial biopsy?
1. History of AUB-Ovulatory Dysfunction AND Ages 45+
2. 30-45 not responding to medical Tx,
3. Hx unopposed estrogen and persistent AUB
4. Endometrial thickness \>5 mm
118
What is Asherman's?
Cause
Symptoms
Disorder of the genital outflow tract
Severe inflammation of the uterus from bands of scar tissue that join parts of the walls of the uterus to one another reducing the volume of the uterine cavity
Cause: uterine instrumentation, endometrium infection
119
Following the rupture of the follicle, the ___ and ____ cells take up ____ and ____ to give the corpus luteum (yellow body) a yellow appearance
Following the rupture of the follicle, the **granulosa** and **theca** cells take up **steroids** and **lutein** pigment to give the corpus luteum (yellow body) a yellow appearance.
120
The proliferative phase of the uterine cycle is under the influence of....progesterone or estrogen?
What days of the cycle are the proliferative phase?
estrogen
Proliferative phase is Days 7-14
121
Estrogen increases the thickness of the endometrium by increasing the number and ____ of _____ cells
Estrogen increases the thickness of the endometrium by increasing the **number** and **size** of **endometrial cells**
122
1. false
2. true
3. true
4. f
123
What hormone is responsible for the LH surge and ovulation?
Estrogen
124
What is considered a frequent period?
Less than 24 days between cycles
125
What is considered an infrequent period?
More than 38 days between cycles
126
127
What is the normal duration of a period?
8 days or fewer
128
What is a normal variation in cycle length?
Shortest to longest shouldn't vary more than 7-9 days
129
What is an irregular cycle variation length?
Any variation more than 8 to 10 days
130
metro menorrhagia define
irregular AND heavy menstrual bleeding
131
How does adenomyosis feel on exam?
Tender (especially during menses)
Enlarged/Heavy feeling
Boggy
132
How to evaluate AUB?
1. R/O pregnancy
2. Where is the bleeding coming from? (r/o bladder, rectum)
3. Is it anovulatory
4. bleeding regular or irregular?
5. Associated symptoms EX bruising
133
What labs are important to order if someone is having amenorrhea or anovulatory bleeding?
TSH
Prolactin
134
135
3 Examples of functional hypothalamic amenorrhea
What will their labs look like?
1. Weight loss below certain level
2. Female athlete: amenorrhea, disordered eating & osteoporosis
3. emotional stress
*not enough GnRH produced therefore no FSH/LH = no estrogen production*
**Low estrogen**
136
What is the most common cause for amenorrhea with an anterior pituitary disorder?
What would your order if you were suspicious of an anterior pituitary disorder?
* Hyperprolactinemia caused by a "prolactinoma" prolactin-secreting adenoma tumor
* Hypothyroidism = hyperprolactinemia
Orders include
* Prolactin level
* MRI/CT pituitary
137
What are some labs you would order for amenorrhea?
* TSH & Prolactin
* FSH & LH
* Provera challenge
138
What does it mean if your patient with amenorrhea has normal TSH, Prolactin, FSH, & LH?
What would you order next? why?
**Functional Hypothalamic Amenorrhea**
Progestin challenge test
* to r/o outflow concerns & see if uterus is being primed with estrogen
139
Progesterone Challenge 10 mg daily for 7-10 days
1. Bleeding \>\>\>
2. No bleeding with Progesterone \>\>\>
3. Bleeding after estrogen \>\>\>\>
4. No bleeding with progesterone or estrogen \>\>\>\>
1. **Bleeding \>\>\>** anovulatory (PCOS) \*not ovulating and getting into that luteal phase for the progesterone...unopposed estrogen\*
2. **No bleeding with Progesterone \>\>\>** Give estrogen for 21 days followed by progesterone
3. **Bleeding after estrogen \>\>\>\>** HPOA issue
4. **No bleeding with progesterone or estrogen \>\>\>\>** endometrial lesion or outflow tract obstruction TX hysterosalpingography or hystroscopy
140
True or False: A positive progesterone challenge test means no outflow concerns and the FNP should look at higher-up components as causes of amenorrhea?
True
141
True or False:
A negative progesterone challenge test is concerning for outflow tract abnormalities?
True
142
True or False:
Low BF and excessive stress/exercise are common causes of functional hypothalamic amenorrhea which affects the HPO axis leading to hypo estrogen states
True
143
How to treat acute vaginal bleeding
Estrogen therapy IV (stops the shedding and regrows the uterine lining)
Once stable, Monophasic COC
or
Progestin therapy if endometrium is thick
144
What is the treatment of choice for chronic anovulation bleeding?
Progestin
145
What is Lupron/Synarel used for? How does it work?
Treats heavy bleeding r/t endometriosis
GnRH agonist
puts the person in menopause by shutting down the whole cycle
146
What are some causes of Menorrhagia?
Heavy menstrual flow/cramping
1. Miscarriage
2. Mid Cycle Ovulation
3. STI - Cervicitis
4. Trauma
5. Oral contraceptives
147
What is primary dysmenorrhea?
Cause?
Painful cramps \*most common cause dysmenorrhea
* Begins 6-12 months after onset menses
Cause:
* Increased prostaglandin production causing uterine contractions
Symptoms
* Ischemic pain "angina of vagina"
* Recurrent symptoms w/ each cycle and resolution with end of menses
* NOT PSYCHOSOMATIC
148
What is a key component of primary dysmenorrhea?
Recurrent symptoms with each cycle and resolution with the end of menses
149
What are the common causes of secondary dysmenorrhea?
usually ages 30-40; less common than primary dysmenorrhea
Causes:
1st - Endometriosis
2nd - Adenomyosis
fibroids, polyps, cysts, cancer, PID/STI, pelvic floor weakness, IBS, Interstitial cystis, UTI
150
What is the gold standard of diagnosis endometriosis?
Laproscope
151
Multiple symptoms of Premenstrual disorder occurs only during...
Luteal phase: \<7 days prior to menses & resolve with menses (days 2-13)
Charted during at least 2 cycles
152
What criteria do you need to be diagnosed with PMD
* **1+ affective symptoms**: emotional lability, anger, feelings of hopelessness, anxious
* **5 PMS symptom**s: poor concentration, appetite changes, decreased interest in activities, fatigue, breast tenderness, bloating, weight gain, joint aches, insomnia or hypersomnia
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PMD Management
* COC: Yaz approved for PMD, diuretic effect
* SSRI if symptoms emotional: Day 14 of cycle for 2 weeks
* Anxiolytics last resort
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What are herbal supplements to treat PMD?
* Vitex agnus-castus (Chasteberry)
* Evening primrose oil
* tumeric
* Calcium supplements
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True or False
Progestin pills or a progesterone IUD are good options for the treatment of PMDD?
**False**
We want to suppress ovulation. Progestin does not suppress ovulation
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What underlying disorders are you ruling out for PCOS? What diagnostic studies would you order?
1. hCG - pregnancy
2. TSH - hypothyroidism
3. Prolactin - hyperprolactinemia
4. OGTT, FBS or HbA1C - Glucose Intolerance
5. Lipids - Dyslipidemia
6. Testosterone - hyperadrogenism
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When working up PCOS, what are other causes of hyperandrogenism?
* Androgen-secreting tumor
* Adrenal gland tumor
* Adult-onset non-classical congenital adrenal hyperplasia
* Cushing's syndrome
## Footnote
*For excessive or rapid onset androgen symptoms*
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What would you prescribe someone with PCOS that does not want contraception?
Medroxyprogesterone acetate 5-10mg po daily for the 1st 14 days of each month
\*\*progesterone alone will not treat hirsutism
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What is the follow up for PCOS?
1. Treat DM, dyslipidemia & hypertension
2. Smoking cessation
3. Lipid profile Q2 years
4. GTT for DM annually or every 2 years if normal
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True or False:
PCOS can put individuals at higher risk for breast cancer?
False
puts them at higher risk for endometrial or uterine cancer
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What are the 3 most common signs of TSS?
Rapid onset Fever
Hypotension
Sunburn like rash
Multiorgan system dysfunction
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How do you diagnose TSS?
1. Involves at least 3 organ systems
usually staph aureas
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What are the benefits of OCPs for dysmenorrhea?
1. Contraception
2. Rapid Relief
3. Cycle Control
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How does OCPs work for dysmenorrhea?
1. Suppress ovulation & endometrial tissue overgrowth
2. Decrease prostaglandin production & lower menses volume
3. Lower intrauterine pressure & cramping
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How is TSS treated?
ED & infectious disease specialist
IV hydration
Supportive care
Sources of bacteria removed and cultured
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What are causes of anovulatory bleeding?
· **Estrogen Withdrawal**
· **Estrogen breakthrough** EX: PCOS (from chronic anovulation from high androgen production), perimenopausal
· **Progesterone breakthrough** EX: Progestin only pills
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What is the characteristic US sign of PCOS?
Thickened, glistening, white, enlarged multicystic ovary
20+ follicles and/or ovarian volume over 10ml
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What is the treatment for PCOS when conception is desired?
Weight loss
Metformin
Referral
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When is an endometrial evaluation necessary? What does it involve?
Post menopausal with uterine vaginal bleeding
Ovulatory dysfunction and older than 45
OR
\<45yrs, unopposed estrogen exposure, failed medical management & persistent abnormal uterine bleeding
