Womens Health

Question 1

Estrogen excess

Answer 1

nausea, breast tenderness, fluid retention

Question 2

Estrogen deficit

Answer 2

early spotting, hypomenorrhea, nervousness, atrophic vaginitis

Question 3

Progesterone excess

Answer 3

increased appetite, tiredness, depression, breast tenderness, hirsutism, post pill amenorrhea

Question 4

Progesterone deficiency

Answer 4

late spotting, break through bleeding, heavy flow with clots

Question 5

Menopause

Answer 5

Complete cessation of menses >=12 mo.
95% of women experience the onset between 39-51 (premature-<40 yo).
Average duration of perimenopause is 4-5 years
Menopause: physiologic, surgical, or medical
Physiologic characteristics
Anovulation occurs more frequently
Menstrual cycles increase in length
Ovarian follicles become less sensitive to hormonal stimulation from FSH and LH
Without ovulation and release of an ovum progesterone is not produced by the corpus luteum. The lining continues to grow until it lacks a sufficient blood supply, at which point it will bleed
FSH levels elevated

Question 6

Symptoms of Menopause

Answer 6

Hot flushes
Sleep disturbances
Anxiety/depression
Vaginal dryness
Sexual dysfunction
Cognitive decline
Bone loss

Question 7

Risk factors for Osteoporosis

Answer 7

Excessive caffeine, soft drink (phosphorus) intake, steroid therapy, ETOH, vit. D deficiency, smoking, hypogonadism, hyperthyroidism and DM are risk factors for osteoporosis

Question 8

Endometriosis

Answer 8

Presence and growth of endometrial tissue outside of the uterus
Chocolate cyst is endometriosis of the ovary. Bleeding of the tissue causes inflammation, then subsequent fibrosis and scar tissue
Affects 6-10 % of reproductive age women
Slightly more prevalent in Asian women
Usually disappears after menopause
May worsen with repeated cycles

Question 9

Endometriosis

Answer 9

Presentation: pelvic pain, infertility, or ovarian mass.
Dysmenorrhea
Deep pelvic dyspareunia (painful intercourse)
Abnormal menstrual bleeding
Infertility (from adhesions)
May experience chronic noncyclic pelvic pain

Management
No treatment if asymptomatic and does not desire pregnancy
If s/s-> OCP (c low estrogen to progesterone ration to shrink endometrial tissue)
Hormonal antagonists (multiple side effects)
TAH c BSO

Question 10

Adnexal Mass

Answer 10

Majority will resolve spontaneously

Need to have hx and exam done

UPT (for childbearing age)
CBC (evaluation for abscess)
U/A (for UTI/kidney stones)
Vaginal/Cervical culture to evaluate for infections

TA/TV U/S-gold standard

Refer large mass (5-7 cm, if concerns for malignancy, or postmenopausal)

Question 11

Ovarian Cancer

Answer 11

Referred to as silent killer because it is the most fatal
Lack of good screening tools
Genetic predisposition
Multiple pregnancies, breast feeding, OC and other methods of BC lowers risks
S/S change in menses, dyspareunia, indigestion, fatigue

Question 12

Cervical Cancer

Answer 12

Third most common type of female cancer in the world
Prevention is available- HPV quadrivalent or Cervarix bivalent vaccines
Risks-high risk sexual behavior, immunocompromised, smokers, exposure to DES.
S/S vaginal dc, intermenstrual bleeding, loss of appetite, weight loss
Screening method of choice are PAP SMEARS

Question 13

Most common cause of abnormal uterine bleeding

Answer 13

STI and pregnancy

Question 14

Abnormal Uterine Bleeding

Answer 14

Differential diagnosis-hormonal imbalance, tumor (fibroids, polyps), infection, contraception (IUD), blood disorders, hypothyroidism, lupus, obesity, medications PCOS, neoplasms, trauma, systemic diseases, etc.

Question 15

AUB

Answer 15

transvaginal ultrasound: first line imaging

Question 16

AUB

Answer 16

transvaginal ultrasound: first line imaging

Question 17

PCOS

Answer 17

May present with AUB (irregular), hirsutism (inflammatory acne is equivalent), obesity

most common cause of infertility in women

‘characterized by ovulatory dysfunction and hyperandrogenism’

‘increased risk for metabolic syndrome, type 2 diabetes mellitus, and possibly cardiovascular disease and endometrial carcinoma’

Leading cause of oligomenorrhea or amenorrhea in premenopausal women

Question 18

PCOS

Answer 18

Initial labs: free testosterone (NL:40 to 60ng/Dl), prolactin, thyroid stimulating hormone (TSH), insulin-like growth factor I (IGF-I), and, if the patient is centrally obese, cortisol

If Testosterone is elevated, it can be due to causes (congenital adrenal hyperplasia, Cushing’s syndrome, prolactin excess, thyroid dysfunction, and acromegaly, ovarian or adrenal tumor, medications, etc.) other then PCOS, which need to be r/o.

Can schedule US to look at the ovaries and adrenals and additional labs (see link)

Question 19

PCOS

Answer 19

Hyperandrogenism and irregular periods and negative US and labs (to r/o other conditions that can mimic PCOS)

After dx is established, may check for metabolic syndrome and DM

Labs: GTT/Fasting Insulin levels/A1c/Lipids

Question 20

PCOS

Answer 20

Effect up to 8% of women
oligomenorrhea
Hyperandrogenism (hirsutism (consider ethnicity) or elevated testosterone)
associated risk factors: cardiovascular disease, obesity, glucose intolerance, dyslipidemia, and obstructive sleep apnea
Irregular cycles

Question 21

PCOS treatment

Answer 21

Consider level of androgenic activity when prescribing OC (caution BMI>30 and >40 year-old -incr. risk of VTE)

Cyclic progestin therapy can induce regular withdrawal uterine bleeding and reduce the risk of endometrial hyperplasia’

Weight reduction

Metformin

OC (adds progesterone, helps to oppose estrogen in anovulatory cycles)

Question 22

High Risk Factors for Ectopic Pregnancy

Answer 22

previous ectopic
previous tubal
tubal
DES exposure
current IUD use
PERFORM ULTRASOUND

Question 23

urine pregnancy test

Answer 23

20-50milli/unit

Question 24

serum pregnancy

Answer 24

5-10 milli/unit

Question 25

Visits during pregnancy

Answer 25

For a healthy pregnancy, let the patient know the recommended schedule for prenatal visits are,
Weeks 4 to 28- 1 prenatal visit per month
Weeks 28-36- 1 prenatal visit every 2 weeks
Weeks 36-40- 1 prenatal visit each week

Question 26

Pregnancy signs to immediately report

Answer 26

Vaginal Bleeding
Rupture of Membranes
Severe HA
Make sure to educate the patient on normal changes precipitated by pregnancy

Question 27

Anemia

Answer 27

all pregnant women 30 mg/day iron