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50 Cards in this Set
- Front
- Back
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How to treat PMS?
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Assure pt that her symptoms are real
Pt should chart her symptoms for several cycles (really premenstrual?) Stress healthy diet, exercise, sleep Consider SSRIs, spironolactone, prostaglandin inhibitors Consider progesterone therapy for non-responders OCPs |
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How to treat breast tenderness associated with PMS?
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Bromocriptine 5mg qday during luteal phase
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What is dysmenorrhea?
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Pelvic pain associated with periods
Cramping Can also be backache, headache, extemity Lightheadedness, insomnia, GI symptoms Nausea, vomiting, diarrhea |
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What difference between primary and secondary dysmenorrhea?
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Primary: aka intrinsic; not associated with identifiable pathology
Secondary: caused by gynecological condition – uterine myomas, adenomyosis, endometriosis, pelvic infection |
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What is incidence of dysmenorrhea?
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As high as 72% of women experience some discomfort
A smaller percentage experience it to a point that it interferes with activities, work, or school Is less common and less severe in women who have given birth |
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How to evaluate dysmenorrhea?
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H&P – r/o other gynecological or non-gyn causes (U or GI)
Get timing of onset and exacerbation – should be tied to menstrual bleeding |
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What is mechanism that causes pain in primary dysmenorrhea?
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Seems to be PGF2α
Causes cramping, nausea, diarrhea, headache |
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How to treat dysmenorrhea?
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Manage both primary and secondary via:
NSAIDs (decrease PGs) OCPs (atrophies endometrium – less and shorter bleeding) COX-2s help Secondary: treat underlying pathology (try medical before surgery) |
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Non-medical options to treat dysmenorrhea?
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Massage
Exercise Heating pad Acupuncture Hypnosis |
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What to do if dysmenorrhea response to medical therapy is inadequate?
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Primary: do more extensive w/u to look for underlying cause – pelvic US, sonohysterography, laparoscopy, MRI
Short-term PO narcotics for a few days of severe sx Secondary: treat underlying pathology (usually via surgery) |
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How much blood is typically lost during menses?
How much is considered abnormal? How long does bleeding typically last? |
35mL
80mL 4d (range: 1-8d) |
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What is abnormal uterine bleeding?
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Bleeding at irregular time intervals
-OR- Bleeding that is excessive but at normal time |
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Define:
1) Menorrhagia 2) Metrorrhagia 3) Menometrohagia |
1) XS bleeding at regular intervals
2) Menstrual bleeding at irregular intervals 3) XS, prolonged bleeding at irregular intervals |
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Define:
1) Intermenstrual bleeding 2) Polymenorrhea 3) Oligomenorrhea 4) Postmenopausal bleeding |
1) Bleeding btw normal cycles
2) Frequent, regular bleeding that occurs in <21d cycles 3) Infrequent, irregular bleeding that occurs in >45d intervals 4) Bleeding that occurs >1yr after menopause, or at irregular intervals while on HRT |
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What are the pregnancy related causes of abnormal uterine bleeding? (3)
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Miscarriage
Ectopic pregnancy Gestational trophoblastic disease |
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What are the infectious causes of abnormal uterine bleeding? (2)
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Cervicitis
Endometriosis |
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What are the neoplastic causes of abnormal uterine bleeding? (4)
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Cervical dysplasia/carcnioma
Endometrial hyperplasia/polyps/carcinoma Submucous leiomyomas Estrogen-producing ovarian tumors |
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What are the systemic causes of abnormal uterine bleeding? (4)
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Thyroid disease
Liver disease Coagulation disorders Sepsis |
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What are the iatrogenic causes of abnormal uterine bleeding? (5)
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Menstrual history: # days of flow, #pads/tampons used per day, impact on daily living
Hx of unusual bleeding from gums; easy bruising, prolonged bleeding after minor cuts Symptoms of wt gain, constipation, hair loss, fatigue, edema Galactorrhea Sexual hx & use of contraception |
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What should you ask in H&P of pt w/ abnormal uterine bleeding?
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Tanner stage of breast & pubic hair development
Ht & wt xs hair growth |
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What tests to order to eval abnormal uterine bleeding?
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Beta-hCG
CBC Coags TSH PRL FSH, LH, Testosterone, DHEA-S (if wondering about PCOS) |
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What is dysfunctional uterine bleeding (DUB)?
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Diagnosis of exclusion after r/o pregnancy-related, infectious, neoplastic, systemic, iatrogenic causes
Is result of anovulation or oligo-ovulation → ovary makes estrogen but no corpus luteum forms & no progesterone is secreted |
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What are major physiologic causes of anovulation? (4)
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Adolescence
Perimenopause Lactation Pregnancy |
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What are major pathologic causes of anovulation (4)
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Hyperandrogenic states
HyperPRL HypoTH Premature Ovarian failure |
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What is connection btw age and anovulation?
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Perimenarchal: teens have immature HPG axis; can't respond to E or LH surge
Perimenopausal: women have declining ovarian fxn |
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When to do endometrial biopsy when evaluating abnormal uterine bleeding?
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When suspect hyperplasia or endometrial cancer: all women over age 35 and any obese woman under 35
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What is incidence of endometrial cancer?
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Age 35: 6.1/100k
Age 40-49: 36.2/100k |
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When to do US in evaluating abnormal uterine bleeding?
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When you've ruled out organic causes of AUB and suspect a structural abnormality (e.g., fibroids or polyps)
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How to medically manage abnormal uterine bleeding in teens?
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Treat any underlying cause (like hypothyroidism)
Anovulation: Can tx w/ Provera or OCPs; Fe for anemia Acute menorrhagia: IV conjugated estrogen 25mg q4H or OCPs 35-50mcg TIDx3d → BIDx2d → QD to finish pack (2mo) |
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How to medically manage abnormal uterine bleeding in reproductive age women?
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Consider OCPs
Mirena Can induce ovulation w/ clomiphene citrate or gonadotropins |
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How to medically manage abnormal uterine bleeding in perimenopausal patient?
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Low dose OCPs if nonsmoker
Can get HRT once menopausal |
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What is non-hormonal medical therapy of abnormal uterine bleeding?
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Can use NSAIDs to reduce these women's abnormally high levels of PGI2 & PGE2:PGF2α, and EN-1
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How to treat abnormal uterine bleeding caused by fibroids?
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GnRH agonist like Lupron (leuprolide acetate) → fibroids re-grow when tx is stopped
Vaginal hysterectomy Myomectomy |
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What are surgical treatments for abnormal uterine bleeding?
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Endometrial ablation (destroys basalis layer) via:
Thermal ablation w/ rollerball or resectoscope Thermal ablation balloon (5% dextrose @87F x 8min) Hydrothermal ablation (NS 80-90C thru insulated sheath Microwave endometrial ablation (thru 8mm applicator) |
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What is success rate of endometrial ablation?
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70-97%
>85% of pts only need 1 treatment |
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If pt fails medical therapy and endometrial ablation, what is option?
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Hysterectomy
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Definition of hirsutism?
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XS body hair growth in anatomic sites in “male” pattern
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What are 3 types of body hair?
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Lanugo: light, thin, found in neonates
Vellous: fine, non-pigmented, found in most adult body regions Terminal: pigmented, coarse, found in scalp, axilla, pubic area of adult men and women, and on face and chest of men. |
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What are 3 phases of growth cycle of hair follicle?
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Anagen: growth
Catagen: involution → hair stops growth and moves up in follicle Telogen: resting phase that precedes hair loss |
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What are causes of hirsutism?
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Increased exposure to androgens 2/2:
Exogenous Increased adrenal androgen production Increased ovarian androgen production Alterations in binding globulins Increased end-organ sensitivity 2/2 increased 5α-reductase activity in skin |
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What are androgens made by body?
Where produced? |
Ovary: testosterone + androstenedione
Adrenals: DHEA, DHEAS Periphery: testosterone + DHT |
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What modulates androgen action? (2)
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1) Sex-hormone binding globulin (grabs and holds circulating androgens, decreasing their free concentration & hence action)
2) 5α-reductase (converts androgens to DHT; can only affect follicle if is DHT) |
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What is Ferriman & Gallwey Scoring System?
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Score hirsutism depending on body site
normal <8 severe >15 |
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What is DDX of hirsutism in women? (7)
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PCOS
Nonclassical adrenal hyperplasia Cushing syndrome\ Androgenic tumors (ovary, adrenals) HyperPRL Exogenous androgens Idiopathic |
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What meds have androgenic activity? (3)
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Anabolic steroids
Danazol Testosterone |
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What is significance of abrupt onset of hirsutism?
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More likely to be associated w/ tumor or exogenous hormone use
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What tests to use w/ pt w/ hirsutism?
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Total testosterone (>200ng/dL = tumor)
DHEAS (>700ug/dL = tumor) 17OH-progesterone (drawn in early morning) PRL 24 urine cortisol or o/n dexamethasone suppression test |
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What are medical treatments for hirsutism?
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OCPs (FDA approved)
Cyproterone acetate (strong progestin + estrogen) Spironolactone (blocks androgen-R) Flutamide (blocks androgen-R) Finasteride (5α-reductase blocker) GnRH analogs (suppress HPG axis) Glucocorticoids (blocks adrenal androgen production) Insulin-sensitizers (for PCOS) |
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What are adjuvant therapies for hirsutism?
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Wt loss
Bleaching/waxing/depilatories/plucking/shaving Electrolysis/laser Eflornithine Hcl cream (Vaniqa) (FDA approved) |
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How long does it take to see improvement in hirsutism after treatment has begun?
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3-6mo
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