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week three Flashcards

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1
Q

gonadal function is controlled by what? does it stay the same throughout an individual’s life?

A

controleld by hypothalmic pituitary axis, varies throughout an individual’s lifetime

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2
Q

when would you test FSH/LH in a premenopausal female?

A

day 3

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3
Q

describe the testosterone peaks for the 3 types of rhythmicity below

seasonal
circadian
pulsatile

A

seasonal (months) - fall
circadian (hours) - AM
pulsatile (mins) - every 90-120

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4
Q

what controls the types of rhythmicity of testosterone?

A

melatonin via:
- pineal gland inputs (seasonal)
- neural connectinos (circadian)
- suprachiasmatic nucleas (mammilian 24-hr clock)

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5
Q

List the broad 4 categories that may be the underlying cause of AUB.

A

Structural
Functional
Hormonal irregularities
Medications

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6
Q

FIGO def acute AUB

A

Acute AUB - episode of bleeding in reproductive age pts, not pregnant, and bleeding warrants immediate intervention to prevent further loss

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7
Q

FIGO def chronic AUB

A

Chronic AUB - bleeding from uterus that is abnormal in duration, volume, and/or frequency present for last 6 months

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8
Q

FIGO def disturbacnes menstrual frequency

A

Disturbances of menstrual frequency - infrequent every 38 days over 6 months (adolescents > 45), frequent every 24 days (<21 adolescents)

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9
Q

FIGO def irregular menstrual bleeding

A

Irregular menstrual bleeding (cycle variation > 20 days)

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10
Q

FIGO def abnormal duration of flow

A

Abnormal duration of flow (<2 days, increased volume or blood loss interfering with pts QOL, light menstrual bleeding)

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11
Q

mechanisms for the cessation of menses

A
  • combo of vasoconstriction, tissue collapse, and vascular stasis
  • damaged tissue released thrombin > promotes formation of fibrin and activates platelets > hemostasis
  • development of ovarian follicle, the resultant release of E2 heals and regenerates the endometrium
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12
Q

local mechanisms of hemostasis

A
  • uterine contractions are due to prostaglandins PGE2a and PGF2a
  • vasoconstriction due to thromboxane A2 (TXA2)
  • vasodilation due to PGI2 and PGE2a
  • endometrial prostaglandins produced from arachidonic acid
  • estrogen affects uterine vascular tone, prostaglandin formation, and endometrial nitric acid formation to aid in the cessation of menstruation
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13
Q

What are important aspects of medical hx to cover in the visit and describe the menstrual hx questions that need to be covered as well.

A

Age
Length of time of problem
Is uterus the source of the bleeding
What is the bleeding pattern
Signs of ovulation present or not
Form of BC
Thorough menstrual hx
Sexual hx
Precipitating factors such as trauma
Pregnancy hx
Complete med hx
Risk of endometrial cancer
Determine if bleeding is nongenital

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14
Q

What are the common etiologies for HMB

A
  • uterine leiomyomas (usu submucosal)
  • adenomyosis (HMB, clots, dysmenorrhea)
  • cesarean scar defect
  • bleeding d/o
  • endometrial hyperplasia/cancer
  • IUD
  • endometrial polyps
  • endometritis or PID
  • arteriovenous malformation
  • disorders of local endometrial hemostasis (alterations in prostaglandins)
  • hypothyroidism
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15
Q

What are the common etiologies for intermenstrual bleeding

A
  • endometrial polyps
  • unscheduled bleeding due to contraceptives
  • endometrial hyperplasia/cancer
  • endometritis or PID
  • previous endometrial trauma (C-section)
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16
Q

What are the common etiologies for irregular bleeding (ovulatory dysfunction)

A
  • occurs commonly at extremes of reproductive age (postmenarchal and menopausal transition)
  • PCOS
  • other endocrine d/o (thyroid dz, hyperprolactinemia)
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17
Q

What physical exams should be performed with amenoorrhea and what are you looking for?

A

Assess for anemia (pallor, conjunctival pallor, dec cap refill) and hematologic pathology (petechiae, puerperal, ecchymosis, mucosal bleeding)

Assess for clinical hyperandrogenism/hyperinsulinemia (hirsutism, obesity, acne, acanthosis nigricans)

Assess for liver dz (spider angioma, palmar erythema, hepatosplenomegaly, ascites, jaundice)

Thyroid assessment (AbN vitals, eye findings, tremors, changes in texture of skin, wt changes, goiter or nodules, abn DTRs)

Inspection of urethra (assess for caruncle or lesions)

Pelvic exam (looking for course of bleeding examining all lower genital tract, speculum exam to assess for infection, trauma, or foregin objects as well as palpating for masses, tenderness, and size/shape/consistency of reproductive organs

Vaginal-rectal exam (external inspection, DRE, fecal occult test, anoscopic exam)

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18
Q

What is the most common cause of AUB in adolescents and the 2nd most common cause?

A

Physiologic anovulation
Coagulopathies

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19
Q

What is the first dx to consider in childbearing age patients?

A

Pregnancy + related conditions

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20
Q

What is the work-up to consider in a pt with AUB after pregnancy testing?

A

Pap/HPV testing
Genital cultures/STI testing
CBC, ferritin, Lfts, PT, PTT
TSH, reflex T4
Luteal phase serum progesterone levels (day 21-23) for ovulation, anovulation, luteal phase defect
Prolactin, total + free salivary testosterone, DHEA, FSH/LH
Complete pelvic US/saline-infusion sonography (SIS)
Endometrial biopsy (EMB)

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21
Q

What are the treatment goals for anovulatory cycles and AUB?

A

Correct the underlying primary etiology
Improve QOL
Prevent episode of acute uterine bleeding
Prevent or treat anemia
Establish regular bleeding pattern (or amenorrhea)
Prevent endometrial hyperplasia/carcinoma

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22
Q

AUB in perimenopausal patients what is the most common cause? What must you be sure to r/o in this age pt?

A
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23
Q

What pts should undergo evaluation for endometrial hyperplasia or endometrial cancer?

A

ALL postmenopasual pts
Age 45-menopause: bleeding that is frequent (onset within <21 days), heavy or prolonged >5 day. Includes intermenstrual bleeding
<45: persistent (>6 mo) abn bleeding, occuring in one of the following setting: hx of unopposed estrogen exposure, failed medical management of bleeding, pts with high risk of endometrial cancer

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24
Q

List the risk factors for endometrial cancer.

A

> 35
Anovulatory cycles - PCO
Obesity
Nulliparity
Tamoxifen therapy
DM
HTN
Fhx colon cancer
Long term unopposed estrogen therapy

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25
What work-up should be considered to evaluate AUB and R/O cancer?
Transvaginal ultrasound (TVUS)
26
List the findings on endometrial biopsy and their risk of endometrial cancer
Hyperplasia without atypia <5% Hyperplasia with atypia 30% Adenocarcinoma in situ (AIS) 40%
27
Why should treatment not be started until the etiology of AUB has been found out?
They will not want to workup the underlying etiology - could miss malignancy and other dx
28
List common botanicals used for hemostasis and for hormone regulation
Hemostatic - cranes bill, ladys mantle, greater periwinkle, yarrow, shepherd's purse, cinnamon, fleabane, geranium; wise woman cinnamon erigeron tincture 5 qtts qid during heavy bleeding Uterine tonics: blue cohosh, sabadilla, squaw vine, raspberry, dong quai, life root Hormone regulation: chaste tree
29
What nutraceuticals can be helpful for uterine bleeding?
Vit C bioflavonoids Vit A Ground flax Probiotics DIM Green tea extract EPO Iron citrate
30
What common pharmaceuticals (with doses) are used for uterine bleeding when there is no malignancy?
Oral contraceptives Oral progestins: MPA/Provera 10mg 14 days/mo, Megestrol/megace (40mg/day) NSIAIDs: ibuprofen 600-1000 mg day 5 days month beginning day 1 of menses, anaprox 550-1100 mg day for 5 days a month Mirena IUD
31
What surgical options are available for AUB
Endometrial ablation/transcervical endometrial resection (pregnancy CI after) Hysteroscopy Myomectomy Hysterectomy (completed childbearing)
32
What are the tx options for endometrial hyperplasia without atypia
Without atypia: OMP 100-400 mg qhs, 3 wk on 1 off OR Mirena IUD
33
What are the tx options for endometrial hyperplasia with atypia
With atypia: Provera 10-20 mg qd x 5-10 days + D&C Tx 6 weeks then biopsy Mirena IUD Hysterectomy
34
Define primary amenorrhea and secondary amenorrhea
Primary: pt hasnormal secondary sexual characteristics but no menarche by 16 yrs (with no secondary sexual ahraacteristics and no menarche, dx an be made around 13/14) Secondary: cessation of menses after at least 1 or more menstrual cycles for a min of 3 cycles of 6 months
35
List the most common etiologies of secondary amenorrhea.
Pregnancy PCOS Thyroid dysfunction Hyperprolactinemia Hypothalamic amenorrhea Ovarian failure
36
List the important aspects of history taking for secondary amenorrhea
Chronic diseases Illicit drugs, trauma, CNS tumors, stress, wt change, diet/exercise changes, exercise hx, sig wt changes Consider anorexia Change in hair quality Gynecologic hx
37
What must be asked in gynecological history? (list them)
Sexual activity and form of BC Galactorrhea or nipple d/c Irregular periods since onset of menarche Sx estrogen deficiency Hx abnormal paps, STIs, procedures Hx of births ending with bleeding Post pill amenorrhea Menstrual hx prior to OC hx
38
What physical exam should be performed and what are you looking for?
Vitals Rapid bounding pulse (hyperthyroid) Slow pulse (hypothyroid, anorexia) HTN: PCOS, cushing's syndrome Hypotension, hypothermia, reduced subcutaneous fat: anorexia BMI: obesity (PCOS), underweight Thyroid exam Parotid gland (swelling), erosion of enamel (eating d/o) Skin: Soft moist skin - hyperthyroidism Dry skin w mild hirsutism - hypothyroidism or hypoestrogenism Acanthosis nigricans - insulin resistance, PCOS Striae - cushing syndrome Hirsutism/acne - PCOS Lanugos - nutritional disorder, anorexia Breast exam (development, hyperprolactinemia) Abdominal exam (hepatosplenomegaly - chronic systemic dz) Pelvic exam: Signs of estrogen influence (rugae, tissue color, cervical mucus) Dec pubic hair, vaginal rugae, thinning mucosa - hypoestrogenism - POF/POI Inc hair extending up thighs/umbilicus - PCOS Ovarian masses Collection of menstrual blood collecting in uterus due to cervical stenosis - hematometr
39
list likely causes that should be investigated if normogonadotropic amenorrhea is present. What labs indicate this?
Normogonadotropic if FSH normal LH is low normal - hypothalamic amenorrhea, chronic disease, rapid wt loss, malnutrition, psych d/o, rec drug use
40
list likely causes that should be investigated if hypogonadotropic amenorrhea is present. What labs indicate this?
Hypogonadotropic if FSH/LH < 5 IU/L - constitutional delay of growth/puberty, kallmann's syndrome
41
list likely causes that should be investigated if hypergonadotropic amenorrhea is present. What labs indicate this?
Hypergonadotropic if FSH >20, LH >40 IU/L - perform karyotype analysis, POF, turners syndrome
42
What is the lab work that is necessary to identify the underlying cause of a pts. secondary amenorrhea and to r/o other DDX’s?
Pregnancy test Thyroid studies Prolactin levels FSH + estrogen CBC, UA, CMP
43
What additional testing is important for young pt’s with athletic amenorrhea?
BMD levels/DEXA
44
What are the underlying causes of hypothalamic amenorrhea and what is the best treatment approach for the first 3-6 months? What treatment should be initiated after 6 months if not the pt. continues to have amenorrhea?
Low estradiol, due to anorexia, female athletic triad Functional - severe chronic disease, rapid wt loss, malnutrition, psych d/o, rec drug use, stress PCOS Treatment: First 3-6 mo: treat cause, inc caloric intake/reduce exercise , stress management, CBT After 6 mo: hormone therapy to avoid potential bone loss and CVD development
45
List some common botanicals that are used to treat secondary amenorrhea
Vitex Black cohosh Rhodiola Maca root
46
What botanical is useful for hyperprolactinemia
Vitex
47
what hormone would be elevated in someone with PCOS? testosterone progesterone estrogen FSH/LH
testosterone
48
what hormones are preferred to be tested around day 3?
FSH/LH Estrogen/oestradiol
49
what hormones are preferred to be tested around day 21?
progesterone to look for signs ovulation has occurred
50
what day of the cycle would you test for pregnancy?
around day 14 continuous if hx of repeat miscarriages
51
difference between pregnancy urine testing and serum testing
Urine testing (qualitative) Serum testing (quantitative)
52
downside of serum hormone testing
doesnt account for pulsatility, cant be used to monitor topical HRT
53
downside of urine hormone testing
one point in time ineffective to monitor topical HRT not well validated
54
downside of saliva hormone testing
can only test steroid hormones saliva contamination
55
describe the appearance of squamous epithelial cells on a wet prep
Large flat cells Square to trapezoid shape Abundant cytoplasm Small usually central nucleus (about size of a WBC)
56
describe the appearance of WBC on a wet prep
Medium sized Round to oval shape May appear granular Segmented nuclei may be present
57
describe the appearance of RBC on a wet prep
Small round cells Clear to faint yellow/green
58
describe the appearance of bacteria on a wet prep
Tiny colorless rods (bacilli) Cocco-bacilli or cocci May be in chains, pairs, or clusters
59
describe the appearance of yeast on a wet prep
Small round to ovoid cells (about the size of RBCs) May see budding or pseudohyphae
60
describe the appearance of trichomonas on a wet prep
Pear shaped Flagellated motile protozoa Dead ones resemble WBCs
61
describe the appearance of clue cells on a wet prep
Squamous epithelial cells coated with cocco-bacilli (Gardnerella/others) Indistinct cell membranes “Furry” looking Over 75% squamous cell occluded by bacteria = clue cell Atypical clue cells: long rods coating cells - indicates cytolytic
62
normal levels of squamous epithelial cells on wet prep
0-30/hpf
63
normal levels WBC on wet prep
< 10/hpf
64
normal levels RBC on wet prep
0-5/hpf
65
normal levels bacteria on wet prep
1+ to 2+, rods should predominate
66
normal levels yeast on wet prep
trace to 1+
67
normal levels trichomonas on wet prep
none
68
normal levels clue cells on wet prep
trace may be normal
69
indications for elevation in squamous epithelial cells on wet prep
extreme inc in # may indicate tissue irritation
70
indications for elevation in WBCs on wet prep
Increased # indicate infection or inflammation No or small increase with BV
71
indications for elevation in RBCs on wet prep
May see crenated or ghost cells
72
indications for elevation in bacteria on wet prep
>2+ may indicate infection Absence of rods (lactobacilli) may indicate imbalance of flora
73
indications for elevation in yeast on wet prep
>1+ may indicate infection and imbalanced flora
74
indications for elevation in trichomonas on wet prep
STI
75
indications for elevation in clue cells on wet prep
>1+ may indicate imbalanced flora If > 1 in 10 SQE cells/hpf = clue cells, can dx BV
76
what feature on wet prep can be dx of BV
If > 1 in 10 SQE cells/hpf = clue cells, can dx BV
77
what organism must be kept at a certain temp and how soon must they be examined?
trichomonas - kept at body temp (37C) and examined within 30 mins or they will die
78
what are some underlying conditions that can cause secondary amenorrhea
functional hypothalmic amenorrhea PCOS ovarian failure/insufficiency thyroid dysfunction
79
what are the major sequelae of PID and what percentage of women with 1 episode acute PID will experience sequelae?
25% - ectopic pregnancy - chronic pelvic pain - tubal factor infertility (TFI)
80
sx of PID
BL lower abdominal or pelvic pain* Deep dyspareunia or pain w jarring movement Onset of pain shortly after menses Cramping Dysuria Fever/chills (50%) Back pain N/V Abnormal d/c or bleeding Vaginal itching and odor Abnormal uterine or postcoital bleeding Less common - RUQ pain fitz high curtis syndrome
81
signs PID
Infected cervix DC contains large # of WBCs > 10/hpf wet prep Abdominal tenderness in lower quadrants commonly with rebound tenderness and hyporesonant bowel sounds CMT, uterine tenderness, and/or unilateral or bl adnexal pain
82
T or F: you should wait until you have a cause and firm diagnosis to begin tx of PID
FALSE - Initiate tx in all sexually active young omwen and women at risk for PID with uterine, adnexal, or CMT in bimanual exam with no other apparent cause - prevent long term sequelae
83
what are common causative organisms PID
CT GC Aerobic/anaerobic bacteria: - genital mycoplasma - bacteroides - prevotella species - peptostreptococcus species - BV - e coli - aerobic streptococci - actinomyces (women with IUD) Non genital pathogens - h influenzae
84
RF PID
STI/hx STI (esp GC/CT) Sex during menses Previous episode PID 14-25 <15 first sexual encounter High # sex partners New/multiple partners Lower socioeconomic status Nulliparous Non white ethnicity (black women) Alcohol use Women > 35 with copper IUD Recent IUD insertion Nonbarrier contraceptives Oral contraceptives Cervical ectopy BV Douching
85
what labs/tests should you run for ALL pts suspected PID
Pregnancy test Wet prep GC/CT HIV Syphilis
86
what are dx tools for PID?
Endometrial biopsy* Laparoscopy * TVUS CT MRI
87
what is some naturopathic tx for PID? can these be used alone?
MUST BE USED AS SUPPORTIVE ONLY, USE CDC PROTOCOL Rest Modified fast Probiotics 3x day Vaginal lactobacillus crispatus Alternating sitz Hot vinegar packs Castor oil packs Vit C u Anti inflammatories Immune stimulating botanicals (mahonia, echinacea, garlic, myrrh) Homeopathy

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