Obgyn 21-1

Front 1

31. Premature ovarian failure?

Back 1

a. Any time menopause occurs w/o another etiology before age 40.
b. Before 35, chromosomal analysis is usually performed.

Front 2

32. Effect of chronic anovulation from Stein-Leventhal syndrome (PCOS)?

Back 2

a. Leads to elevated oestrogen and androgen..
b. The excess androgen is converted peripherally to oestrogen by adipose.
c. Further, the elevated androgens lead to a decrease in the production of sex hormone binding globulin (SHBG), resulting in even higher levels of free oestrogen and androgens.

Front 3

33. Effect of Stein-Leventhal syndrome (PCOS) on LH/FSH?

Back 3

a. The hyperestrogenic state leads to an increased LH:FSH ratio, atypical follicular development, anovulation, and increased androgen production.

Front 4

34. Tx of Stein-Leventhal syndrome (PCOS) pts who wish to become pregnant?

Back 4

1. Clomiphene citrate
2. Corticosteroids
3. Metformin

Front 5

35. Tx of Stein-Leventhal syndrome (PCOS) who do not wish to become pregnant?

Back 5

a. Either cyclic progestins or Depo-Provera to ↓ risk of endometrial hyperplasia and cancer 2º to unopposed ostrogen.

Front 6

36. What is prolactin release inhibited and stimulated by?

Back 6

a. Inhibited by dopamine
b. Stimulated by Thyrotropin-releasing hormone (TRH): so hypothyroid people w/excess TRH will have ↑ prolactin and 2º amenorrhea.

Front 7

37. Meds that ↑ prolactin levels?

Back 7

a. Dopamine antagonists (Haldol, Reglan, Phenothiazines)
b. TCAs
c. Estrogen
d. MAOIs
e. Opiates.

Front 8

38. Note: Empty Sella syndrome: in which the subarachnoid membrane herniates into the sella turcica, causing it to enlarge and flatten, is another cause of Hyperprolactinemia.

Back 8

38. Note: Empty Sella syndrome: in which the subarachnoid membrane herniates into the sella turcica, causing it to enlarge and flatten, is another cause of Hyperprolactinemia.

Front 9

39. Approach to 2º amenorrhea?

Back 9

a. First get β-HCG to r/o pregnancy.
b. Check prolactin and TSH levels. (if both elevated, tx hypothyroidism)
c. If prolactin is normal, do progesterone challenge

Front 10

40. Progesterone challenge?

Back 10

10mg orally for 7-10 days progesterone to mimic progesterone withdrawal.
b. Performed to assess adequacy of endogenous oestrogen production and outflow tract.

Front 11

41. Withdrawal bleeding occurring after progesterone challenge indicates?

Back 11

a. The presence of oestrogen and an adequate outflow tract.
b. In this case, amenorrhea is usually secondary to anovulation, which can be caused by a variety of endocrine disorders that alter the pituitary/gonadal feedback such as PCOS, tumours or ovary and adrenals, Cushing, thyroid disorders, and adult onset of adrenal hyperplasia.

Front 12

42. Absence of withdrawal bleeding occurring after progesterone challenge indicates?

Back 12

a. Must then be evaluated w/oestrogen and progesterone administration.
b. If there is still no menstrual bleeding, an outflow tract disorder such as Asherman syndrome (intrauterine adhesions) or cervical stenosis is suspected.

Front 13

43. If there is bleeding after giving oestrogen/progesterone?

Back 13

a. Suggests intact and functional uterus w/o adequate endogenous oestrogen stim.
b. Measure FSH and LH to differentiate b/t hypothalamic/pituitary disorder (low/normal FSH and LH) and
c. Ovarian failure (High FSH/LH).

Front 14

44. Tx of macroadenomas?

Back 14

a. Surgical resection.
b. Some pts w/macroadenomas and most w/microadenomas are tx w/bromocriptine. Dopamine agonist that often causes tumour regression and resumption of ovulation.

Front 15

45. Tx of pts who respond to progesterone challenge?

Back 15

a. Should be withdrawn w/progesterone on a regular basis to prevent endometrial hyperplasia.
b. OCPs are useful in this case and may be beneficial in management of hirsutism.
c. Contraindicated if pt is a smoker >35. In this case, progesterone alone is indicated due to ↑’d risk of CVA and venous thromboembolism w/oestrogen usage.

Front 16

46. Ovulation induction for pts w/hyperprolactinemia?

Back 16

a. Bromocriptine.

Front 17

47. Ovulation induction for pts who respond to progesterone challenge?

Back 17

a. Clomiphene citrate, which acts as an antiestrogen to stimulate gonadotropin release.