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234 Cards in this Set
- Front
- Back
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What are purposes of preventative health and wellness?
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Prevention of chronic disease
Improve health/wellness Increase life expectancies Focused on most prevalent chronic diseases Cost effectiveness |
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What are benefits of breastfeeding to baby?
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Passive Immunity
Decreased risk of SIDS, DM, asthma, leukemia, lymphoma |
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What are benefits of breastfeeding to mom?
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Lowers risk of post partum depression and ovarian cancer
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Why is balance an important part of exercise?
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Balance exercises like Tai chi increase longetevity and decrease fall risk
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T/F: It is good to establish good eating habits using a food pyramid as a guideline early in kids?
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True
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According to the USDA, what are exercise requirements to maintain weight? To lose weight?
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Maintain: 60 minutes
Lose: 60-90 minutes of vigorous exercise most days |
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What are the risks of tobacco to pregnant mothers and to the fetus?
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Mom: infertility
Fetus: preterm delivery, low birth weight, stillbirth, SIDS |
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T/F: Smoking doubles a person's CV risk.
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True
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What is the #1 cancer in women?
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Lung cancer
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What cancers is a female smoker at highest risk for?
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Lung, oral, uterine
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By how much is CVD delayed in women?
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Approximately 15 years
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T/F: CVD is the leading cause of death in women.
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True
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T/F: Men are more likely to die from CVD than women?
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False
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What CDC intiated program is designed to increase awareness of women's health, especially prevention and CVD?
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WISEWOMAN
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T/F: Tobacco use predisposes women to osteoporosis?
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True. It lowers bone density and increases risk of hip fractures.
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Why are women more likely to die from CVD than men?
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Women are less likely to be appropriately diagnosed, have different symptoms, often don't get appropriate Tx, and women make up <1/3 of CVD trials.
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What are general population CV risk factors?
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DM, obesity, HTN, Hyperlipidemia, >55yo, smoking, sedentary lifestyle, certain races/ethnicities
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What are women specific CV risk factors?
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Maternal-placental syndromes
Hypertensive disorders of pregnancy Turner's syndrome |
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What are nonpharmacological recommendations for HTN?
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Weight loss, activity dec sodium intake, increase veggies/fruits and K+, avoid excess EtOH
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T/F: 20% of women have cholesterol greater than 200mg/dL
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False. 48% do.
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What are ATP-3 guidelines for cholesterol screening?
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Screen q5years for adults over 20yo.
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T/F: On average, women average 10mg/dL lower HDL?
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False. They average 10mg/dL higher.
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T/F: Aspirin is an appropriate choice for stroke prevention in a 37yo diabetic woman.
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False. The ADA/AHA guidelines recommend it in people over 40 if they have DM or CV risk factors.
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T/F: USPSTF recommends aspirin for stroke prevention in people 55-79 when potential benefits outweigh GI bleed risk?
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True
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What are risk factors for DM in women?
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Impaired fasting glucose or glucose tolerance
>45yo FH overweight Sedentary lifestyle Low HDL, high TG, HTN certain races/ethnicities gestational diabetes baby >9lbs at birth |
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What preventative measures should be taken for diabetics?
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Weight loss
control BG, BP, cholesterol Foot and eye care |
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T/F: USPSTF says you should screen for diabetes in asymptomatic adults with BP>135/80mmHG?
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True
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What screening tools are used for diabetes?
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FBG, 2hr post load glucose, A1C
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What complications does DM have that are woman-specific?
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Recurrent yeast infections (glucose is good growing environment)
Higher risk of premature menopause and CVD |
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T/F: TZD drugs used for DM are related to ovulation?
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True. They can stimulate ovulation in anovulatory women.
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How do you screen for gestational diabetes?
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Assess for risk factors initially, then do a glucose tolerance test at 24-48 weeks.
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What are exclusions for GD screening?
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<25yo
normal BMI no FH no history of abnormal glucose no history of poor obstetric outcome not a high risk ethnic group If any of these are not met, you must screen!! |
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T/F: Birth control may increase blood glucose?
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True
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What's the difference between SERMs and Aromatase inhibitors in breast cancer prevention?
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SERMS (e.g. tamoxifen) are more often used to decrease risk in pre-menopausal women.
Aromatase inhibitor (e.g. anastrazole) are more often used in post-menopausal women w/ history of breast cancer |
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T/F: There is a relationship between exercise and breast cancer?
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True! Strenuous exercise 3-4 days/wk can decrease your risk by 40%
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T/F: Breastfeeding increased breast cancer risk later in life?
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False. Breastfeeding decreased risk by 4% with each successive child
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Are early or late pregnancies better in terms of breast cancer prevention?
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Early
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T/F: Prophylactic mastectomy may reduce risk of breast cancer by up to 90%?
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True, although reports may be exaggerated in this regard.
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What are breast cancer risk factors?
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combo hormone therapy
exposure of breast to radiation obesity alcohol FH |
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During what ages is mammography recommended?
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40-70yo
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T/F: Breast self exams have been shown to greatly reduce risk of cancer?
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False, although they are still recommended despite poor evidence
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How to avoid HPV infection?
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Abstinence
Barrier protection/spermicidal gel HPV vaccine |
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How to prevent cervical cancer?
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Avoid HPV
Avoid cigarette smoke (passive+active) <7 full term pregnancies avoid long term OC use get regular gynecological exams and cytologic screening |
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How often should a PAP test be performed?
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q2-3years
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During what ages is a PAP test beneficial?
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Ages 25-60yo.
(60yo cut off assumes Hx of neg results) |
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T/F: Women without a cervix can get a PAP test?
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False. women without a cervix should not get a PAP smear
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T/F: A PAP test can decrease incidence and mortality by 80%, assuming regular screenings
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True
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What vaccines should be up to date before pregnancy?
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Rubella (MMR)
chicken pox Tdap (tetanus, diphtheria, pertussis HPV if <26yo |
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T/F: It is ok to give live vaccines during pregnancy, but only during the 1st trimester?
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False. Live vaccines shouldn't be given within a month of pregnancy.
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What vaccines can be given to a pregnant lady?
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Flu (killed)
Hep B Meningococcal Pneumococcal Rabies |
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T/F: Breast self exams have been shown to greatly reduce risk of cancer?
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False, although they are still recommended despite poor evidence
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How to avoid HPV infection?
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Abstinence
Barrier protection/spermicidal gel HPV vaccine |
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How to prevent cervical cancer?
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Avoid HPV
Avoid cigarette smoke (passive+active) <7 full term pregnancies avoid long term OC use get regular gynecological exams and cytologic screening |
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How often should a PAP test be performed?
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q2-3years
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During what ages is a PAP test beneficial?
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Ages 25-60yo.
(60yo cut off assumes Hx of neg results) |
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T/F: Women without a cervix can get a PAP test?
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False. women without a cervix should not get a PAP smear
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T/F: A PAP test can decrease incidence and mortality by 80%, assuming regular screenings
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True
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What vaccines should be up to date before pregnancy?
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Rubella (MMR)
chicken pox Tdap (tetanus, diphtheria, pertussis HPV if <26yo |
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T/F: It is ok to give live vaccines during pregnancy, but only during the 1st trimester?
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False. Live vaccines shouldn't be given within a month of pregnancy.
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What vaccines can be given to a pregnant lady?
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Flu (killed)
Hep B Meningococcal Pneumococcal Rabies |
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What is the difference between Guardasil and Cervarix?
--think indiction, type, age |
Guardasil
quadravalent HPV4 females 9-26yo covers HPV6,11,16,18 males 9-26yo for genital wart prevention (due to HPV6,11) Cervarix bivalent HPV2 females 10-25yo covers HPV 16,18 (cause 70% of lesions) |
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T/F: Cervarix can be given for genital wart prevention, but only in ages 10-25yo?
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False. Cervarix doesn't cover HPV 6 or 11, the main causes of genital warts. You need to quadravalent vaccine. The age range is correct for Cervarix though.
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HPV vaccination is common for girls of what age?
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11-12yo
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What is the HPV vaccination schedule?
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3 doses
#1 #2 (1-2months after #1) #3 (6months after #1) |
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What are common adverse reactions to the HPV vaccine?
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HA, fever, injection site reactions, syncopal episodes (monitor in office for 15min)
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T/F: If HPV vaccination is interrupted by more than 3 months, you must restart?
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False. Restarting is not needed for interuptions of HPV vaccination.
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T/F: Hormal changes and stress put women at greater depression risk?
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True
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What are USPTSF guidelines for bone mineral density (BMD) screening?
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>65yo in general
>60yo with risk factors for osteoporotic fractures |
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What are prevention measures against osteoporosis?
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Calcium/vitamin D
regular weight-bearing exercise avoid smoking and excessive EtOH engage healthcare provider about bone health BMD testing and Tx when appropriate |
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What are NIH calcium requirements per age group?
11-24yo? 25-50yo? postmenopausal,<65yo, on esterogen? postmenopausal, no estrogen? ALL women >65yo? Pregnant/nursing? |
11-24yo-------1,200-1,500mg
25-50yo-------1,000mg postmenopausal,<65yo, on esterogen-----------1,000mg postmenopausal, no estrogen---------1,500mg ALL women >65yo-----------1,500mg Pregnant/nursing--------1,200-1,500mg |
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What are National Osteoporsis Foundation daily Vitamin D requirements?
<50yo? >50yo? |
<50yo-----------400-800IU
>50yo-----------800-1,000IU |
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T/F: D2 is superior to D3?
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False. They are equally efficacious.
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What are nonpharmacological ways to get adequate vitamin D?
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Eat fortified foods and get adequate exposure to direct sunlight.
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What is the average success rate of OCs?
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95-99%
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How does estrogen work in OCs?
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It suppresses the FSH/LH normally seen in response to decreasing estrogen levels. It accelerates ovum transport and inhibits ovum implantation.
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How to counsel on Sunday start?
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Start on the sunday after menses begins, use a back-up for at least 1 week.
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How to counsel on Day 1 start?
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Start on first day of menses. Back-up is not required
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How to counsel on Quick start?
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Start ASAP, use back-up for at least 1 week. Requires a pregnancy test first.
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What are ACHES?
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A: abdominal pain (gallbladder or liver)
C: chest pain (PE or MI) H: HA (stroke) E: eye problems (stroke, uncontrolled HTN) S: severe leg pain (DVT) |
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How to counsel on a new OC Rx?
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Give package insert
Describe when to start Use additional method Take daily at same time Watch for ACHES What to do if missed pills |
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What to do if OC doses are missed?
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1 pill missed = take ASAP or take 2 pills next day
2 pills missed = take 2 pills for next 2 days (may separate pills due to nausea) 3+ pills missed = depends, but likely restart |
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What to do if an OC patch falls off?
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Replace patch.
If patch was missing for >24h, use backup method |
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What to do if an OC ring falls out?
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Rinse and reinsert
If out >3h, use backup method |
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What to do if progestin only pill is more than 3 hours late?
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Use back up method for next 48 hours.
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What adverse effects are estrogenic related?
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Breast tenderness, fluid retention, weight gain, HTN, thromboembolism, nausea, early bleeding
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What adverse effects are progestogenic related?
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Acne, oily skin, depression, fatigue, lethargy, hirsutism, libido, weight gain, late bleeding
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Which OC is approved for PMDD?
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Yaz (EE+drospirenone)
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T/F: Potassium may be a concern with Yaz?
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True. Drospirenone is related to spironolactone and may cause hyperkalemia.
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Which 3 progestins have low androgenic activity (good for acne)?
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Norgestimate
Desogestrel Drospirenone |
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Which OC may help migraine sufferers?
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Seasonale/Seasonique
Migraine suffers may be estrogen senstive and will benefit from long term constant levels. |
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T/F: Biphasic and triphasic options help PMS sufferers best?
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False. These people need more constant levels and should shy away from biphasic/triphasic pills
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What is the difference between Seasonale and Seasonique?
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Seasonale has a week of placebo at the end while Seasonique has a week of 10mcg estrogen instead.
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What is Lybrel? How is it taken?
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Continuous cycle contraception with 20mcg estrogen/90mcg levonorgestrel. It is taken every single day, all year, with no placebos.
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What is the intended effect of Lybrel? What is the most common adverse effect?
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By the end of the 1st 7 months, it causes complete amenorrhea in 71% of women.
There is typically a lot of breakthrough bleeding, especially in the 6 weeks to 6 months period, as the body adjusts to the constant hormone levels. |
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What are the benefits of continuous oral contraception?
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Decreases in:
PMS symptoms menstrual cramps menstrual migraine anemia endometriosis endometrial cancer ovarian cancer loss of work |
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T/F: Lybrel and LoSeasonique are in the same catagory of OCs.
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False. Lybreal is a continuous cycle OC, while LoSeasonique is an extended cycle OC.
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How do OCs interact with warfarin?
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They increase clotting factor synthesis to pharmacodynamically counteract warfarin.
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How do OCs interact with exenatide?
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Exenatide slows gastric emptying, which increases OC absorption.
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St. John's Wort is a _______ enzyme inducer
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CYP3A4
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T/F: OCs interact with some anticonvulsants.
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True
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How to counsel a patient picking up Trisprintec and Augmenting?
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Use back up method for duration of AB Tx and for 1 week afterwards because AB may decrease absorption by altering GI flora.
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How often does a patient receive Depo-Provera injections?
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Every 12 weeks
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What are the adverse effects associated with Depo-Provera?
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Osteoporosis (extremely high progestin dose antagonizes E)
Irregular bleeding (possibly even amenorrhea) Weight gain Delayed fertility (may take up to 10months after stopping to get pregnant) |
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What is the black box warning on Depo-Provera?
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Osteoporosis. Use as a long term birth control (>2 years) should be after failure of other options.
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What is Ortho-Evra? How to use it?
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An OC patch!
Apply weekly for 3 weeks, then leave it off for week #4. |
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What is Nuva Ring? How to use it?
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An OC ring!
Insert into vagina, leave in place for 3 weeks, then leave out for week #4. |
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When will a patient on Nuva Ring expect menses?
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During the week off, when hormone levels finally drop.
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What are the advantages of Ortho Evra?
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Simple to use
Easy adherence Highly effective |
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What are the disadvantages of Ortho Evra?
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Patch detachment
Increased estrogen exposure |
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What are the advantages of Nuva ring?
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Easy to use
Inconspicuous Good for adherence Highly effective |
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What are the disadvantages of Nuva ring?
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Slippage
Expulsion |
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T/F: Due to its lower systemic estrogen exposure, Ortho Evra is a superior option in those with embolism risks?
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False. Ortho Evra has higher estrogen exposure compared to oral tablets. Nuva Ring has the least exposure. Ortho Evra should be avoided in those at risk for embolisms or who are >38yo.
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What contraception do you recommend to a breastfeeding mother?
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Progestin only products.
As child weans, you can switch to E/P combo products. |
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What contraception would you recommend for a non-breastfeeding post-partum mother?
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Progestin only anytime or
Use E/P products after 3 weeks. |
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When can a new mother use IUDs?
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Starting 6 weeks post partum
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T/F: Diaphragms need to be refitted after pregnancy
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True
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What is Implanon?
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A contraceptive product placed under the skin which yields protection for 3 years. It is 99% effective and good for long term contraception or if estrogen is contraindicated.
Not studied in those >130% of IBW |
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Why are estrogen products a bad idea in breastfeeding moms?
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Estrogen can bind to the prolactin receptors and decrease milk production.
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What is the MOA and AE for IUDs?
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They create an unfavorable environment for implantation.
AE: ectopic pregnancy, bleeding, risk of PID, possibly scarring or infertility |
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What is the difference between Mirena and Paragard?
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Mirena = 5 year
Paragard = 8-10 year |
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What is the Today sponge?
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A contraceptive polyurethane sponge. Provides 24 hour protection, must be wetted prior to insertion, higher failure rate compared to OCs.
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What is Lea's shield?
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A silicone rubber barrier device. It is one-size-fits-all and reusable. Efficacy is similar to the sponge.
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When are mini pills primarily used?
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In breastfeeding mothers who can't take estrogen products.
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What are the advantages of the mini pill (progestin only)?
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No estrogen side effects
Minimal progestin side effects OK with breastfeeding OK for smokers |
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What are the disadvantages of the mini pill (progestin only)?
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Less effective
Irregular bleeding Amenorrhea Complex instructions Strict compliance |
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T/F: A high Pearl indext indicates that an OC is better.
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False. A lower Pearl Index shows greater efficacy.
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What are the 2 methods of calculating the Pearl Index?
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1:
[#pregnancies/#months exposure]*1200 2: [#pregnancies/#cycles]*1300 |
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What is the most common method of measuring OC efficacy?
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The Pearl Index
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What percent of women miss 1 pill per month?
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50%
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Rank these in terms of failure rate:
OC, condom, injectible, abstinence, diaphragm |
abstinence (22%)
male condom (15%) diaphragm (13%) OCs (9%) Injectibles (2-4%) |
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Implantation takes approximately ________ days.
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6-7
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What is the medical definition of start of life?
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Implantation
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What is the difference between an EC and an abortifacient?
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EC: drug/device that prevents pregnancy after unprotected intercourse
Abortifacient: drug intended to terminate a pregnancy after implantation has occured |
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Initial EC formulations contained high estrogen doses. Why has that changed?
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High estrogen doses cause nausea. Emesis after ingestion left questions regarding how much was absorbed.
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When should an EC be used?
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Efficacy is increased the earlier it is given.
Best if <3 days. Can be used up to 5 days. Pointless after 6-7 days. |
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T/F: EC products are 99% effective at preventing pregnancy?
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False. They are 75-89% effective.
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How do EC products work? (4 possibilities)
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1. Inhibit/delay ovulation (prevent LH surge, delays ovulation, sperm is cleared before ovulation occurs)
2. Prevent fertilization (progestins thicken cervical mucus and prevent sperm transport) 3. Interfere with sperm transport 4. Inhibit implantation |
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What are contraindications for EC products?
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Progestin only: pregnancy or allergy
Estrogen/progestin combo: thromboembolic disease, stroke, undiagnoses abnormal genital bleeding |
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T/F: In general, risks of EC often outweigh benefits?
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False. The short term Tx of these products means that risks rarely outweight the benefit.
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T/F: Triphasic OCs are good options for use as EC.
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False. The dose depends on the week that the pills are from, so the levels may not be high enough. Use monophasic pills so you can predict concentrations.
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What is the Yuzpe regiment?
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The old standard.
2 doses separated by 12 hours EE 100mcg per dose levonorgestrel 0.5mg per dose |
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Why have LNG regimens replaced the Yuzpe regiment?
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Avoiding high dose E means nausea goes from 51% to 23% and vomiting goes from 23% to 6%
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What to do if you vomit after using the Yuzpe regimen?
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If <2 hours, repeat dose
If >3hours, enough was absorbed, no big deal |
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What to do if a cycle hasn't occurred within 3 weeks after EC use?
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Go to physician for pregnancy test.
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Next Choice is officially labeled as 1 pill now and 1 in 12h. What is an alternative?
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Take 2 now (makes equivalent to Plan B one step)
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Can you sell Next Choice to a 17 year old without an Rx?
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Yes. EC products are OTC if >17yo and Rx if <16yo.
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What is ella (ulipristal acetate 30 mg)?
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A single dose progesterone agonist/antagonist. By antagonizing progesterone, it makes the environment unfavorable. It is Pregnancy catagory X, Rx only, and pregnancy must be ruled out.
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What is an IUD?
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Usually copper, it is inserted within 5 days of intercourse to prevent pregnancy (99.8% effective). May also be used as a contraceptive).
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Which IUD is not approved for contraception?
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Mirena (LNG eluting IUD)
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How to start conctraception after an EC episode?
|
Use barrrier methods immediately.
Start short term contraceptives either now or after next cycle (with back up for 1st 7 days) Long term contraceptives can be used after the next cycle and after pregnancy is ruled out. |
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What is the Washington State Project?
|
Allowing pharmacists to work under the practicing scope of a physican and write EC prescriptions.
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What types of surgical abortion can be done at...
6-12 weeks 12-15 weeks 15-21 weeks >21 weeks |
6-12 wks: vacuum aspiration
12-15 wks: dilation and curettage 15-21 weeks: dilation and evacuation >21 wks: dilation and extraction |
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What is RU-486?
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The abortion pill, marked as Mifeprex. It is approved up to the 49th day since the last period. It is distributed by physicians.
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What are the 3 drugs used for medical abortion?
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Mifeprostone
Methotrexate Misoprostol |
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What is the general mechanism of action for medical abortion drugs?
|
They antagonize progesterone, induce uterine contractions, and inhibit embryo development (methotrexate)
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Which drugs is a prostaglandin E1 analogue?
|
Misoprostol
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What is a problem with the misoprostol vaginal product?
|
It has higher bioavailability, but also increases the risk of infection.
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T/F: Mifepristone causes embryo detachment and cervical dilation.
|
True
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What is the FDA approved regimen for drug incuded abortion?
|
Day 1: 600mg (3 tabs) mifepristone
Day 3: 400mcg misoprostol Day 15: F/U to ensure termination Alternative: Day 1: Mifepristone 200mg Day 3: Misoprostol 800mcg vaginally |
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What are adverse effects of abortion drugs?
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Excessive vaginal bleeding
Abdominal pain Uterine cramps Diarrhea, N/V Bacterial infection (clostridium) Incomplete termination |
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What is methotrexate?
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A folic acid antagonist that interferes with DNA synthesis.
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What are the adverse effects of methotrexate?
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N/V/D
Fever and chills Stomatitis/oral ulcers Vaginal Bleeding cytotoxic effect |
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How do you use methotrexate for abortions?
|
Give orally followed by vaginal misoprostol 800mcg 3-7 days later.
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What are the advantages for medical abortion?
|
Can be done earlier (by 7 wks)
Safer (no anesthesia)(but bleed risk) Less traumatic (depends) |
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What are the disadvantages for medical abortion?
|
More N/V, pain
Lower rate of success than surgery More clinic visits (Day 1,3,15) |
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What is dysmenorrhea?
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Cramping pain in the lower abdomen occurring just before or during menstruation, in the absence of other diseases
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What is the difference between primary and secondary dysmenorrhea?
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Primary is in the absence of pelvic disease while secondary is in the presence of pelvic pathology.
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What is the most common gynecological problem?
|
Primary dysmenorhea
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What are uterine fibroids? How are they classified?
|
They are benign tumors that grow out of the uterine musculature and cause pain. They are a type of secondary dysmenorrhea.
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When does dysmenorrhea usually present?
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Adolescence
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Symptoms of dysmenorrhea are usually worse in the first ______ days of menses.
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2
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Cramping from dysmenorrhea usually occurs within ______ of menses.
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hours
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How do prostaglandins, particularly PGF2-alpha and PGE2, contribute to dysmenorrhea?
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They lead to myometrial contractions, ischemia, sensitization of nerve endings, and stimulation of GI tract
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What are nonpharmacological Tx options for dysmenorrhea?
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Topical heat therapy, exercise, dietary changes (low fat/vegetarian), acupuncture, acupressure.
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How effective is topical heat therapy for dysmenorrhea when used for 12h?
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It is as effective as ibuprofen 400mg TID
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How does heat help dysmenorrhea?
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It increases oxygen supply to the spasming muscles to releive pain.
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What is the first line therapy for dysmenorrhea?
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NSAIDs. They inhibit the prostaglandin synthesis and work in 30-60 minutes.
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T/F: All NSAIDs are efficacious for dysmenorrhea
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Yes, with the exception of aspirin. Naproxen and ibuprofen may be the best options though.
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Is APAP a good pain reliever for dysmenorrhea?
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No
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How do OCs help dysmenorrhea?
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They inhibit endometrial growth and reduce menstrual fluid volume.
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How effective are OCs for dysmenorrhea?
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They are highly effective, but may take 3 cycles to achieve maximum effect.
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T/F: Depo-Provera and LNG IUDs can also be used for dysmenorrhea?
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True
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How do you evaluate a case of abnormal urterine bleeding?
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Frequency, regularity, duration, volume
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What is oligomenorrhea?
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Intervals >35 days (enhanced follicular phase)
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What is polymenorrhea?
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Intervals <21 days (decreased luteal phase)
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What is menorrhagia?
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Normal interval, but with excessive flow and duration (>80mL/cycle or >7days)
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What is metrorrhagia?
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Irregular intervals, especially between cycles
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What is menometrorrhagia?
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Irregular interval with excessive flow and duration
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How do you evaluate AUB?
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"Rule out pregnancy (can cause bleeding)
Physical exam (large uterus=pregnancy or fibroids) Iatrogenic causes(meds, anticoagulants, soy, ginseng) Systemic causes (thyroid)" |
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What is dysfunctional uterine bleeding?
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A diagnosis of exclusion. Anovulatory cycles are especially common in the 1st few years of menses because the HPH axis isn't fully developed and in the elderly because LH levels don't peak to cause ovulation.
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What are causes of menorrhagia?
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"von Willebrand's disease (dec clotting factors)
Liver disease Hypothyroidism Uterine fibroids Gynecological cancers" |
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T/F: Menorrhagia is only associated with ovulatory cycles.
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False
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How to Tx menorrhagia is an ovulatory patient?
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"If contraception is not desired, use NSAIDs or progestin therapy(luteal phase or 21 days).
If contraception is OK, use OCs to decrease endometrium or LNG IUD (if long term is OK)" |
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How to Tx menorrhagia is an anovulatory patient?
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"A progestin in required in these patients because anovulation means unopposed estrogen, which increases endometrial cancer risk.
Tx with OCs , LNG IUD, or progestin only therapy." |
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How would you treat a case of emergency bleeding in a hospital setting?
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25mg conjugated estrogens IV q4-6h until bleeding ceases. (high dose E causes immediate endometrials growth, which inhibits the sloughing process)
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______ of women have iron deficient anemia
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2/3
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What is amenorrhea?
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failure of menstrual function
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What is the difference between primary and secondary amenorrhea?
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Primary is no menses by 16yo, secondary is no menstrual bleeding for 3 cycles or 6 months
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What populations are at increases risk for amenorrhea?
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athletes, college students, ballet dancers
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What are causes of amenorrhea?
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unexpected pregnancy, structural causes (scarring), PCOS, ovarian or adrenal tumors, premature ovarian failure, hyperprolactinemia (neg feedback on gonadotropin releasing hormone), hypothyroidism, pituitary disorders, anorexia, excessive exercise, hypothalamic amenorrhea
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What are consequences of amenorrhea?
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Anxiety, estrogen deficiency (menopausal Sx like bone loss, hot flashes, urogenital Sx, maybe CVD), and low progesterone (causes endometrial hyperplasia due to unopposed estrogen)
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Is checking estradiol levels a good way to test for amenorrhea?
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No, the levels fluctuate too much.
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What is the progestin challenge?
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"Used as a diagnostic in amenorrhea.
Give 10mg MPA PO QD for 10 days. You expect withdrawal bleeding in 2-7days. If positive, it shows that you have adequate estrogen, but no ovulation. If negative, it suggests impaired outflow or inadequate estrogen. If negative, give high dose estrogen for 21 days, then repeat the progestin challenge. If positive, it shows that you had inadequate estrogen. If negative, it suggests impaired outflow." |
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What are the goals of Tx for amenorrhea?
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Tx underlying causes, restore cycle and treat infertility, asssess bone density, assess CV risk
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What is endometriosis?
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Presence of endometrial tissue outside the uterine cavity
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What are the consequences of endometriosis?
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Pelvic pain (caused by inflammation as body fights "foreign" tissue) and infertility (caused by fallopian tube scarring)
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What is the clinical presentation of endometriosis?
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dysmenorrhea, dyspareunia (pain w/ intercourse), chronic pelvic pain, premenstrual spotting, low back pain, painful defecation
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What procedure diagnoses endometriosis?
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Laparoscopy
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What is the preferred therapy for endometriosis?
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OCs - Extended or continuous cycle provides maximal effect. These decrease endometrial tissue synthesis. 35-40mcg estradiol is better than 20mcg. High dose progestin therapy is also an option.
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What is the second line therapy for endometriosis?
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GnRH agonists. These decrease estrogen to induce a menopausal like state. This may lead to menopausal Sx like hot flashes and bone density decreases
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What is "add back" therapy in terms of GnRH agonists?
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Giving the patient enough estrogen to relieve menopausal side effects, while still not defeating the purpose of the GnRH agonist
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Is danazol a good Tx for endometriosis?
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No. It causes lipid abnormalities and has androgenic side effects.
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What are the key components of PCOS?
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"Androgen excess
menstrual irregularites (oligo- or amenorrhea) polycystic ovaries (multiple immature follicales) insulin resistance" |
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How does insulin relate with PCOS?
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Insuline increases androgen production and decreases sex hormone-binding globulin (more free androgens)
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How does PCOS present?
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"oligomenorrhea/amenorrhea
AUB hirsutism acne androgenic alopecia acanthosis nigricans" |
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What are consequences of PCOS?
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obesity, impaired glucose tolerance, DM2, HTN, dyslipidemia, CVD, sleep apnea, endometrial hyperplasia/cancer (lack protective progestins), infertility
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What is the nonpharmacological Tx of PCOS?
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Weight loss via diet and exercise. Hirsutism can be Tx with bleaching, waxing/shaving, depilatories, laser hair removal
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What are the goals of Tx for androgen excess?
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"Suppress ovarian androgen production
Increase SHBG levels inhibit conversion of testosterone to DHT inhibit testosterone activity at tissues" |
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What is the first line therapy for androgen excess?
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OCs - suppress LH production, increase SHBG, decrease free testosterone. You should use a progestin with low androgenicity: norgestimate, desogestrel, drospirenone
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Other than Ocs, how can you Tx androgen excess
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Spironolactone (100-200mg QD, take 6 months), finasteride, flutamine (antiandrogen), eflornithine (Vaniqa)
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How to treat oligo- or amenorrhea?
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Use an OC with low androgencity, intermittent progesterone (Provera 5-10mg for 7-10 days every 1-2months), weight loss, metformin, TZDs
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What are the Rotterdam criteria for defining PCOS?
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"Needs 2 of 3:
--hyperandrogenism and/or hyperandrogenemia --oligo- or anovulation --polycystic ovaries" |
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T/F: Actos is a good treatment for PCOS in someone who wants to be pregnant?
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False. TZDs are not good options in that case (may cause fetal growth retardation)
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What are basic treatment options for infertility related to PCOS?
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Clomiphene, metformin, clomiphene+metformin, gonadotropin therapy
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What is the surgical option for PCOS?
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Ovarian drilling. It decreases androgen production, increases pregnancy rate, lowers risk of multiple pregancies, but is 3rd or 4th line option
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How to treat hyperinsulinemia in relation to PCOS?
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Weight loss, metformin (consider renal dysfunction), TZDs (may cause weight gain)
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How is infertility defined?
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Inability to conceive after 12 months of unprotected intercourse? 6 months if >35yo
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What is male infertility?
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Low or absent sperm count (<1million, normal=20) or abnormal sperm morphology (need 30-50% with normal morphology and 75% to be alive)
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What are risk factors for infertility?
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Alcohol, diet, tobacco, toxins, hot tub
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How is fertility assessed?
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hysterosalpingogram, hysteroscopy, saline infusion sonohysterography, laparoscopy
Assess ovulatory function by looking at progesterone levels (>3ng/mL in midluteal phase is good) Assess ovarian reserve: FSH, estradiol, ultrasound |
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How to use basal body temperature charting?
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Take temp before rising in morning for a couple months to get baseline data. Start the day after a menses. Temp increases 0.4-0.6 due to increasing progesterone levels after ovulation.
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How to use a fertility monitor?
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Start on the first day of cycle. The machine will ask for readings throughout cycle and tests for LH and estrogen levels. It will give you the 6 most fertile days of your cycle.
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How to use an ovulation prediction kit?
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Begin testing 3-4 days prior to ovulation (may need baseline data to predict, or just start on day 9). Test daily at the same time of day. It looks for LH in urine. When color change is positive, fertility is highest in the next 24h
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What is intrauterine insemination?
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Sperm are separated from semen, the high quality ones are selected and then inserted into the uterus via catheter. This is performed after ovulation or ovulation induction.
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