week four Flashcards by tia meechan

What is the dx criteria of PCOS

Rotterdam

Ovarian dysfunction (irregular or absent ovulation)

Clinical and/or biochemical evidence of androgen excess

Polycystic ovaries (TVUS)

Presence of 12+ follicles in at least one ovary measuring 2-9 mm in diameter and/or ovarian volume > 10 (not necessary for dx)

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What is the pathophys behind insulin resistance in PCOS?

Dec SHBG > inc testosterone bioactivity > android or visceral fat

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Pathophys of ovarian hyperandrogenism in PCOS

Intrinsic abnormality of theca cell steroidgenesis

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Pathophys anovulation in PCOS

Persistent estrogen production arising primarily from peripheral conversion of androgens to estrone and inc androgens in the ovary

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Pathophys increased LH in PCOS

Primary neuroendocrine defect and inc androgens > inhibits feedback effects of estrogens and progesterone on pulsatile LH release

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Pathophys dec FSH in PCOS

Feedback effect of chronic unopposed estrogen secretion > dec aromatase activity

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List the ways hyperandrogenism presents clinically from most to least common

PCO
Obesity
Oligomenorrhea
Hirsutism
Acne
Metabolic syndrome
Alopecia

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What are mechanisms that underlie CVD in the PCOS patient?

Inc insulin > inc homocysteine

Impairment of cardiac structure + function (inc cardiac size, inc BP, dec EF)

Endothelial dysfunction and dec max O2 consumption due to IR

Elevated CRP

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What are some of the MOA for development of endometrial hyperplasia and carcinoma in the PCOS patient?

Anovulation, presence of DMII (hyperinsulinemia), obesity, HTN

Insulin upregulates estrogen producing aromatase enzyme system in glands and stroma

Progesterone resistance due to dysregulation of endometrial gene expression

Hyperandrogenism

Hypersecretion LH which modulates endometrial growth

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What is the initial lab work for PCOS dx? What imaging can be ordered after and why?

initial working is serum free testosterone and FSH/LH

TVUS can be ordered if necessary to meet 2 of 3 dx criteria

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What are some of the goals of medical management in a PCOS patient?

Restoring ovulation
Normalize endometrium
Amelioration hyperandrogenism sx
Reduce IR
Manage underlying metabolic abnormalities
Reduce RF for DM2 and CVD
Contraception*

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What are the main lifestyle treatments used in management of PCOS? What difference do they make?

Mindfulness stress management (dec cortisol, BP, blood sugar)

Weight loss (restore cycles, improve preg rates)

Exercise (dec IR, BP, improves lipids)

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What are some effective nutraceuticals for PCOS pts?

Fish oil
Vit E succincinate
N acetyl cysteine
Chromium
Vit D3
Probiotics
DCI
MI

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What are some herbs used in PCOS pts with glucose-insulin issues and dyslipidemia?

Berberine
Gymnema
Cinnamon
Flax
Nettle
Saw palmetto
Mentha spicata
Vitex
Cimifuga racemosa
Peonia lactiflora
Tribulus terrestris
Licorice
Maitake mushroom

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When is metformin useful with PCOS?

Off label to treat or prevent oligomenorrhea, hirsutism, infertility, obesity, to prevent DM2

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What are pharmaceutical options for PCOS pts?

Progesterones
Progestins
Mirena IUD
OCP
Metformin
Statins
Acarbose alpha glucosidase inhibitor
Spironolactone
Letrozole

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What are the six sources of pelvic pain?

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GI
Uro
Gyn
Psych
MSK
Neuro

What are the most common psych causes of pelvic pain?

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2nd chakra issues - fear of losing control, relationships, etc
Depression
Physical/sexual abuse
Somatisation

What are the main GI causes of pelvic pain?

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IBS
IBD

What are the main urological causes of pelvic pain?

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What are the main MSK/neurological causes of pelvic pain

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Abdominal wall myofascial pain (trigger points)
Pelvic floor myalgia/elevator ani spasm

What are the main gynecological causes of pelvic pain?

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Adhesions
Adendomyosis
Endometriosis

Red flag sx in pelvic pain

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Unexplained wt loss
Hematochezia
Perimenopausal irregular bleeding
Post menopausal vaginal bleeding
Post coital bleeding

What is an important consideration when prescribing anti-inflammatory pain meds for dysmenorrhea?

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Clothing/DRESS syndrome ?

What are the three most common conventional therapies for dysmenorrhea?

NSAIDs Hormonal contraceptives Mirena IUD

How does estrogen dominance increase pain in endometriosis?

Inc estrogen > inc BDNF > inc hyperplasia

What three body system disorders does endometriosis act like?

Autoimmune - immune defects unable to clear tissue when implanted, higher immune cells Cancer - mesothelium invaginates and undergoes metaplasia into endometrial tissue Endocrine - endometriosis glandular elements secrete paracrine substance that causes inflamatory response in surrounding tissue

What are the most common sites for endometriosis to implant?

Cul de sac Left broad ligament Left utero-sacral ligament

What are the most common sx of endometriosis?

Dysmenorrhea Non menstrual pelvic pain Deep dyspareunia/dyschezia Lateral pelvic pain Bladder pain, frequency, dysuria Irregular vaginal bleeding IBS Infertility

How is endometriosis definitively diagnosed?

Histologically on laparoscopy or laparotomy finding extrauterine endometrial cells

What are the goals in managing endometriosis?

Relieve sx Prevent complications of annexation masses Exclude malignancy Improve subfertility Preserve ovarian function

What are the standard conventional treatments for endometriosis?

Combined contraceptives Progestins Mirena IUD GnRH analogs, agonists, antagonists Androgen agents Aromatase inhibitors NSAIDs Surgery

What are the ways progestins treat endometriosis?

Anti-angiogenic Immunomodulatory Anti-inflammatory Inhibits implantation and growth of refluxed menstrual endometrium Suppresses menses, dec pain

What is an example of an endocrine disruptor that contributes to endometriosis? How so? How would a woman be exposed?

PCBs - mimic estrogens, interfere with hormone processes Found in meat, fish, eggs, milk

What are the main symptoms related to adenomyosis?

Dysmenorrhea Menorrhagia Large clots

Describe the classic presentation for pelvic congestion syndrome

Multiparous woman with chronic dull pelvic pain, typically with postcoital ache that may last for days Fullness in legs, bladder irritability Sx better lying, worse inc intraabdominal pressure

What is thought to be the most likely underlying etiology for PMS/PMDD?

CNS NTs interacting with sex hormones, causing abnormal response to normal hormonal changes

What is the only proven RF for PMS/PMDD? What are others?

Ovulatory cycles Age Stress Genetics (ESR1) Obesity Smoking Overall health Depression and anxiety

PMS dx criterai

1+ sx that causes interference; occurs 5 days before onset, remit within 4 days of menses onset, don’t recur til day 13. present 3 consecutive cycles Still present in absence of rx, hormones, drugs, alcohol 1-4 sx of any nature 5+ sx behavioral

PMDD dx criteria

5+ sx; occurs 5 days before onset, remit within 4 days of menses onset, don’t recur til day 13. present 3 consecutive cycles Still present in absence of rx, hormones, drugs, alcohol Have to have at least one affective/psych sx

week four Flashcards

(40 cards)