Abnormal Bleeding

Question 1

Normal Bleeding
* Cycle length: ___ days
* Menstruation lasting ___ days
* ___ mL of blood per day
* median age of menarche ___ years

Answer 1

• 22-35 days
• 3-7 days
• 35
• 12.4 years

Question 2

Dysmenorrhea definition

Answer 2

painful menstruation

Question 3

Patho of Dysmenorrhea

• build up of ___ acids in cell membranes, then released
• ___ and ___ released in the uterus
• ___ reponse causes symptoms

Answer 3

• fatty acids
• Prostaglandins and leukotrienes
• inflammatory

Question 4

Risk Factors of Dysmenorrhea

• less than ___ years old
• weight loss ___
• depression/anxiety
• ___ menses
• menarche before ___ yo
• no previous ___ (nulliparity)
• smoking

Answer 4

• 20 yo
• attempts
• heavy
• 12 yo
• pregnancy

Question 5

First Line treatments for Dysmenorrhea

Answer 5

• NSAIDS
• OC
• non-pharmacologic

Question 6

Second Line treatments for Dysmenorrhea

Answer 6

• DMPA
• Levonorgestrel IUD

try IUD before shots

Question 7

Primary Amenorrhea:
no menses by age ___

Answer 7

15

Question 8

Secondary Amenorrhea: no menses for ___ months in someone who was previously menstruating

Answer 8

3 months

Question 9

Patho of Amenorrhea

• Uterus and ovaries (___ abnormalities)
• Pituitary gland (disruption ___)
• hypothalamus (anorexia, exercise, stress)

Answer 9

• anatomical
• hormones (GnRH, LH, FSH, and prolactin)

Question 10

Drug Induced Amenorrhea

• First-Gen antipsychotics (3)
• Second-Gen antipsychotics (1)
• Antihypertensives (1)
• GI promotility agents (1)

Answer 10

• prochlorperazine, chlorpromazine, haloperidol
• risperidone
• verapamil
• metoclopramide

Question 11

Treatment for Amenorrhea

If low estrogen is the cause, add estrogen (must also have progestin)
* Conjugated equine estrogen (3)
* Estradiol (patch) (2)

Answer 11

• Premarin, Cenestin, Enjuvia
• Climara, Vivelle-Dot

Question 12

Treatment for Amenorrhea

if caused by medications that increase ___ levels, provide dopamine agonist (2)

Contraindications: ___ feeding and uncontrolled ___

Answer 12

• prolactin
• Bromocriptine and Cabergoline
• breastfeeding, hypertension

Question 13

Oligomenorrhea Definition:
Menstrual cycle interval > ___ days (but less than ___ days)

Answer 13

35 days, 90 days

Question 14

T or F: Oligomenorrhea has simialr causes and treatment approaches as amenorrhea

Answer 14

True

Question 15

Polymenorrhea Definition:
menstrual cycle greater than ___ days.

Answer 15

21 days

Question 16

Causes of polymenorrhea (4)

Answer 16

• stress
• STDs
• Endometriosis
• menopause

Question 17

HMB Definition:
bleeding over ___ mL OR lasting over ___ days

Answer 17

• 80 mL
• 7 days

Question 18

Patho of HMB

Hematologic: bleeding/ ____ disolders
Hepatic: ___
Endocrne: ___ thyroidism
Uterine: ___ abnormalities and uterine ___

Answer 18

• clotting
• Cirrhosis
• hypothyroidsm
• structural, fibroids

Question 19

Chronic HMB Treatment

Hormonal (5)

Answer 19

• CHC
• progestins
• Levonorgestrel IUD
• Danazol
• GnRH agonists

Question 20

Chronic HMB Treatment

Non-hormonal (3)

Answer 20

• NSAIDs
• Tranexamic Acid
• Iron

Question 21

Contraindiations to tranexamic acid:
* active or history of ___ or pulmonary ___
* history of ___

Answer 21

• DVT, embolism
• seizure

Question 22

Acute HMB Treatment

1. high dose ___
2. ___ 20 mg PO TID x7 days
3. ___ acid

Answer 22

• estrogen
• medroxyprogesterone
• tranexamic

Question 23

Metrorrhagia Definition:
Irregular menstrual bleeding ___ cycles

Answer 23

between

Question 24

Causes of Metrorrhagia

Answer 24

• hormone imbalance
• Fibroids, polyps,endometriosis
• Medications
• IUDs
• infections

Question 25

Endometriosis Definition: Pelvic inflammatory condition associated with growth of endometrial tissue found ___ the uterus

Answer 25

outside

Question 26

T or F: Endometriosis had the same risk factors as dysmenorrhea

Answer 26

True

Question 27

Most supported theory behind endometriosis: ___ menstrual flow

Answer 27

retrograde

Question 28

First line endometriosis treatment (3)

Answer 28

* NSAIDs * CHCs * Progestins

Question 29

Second line endometriosis treatment (2)

Answer 29

* GnRH agonsits/antagonists * Danazol

Question 30

Third line endometriosis treatment (1)

Answer 30

* aromatase inhibitors

Question 31

Danazol is an ___ that supresses ___ and ___. * Blackbox warning for ___ * containdicated in ___ and ___feeding

Answer 31

androgen, LH, FSH * thromboembolism * pregnancy and breastfeeding

Question 32

T or F: the patho of fibroids is not well understood

Answer 32

True

Question 33

Risk factors for fibroids: * ___ race * time since last ___ * premenopausal * hyperstension * menarche less than ___ yo

Answer 33

* black * birth * 10

Question 34

protective factors against fibroids * smoking * more than ___ pregnancies * hormonal ___ use

Answer 34

* 3 * contraception

Question 35

# Treatment of fibroids * NSAIDs * hormonal contraception * ___ acid * ___ agonists * selective ___ receptor modulators (SPRM)

Answer 35

* tranexamic * GnRH * progesterone

Question 36

# GnRH Agonists for Uterine Fibroids * ___ term preoperative * ___ size * __ blood loss * Decrease ___ and ___ time * long term treatment associated with ___ symptoms and ___ loss * Increased recurrence risk with ___

Answer 36

* short * decrease * decrease * operative and recovery * menopausal, bone * myomectomy

Question 37

# SPRM for Uterine Fibroids * ___ term preoperative * ___ size * decrease blood ___ * Decrease ___ and ___ time * not associated with ___ estrogenic effect * increased recurrence risk with ___ * HA and ___ tenderness not FDA-approved * mifepristone ___ mg daily * ulipristal ___ mg daily

Answer 37

* short * decrease * loss * operative and recovery * hypo-estrogenic * myomectomy * breast * 10-50 mg * 5-10 mg

Question 38

T or F: Fibroids can increase the risk of complications during pregnancy

Answer 38

True; can rseult in miscarriage, premature, abnormal fetal position, and placental abruption

Question 39

# PMS Must have at least 1 symptom (affective or somatic) for at least ___ menstrual cycles

Answer 39

3

Question 40

# PMDD included in the DSM-5 * must have at least ___ symptoms with at least 1 in 2 different criteria for ___ consecutive months

Answer 40

* 5 symptoms * 2 months

Question 41

# PMS and PMDD similarities * Onset: 5-7 days prior to menses (during the ___ phase) * Symptoms ending at the start of the ___ phase (onset of menses) * Requires ___ free period for diagnosis

Answer 41

* luteal * follicular * symptom

Question 42

# Patho of PMS/PMDD Largely unknown, many theories: * reduced levels of ___, ___, and ___ * fluctuations in ___ and ___

Answer 42

* serotonin * GABA * allopregnanolone * estrogen * progesterone

Question 43

PMS/PMDD First Line Treatment

Answer 43

* SSRIs * NSAIDs * Spironolactone

Question 44

PMS/PMDD Second Line Treatment

Answer 44

* Venlafaxine * Duloxetine * Clomipramine * Alprazolam * COCs

Question 45

PMS/PMDD Last Line Treatment

Answer 45

* GnRH agonists * Surgery

Question 46

Patients on SSRIs typically see improvement in symptoms within ___ menstrual cycles

Answer 46

2-3

Question 47

FDA approved SSRIs for PMS/PMDD * Fluoxetine ___ mg daily * Sertraline ___ mg daily * Paroxetine CR ___ mg daily

Answer 47

* 20 mg * 50-150 mg * 12.5-25 mg

Question 48

# Spironolactone for PMS/PMDD * Non-FDA approved indication * antimineralcorticoid and antiandrogenic effects interfere with ___ synthesis * Dose: ___ mg daily on days ___ * decreases fluid ___, somatic symptoms, ___ tenderness, and low mood * SE: ___kalemia and irregualr menses

Answer 48

* testosterone synthesis *100 mg, 15-28 * retention, breast * hyperkalemia

Question 49

Second Line options for PMS/PMDD in order

Answer 49

1. SNRIs 2. COCs 3. Clomipramine 4. Alprazolam

Question 50

T or F: for second line treatment of PMS/PMDD you should consider Alprazolam beforeClomipramine

Answer 50

False; Xanax is last option

Question 51

# How SSRIs Help PMS/PMDD * emotional and physical symptoms * ___ funtioning * work performancy * quality of life

Answer 51

psychosocial

Question 52

# How Spironolactone Helps PMS/PMDD * ___ tenderness * bloating * ___ mood

Answer 52

* breast * low

Question 53

# How COCs Help PMS/PMDD * physcial symptoms: bloating, HA, abdominal pain, breast tenderness * ___ functioning and productivity | ***COC can also cause physical symptoms

Answer 53

social

Question 54

# How Alprazolam helps PMS/PMDD * depression * tension * anxiety * irritability * hostility * and ___ withdrawal

Answer 54

social