Women's Health
Primary amenorrhea may be diagnosed by age 15 years. What should be present for this diagnosis? Select all that apply. 1. Normal growth 2. Presence of secondary sexual characteristics 3. Elevated testosterone level 4. Hyperprolactinemia
1. Normal growth 2. Presence of secondary sexual characteristics
What differentiates pelvic pain from abdominal pain? 1. Pain below the umbilicus is pelvic pain 2. Duration of pain 3. Gender specific 4. Age of the patient
1. Pain below the umbilicus is pelvic pain
The primary risk factor for development of breast cancer in women of average risk is: A) age. B) smoking history. C) number of live births. D) exposure to estrogen.
A) AGE Explanation: Age is the most important risk factor for developing breast cancer in women of average risk. Breast cancer is more common in older women and has a higher mortality rate when discovered. Nearly 85% of breast cancer occurs in women who are 50 years of age or older. Exposure to estrogen and genetic factors are important risk factors but do not contribute to development of breast cancer as greatly as age does in women of average risk. Hence, the reason for diligent annual screening in women who are 50 years of age and older.
A young female adult presents with vaginal discharge and itching. Besides trichomoniasis and yeast, what else should be included in the differential? A) Bacterial vaginosis B) Chlamydia C) Herpes genitalis D) Syphilis
A) Bacterial vaginosis Explanation: The most common cause of vaginal discharge in women of child-bearing age is bacterial vaginosis. The most common presentation is a complaint of vaginal discharge with a fishy odor, most noticeable after sexual intercourse. The vaginal discharge is cream colored and thin. Chlamydia produces a discharge but it is not reported as pruritic. Herpes does not produce a discharge. Syphilis produces a lesion.
Which form of birth control presents the highest risk to a female patient if she is exposed to a sexually transmitted disease (STD)? A) Intrauterine device B) Progestin only pill C) Diaphragm D) Oral contraceptives
A) Intrauterine device Explanation: Exposure to an STD always increases the likelihood of contracting an STD. However, the patient is at very high risk of developing pelvic inflammatory disease when there is an implanted foreign body. An example of this is an intrauterine device (IUD). The risk is also increased with a diaphragm, but, because it is not implanted for long periods at a time, the risk is less than with an IUD
24 year-old female patient who is sexually active complains of vaginal itching. If she has bacterial vaginosis, she might complain of: A) a "fishy" vaginal odor after coitus. B) a truncal rash. C) copious vaginal discharge. D) midcycle bleeding.
A) a "fishy" vaginal odor after coitus. Explanation: Bacterial vaginosis is a clinical syndrome where high concentrations of anaerobic bacteria replace normal vaginal flora. This produces many symptoms that cause complaints in women. The typical symptoms are a "fishy" odor emanating from the vagina, itching, and vulvovaginal pruritis and burning. A typical complaint is an unpleasant odor after coitus.
Athletic amenorrhea increases the risk of: A) osteoporosis. B) an eating disorder. C) covert hypothyroidism. D) breast cancer.
A) osteoporosis. Explanation: Athletic amenorrhea creates states of prolonged hypoestrogenemia. This results in an increased risk of osteoporosis.
Primary Amenorrhea
Absence of menses by age 15 years (could consider earlier if abnormalities present) • Often secondary to dysfunction in the hypothalamus, pituitary, ovaries, uterus, or vagina • Many causes • Refer for dx, tx
Primary Dysmenorrhea
Absence of pelvic pathology but likely have a lot of prostaglandins being produced • Usually starts in adolescence • Pain starts 1-2 days prior to onset of menses, then resolves over the next 12- 72 hours • May present with nausea, diarrhea, fatigue, dizziness, HA, back pain • Improves with NSAIDs, hormonal contraceptives • Improves with age and parity
A young female has breast buds bilaterally. This represents Tanner Stage: A) 1 B) 2 C) 3 D) 4
B) 2 Explanation: Tanner Stage II is characterized by the formation and presence of breast buds, small areas of surrounding glandular tissue, and widening of the areola.
A patient who is scheduled for pelvic exam with PAP smear should be advised to avoid douching, sexual intercourse, and tampon use before her exam. For how long should she be advised to avoid these activities for optimal evaluation? A) 24 hours B) 48 hours C) 36 hours D) One week
B) 48hours Explanation: The general recommendation is to avoid these activities and any vaginal medication for 48 hours prior to PAP smear. Douching and tampon use can remove superficial cells which are the ones collected and used as representative samples on PAP smear. Sexual intercourse should be avoided because there can be specimen contamination by the male partner and semen can make the smear thick and difficult to read. With vaginal medications or creams, either can serve as a barrier to epithelial cell sampling.
In collection of a specimen for a PAP smear, how is the endocervical specimen collected? A) After the ectocervical specimen with a broom B) After the ectocervical specimen with a brush C) Before the ectocervical specimen with a broom D) Before the ectocervical specimen with a brush
B) After the ectocervical specimen with a brush Explanation: Ectocervical specimens are collected first to minimize any bleeding that can occur from endocervix when it is sampled. The brush is considered a superior tool for collection of endocervical specimens because it produces the highest yield of endocervical cells, and thus, is a good reflection of the health of the cervix. Alternatively, a cervical broom can be used to collect cells. It collects endocervical cells and ectocervical cells simultaneously. It is rotated for 5 turns before the samples are placed on the slide. This may be used in pregnant women.
A 16 year-old female is diagnosed with primary dysmenorrhea. She has taken over the counter ibuprofen in 800 mg increments every 8 hours during menses for the past 3 months with minimal relief of symptoms. What intervention will provide greatest relief of dysmenorrhea symptoms? A) Flurbiprofen during menses B) Combined oral contraceptives C) Daily multivitamin with B12 supplementation D) 30 minutes of regular exercise daily
B) Combined oral contraceptives Explanation: NSAIDs and hormonal contraceptives represent the mainstay of pharmacologic treatment for dysmenorrhea. NSAIDs produce an 80-86% response rate when used for dysmenorrhea. The general recommendation is that when one agent (NSAIDs or hormonal contraceptives) does not produce relief of symptoms, the other agent should be tried. Hence, the best choice is oral contraceptives. Both agents should be considered for women who are symptomatic with one agent only.
An adolescent female has had normal menses for almost 2 years. She has not had menses in 3 months. She is diagnosed with polycystic ovarian syndrome (PCOS). What else is a common finding? A) Obesity B) Elevated insulin levels C) Positive pregnancy test D) Elevated blood pressure
B) Elevated insulin levels Explanation: PCOS is a systemic disease characterized by multiple cysts about the ovaries. Overweight states are common but not obesity. Normal weight is also seen in these patients. This patient will not have a positive pregnancy test unless she is pregnant. There is no indication from the information that this is the case. She likely has had not had menses because of anovulation. There is no associated blood pressure elevation, though this should be watched closely. Elevated insulin levels are usual findings in patients who have PCOS.
An initial pharmacologic approach to a patient who is diagnosed with primary dysmenorrhea could be: A) acetaminophen. B) NSAIDs at the time symptoms begin or onset of menses. C) NSAIDs prior to the onset of menses. D) combination acetaminophen and NSAIDs
B) NSAIDs at the time symptoms begin or onset of menses. Explanation: Pain associated with dysmenorrhea is likely due to prostaglandins which can cause prolonged contraction of the uterus. This produces uterine ischemia, sometimes termed "uterine angina". NSAIDs (non-steroidal anti-inflammatory drugs) are prostaglandin synthesis inhibitors. These are usually started at the onset of menses or onset of symptoms and continued for 2-3 days depending on the symptom pattern of the patient. There is no demonstrated increase in efficacy when acetaminophen is added or given alone.
A patient asks the NP's advice about an herb to help with her hot flashes. The NP knows these: A) are safe to use in all patients. B) may be contraindicated in patients with history of breast cancer. C) substances have a mild estrogenic effect and will halt hot flashes. D) help prevent osteoporosis.
B) may be contraindicated in patients with history of breast cancer. Explanation: The herb that the patient is asking about is probably black cohosh, Actaea racemosa. It is a phytoestrogen. This means that it provides estrogen from a plant source. If estrogen is contraindicated in a patient, then it does not matter whether it comes from plants or is produced synthetically. There is a potential safety concern in using black cohosh in women with breast cancer or who are at high risk of breast cancer because of the estrogenic effects that are possible on the breasts.
A patient who is 35 years old has identified a small, discrete mass in one breast. How should this be evaluated? A) Ask whether the mass changes at the time of menses. B) Order a mammogram and ultrasound to assess the mass. C) Have her return 3-10 days after next menses. D) Order a mammogram 3-10 days after next menses.
B) Order a mammogram and ultrasound to assess the mass Explanation: Clinical evaluation of a breast mass begins with a good history of the mass and a physical exam of the breasts, lymph nodes, neck, and chest wall. While asking about whether the mass changes with menses is a good question in history, a mammogram should be the first radiographic assessment in females with breast complaints who are over age 30. This patient is 35 years old. An ultrasound is used for evaluation of a focal abnormality in a breast, especially if it has been identified on a mammogram. In this patient, both are prudent since there is a discrete, palpable mass. Re-assessing the mass 3-10 days after next menses may be appropriate for a female younger than age 30 depending on her history and physical exam.
A 54 year-old female presents with a small to moderate amount of vaginal bleeding of recent onset. She has been postmenopausal for approximately 2 years. What diagnosis is least likely? A) Endometrial carcinoma B) Ovarian cancer C) Endometrial hyperplasia D) Uterine polyps
B) Ovarian cancer Explanation: Ovarian cancer may present as an adnexal mass, pelvic or abdominal symptoms and a variety of others. Postmenopausal bleeding (PMB) is a very uncommon presentation of ovarian cancer, but can present this way. In women with PMB, other causes of uterine pathology should be evaluated before considering ovarian pathology. In early menopause, the most common etiology is atrophy of the endometrium or vaginal mucosa. This patient is postmenopausal for approximately 2 years. Other common causes of PMB are polyps, fibroids, and endometrial hyperplasia.
A 28 year-old female presents with a slightly tender 1.5 cm lump in her right breast. She noticed it two days ago. She has no associated lymphadenopathy and there is no nipple discharge. How should she be managed? A) Mammogram B) Ultrasound and mammogram C) Re-examination after her next menses D) Clinical exam only
B) Re-examination after her next menses Explanation: Women who are less than age 35 years, who have no associated suspicious findings of breast cancer should delay imaging studies until re-examination 3-10 days after the last menstrual period to determine whether the lump changes in size or becomes non-palpable. If there are associated suspicious findings on exam like palpable nodes, a large lump (>2.0 cm), or nipple discharge, then diagnostic evaluation should not be delayed. If management involved a return visit for re-examination after menses, and the lump is unchanged, ultrasound is certainly advised. Mammogram may not yield good information in a 28 year-old because of the density of the breast tissue. Baseline mammogram may be advised. Direction from a radiologist or breast surgeon should be sought.
A 20 year old female reports that her grandmother and mother have osteopenia. What should she be encouraged to do to reduce her risk of osteopenia? A) Aerobic exercise, weight loss, low fat diet B) Smoking cessation, weight bearing exercise C) Calcium supplementation, vitamin A, C & D intake D) Optimal caloric intake, vitamin D supplementation
B) Smoking cessation, weight bearing exercise Explanation: Cigarette smoking accelerates skeletal bone loss. The mechanism is unknown, but, it may be due to increased metabolism of estrogen. Therefore, smoking cessation is important in prevention of osteopenia as well as other diseases and conditions. Exercise should occur at least 30 minutes three times per week to maintain bone density. This has also shown to decrease incidence of hip fractures in older women. Walking increases hip and spine density. Vitamin D (at least 1000 IU per day) and calcium intake (1200-1500 mg per day) should accompany weight bearing exercise and smoking cessation.
15 year-old female has never menstruated. She and her mother are concerned. What is most important for the NP to assess? A) Stature B) Tanner stage C) Anemia D) Family history of amenorrhea
B) Tanner stage Explanation: Tanner staging, or sexual maturity ratings are very predictable changes that occur with puberty. These should be assessed. In females, breasts and pubic hair signify specific pubertal changes that constitute maturation. These are not age specific, but at 15 years a Tanner Stage 3 or more would be characteristic of expected maturation. Menses should follow soon.
After a vaginal exam, a patient received a prescription for metronidazole. What was her likely diagnosis? A) Syphilis B) Trichomonas C) Chlamydia D) Gonorrhea
B) Trichomonas Explanation: Trichomonas can be treated with metronidazole orally. This is usually effective and is generally well tolerated as long as the patient avoids alcohol. Alcohol in the presence of metronidazole can produce a disulfiram reaction. Another medication used to treat trichomonas is tinidazole. The exact mechanism of tinidazole is unknown, but is an antiprotozoal.
A 51 year-old female patient presents with a 2 cm palpable breast mass. How should this be evaluated to determine whether it is solid or cystic in nature? A) Mammogram B) Ultrasound C) MRI D) Clinical breast exam
B) Ultrasound Explanation: The diagnostic test of choice to differentiate a solid from a fluid filled breast mass is ultrasound. More than 90% of breast masses in women in the 20s to early 50s are benign. However, they must be evaluated. Clinical breast exam is unable to differentiate fluid filled from solid masses. MRI is not used unless a history of breast cancer is present. Mammography has the potential to evaluate the presence of a mass, but is of inadequate benefit in assessing whether it is fluid filled or not.
Clue cells are found in patients with: A) leukemia. B) bacterial vaginosis. C) epidermal fungal infections. D) pneumonia.
B) bacterial vaginosis Explanation: The hallmark finding in a patient with bacterial vaginosis (BV) is clue cells on microscopic exam. Clue cells are epithelial cells with adherent bacteria. The most common clinical feature is an unpleasant, "fishy" smelling discharge that is more noticeable after sexual intercourse. BV can produce a cervicitis. It is a risk factor for HIV acquisition and transmission. Metronidazole is the most successful therapy. The usual oral regimen is 500 mg twice daily for 7 days. Alcohol should be avoided.
The clinical syndrome resulting from replacement of normal vaginal flora with anaerobic bacteria is: A) candidal vaginitis. B) bacterial vaginosis. C) pelvic inflammatory disease. D) herpes simplex.
B) bacterial vaginosis. xplanation: Bacterial vaginosis (BV), results when normal vaginal flora such as Lactobacillus sp. are replaced with anaerobic bacteria like Prevotella, Mobiluncus and Gardnerella. This is usually, but not always associated with sexual activity. Women who have never been sexually active are less affected
1. A 4 year-old female is brought in to the clinic by her mother who reports that she is constantly scratching "her private part". The patient states that it itches. On exam, the vagina is red and irritated. How should the NP proceed? A) Call child protection for suspected sexual abuse B) Prescribe a cortisone cream C) Collect a vaginal swab of the external vagina for microscopic evaluation D) Prescribe a topical antifungal
C) Collect a vaginal swab of the external vagina for microscopic evaluation Explanation: This child has a vaginitis. There are many diagnoses in the differential including pinworms, yeast, contact irritants from soap or bubble bath, etc. Since the diagnosis is not clear, some evaluation must occur in order to determine the diagnosis so proper treatment can be initiated. Since the description of the problem does not indicate what the diagnosis is, it is inappropriate to treat with a cortisone cream or topical antifungal.
Three of the following interventions are appropriately used to prevent osteoporosis after menopause. Which one is not? A) Limited alcohol intake B) Performance of weight-bearing activities for 40 mins. at least 5 days/week C) Estrogen replacement therapy D) Adequate calcium & vitamin D intake
C) Estrogen replacement therapy Explanation: Prevention of osteoporosis may be optimized by elimination of risk factors and engaging in interventions that maximize bone density. Good nutrition from infancy throughout adulthood is a major component of good bone health. Others include engaging in weight-bearing exercises, adequate intake of calcium and vitamin D, smoking cessation, limiting alcohol consumption to moderate amounts, and avoidance when possible of medications that may decrease bone density (corticosteroids, anticonvulsants). Osteoporosis occurs at accelerated rates in women who are post-menopausal. The lack of estrogen can produce rapid bone loss due to bone resorption. Estrogen replacement is not used to prevent or treat osteoporosis.
A nurse practitioner identifies filamentous structures and many uniform, oval shaped structures during a microscopic exam of vaginal discharge. These are probably: A) bacteria. B) sperm. C) Hyphae and Yeast D) Candida albicans.
C) Hyphae and Yeast Explanation: Filamentous structures likely describe hyphae. Typically, hyphae are the mechanism that allows fungal growth. The uniform oval shaped structures are likely yeast. These can range in size but are usually large and unicellular. Visualization of hyphae and yeast should prompt an immediate diagnosis of a fungal infection. Candida albicans is a specific fungus, often found in vaginal secretions. Since there are many fungi that can produce hyphae and yeast, it is not possible to diagnose Candida albicans specifically.
A female should be told to take her OCP at bedtime if she experiences: A) weight gain. B) headaches. C) nausea. D) spotting.
C) Nausea Explanation: A common side effect of oral contraceptives is nausea. This is probably related to increased hormone levels (estrogen and progesterone). An easy way to combat nausea is to take the pill before going to sleep at night. Most patients will sleep through the symptom of nausea.
A 70 year-old female has been in a mutually monogamous relationship for the past 33 years. She has never had an abnormal Pap smear, what recommendation should be made regarding Pap smears for her? A) They may be continued annually. B) They should be performed every 5 years. C) can be discontinued now. D) They can be discontinued at age 75 years.
C) can be discontinued now. xplanation: Pap smears screen for cervical cancer. Cervical cancer is very uncommon in older women, especially those who have no risk factors. Most learned authorities agree that screening for cervical cancer can be discontinued in women aged 65-70 years unless there are risk factors (previous GYN cancer, HIV positive). This patient still needs to visit the nurse practitioner for an annual exam but sampling of cervical cells can be discontinued in a patient of this age.
An 84 year-old female patient is a resident in an assisted living facility. She has early dementia. She walks daily and has had urinary incontinence for years. Her urinary incontinence is likely to be: A) urge. B) stress. C) mixed. D) unable to be determined.
C) mixed. Explanation: The most common type of urinary incontinence in women is mixed incontinence. This refers to at least two simultaneous mechanisms. Usually detrusor overactivity and impaired urethral sphincter function are present, giving mixed incontinence characteristics of urge and stress (exertional) incontinence. Stress incontinence is characterized by leakage of urine following sneezing, coughing, or laughing. Urge incontinence is characterized by the sudden urge to urinate that cannot be delayed.
Women who use diaphragms for contraception have an increased incidence of: A) sexually transmitted diseases. B) pregnancy. C) urinary tract infection. D) pelvic inflammatory disease.
C) urinary tract infection. Correct Explanation: The exact mechanism for increased urinary tract infections is unknown, but it is believed to be due to nonoxynol-9 induced changes in vaginal flora. Another consideration is the possible contamination that might accompany insertion before each episode of coitus. Care and cleaning of the diaphragm must take place, or that could be a contributor to increased bacteria.
Polycystic Ovarian Syndrome (PCOS)
Chronic, complex endocrine disorder associated with oligo-ovulation and/or anovulation •Characterized by formation of cysts in the ovaries (hence, "polycystic") •Common endocrinopathy; affects 6.5 -8% of females •Endocrine Society has a diagnostic algorhythm; Rotterdam Criteria for diagnosis
Polycystic Ovarian Syndrome (PCOS)
Cutaneous symptoms: acne, hirsutism, alopecia, acanthosis nigricans •Anovulatory symptoms: amenorrhea, oligomenorrhea, dysfunctional uterine bleeding,and infertility (typically begins in teenage years) •Hyperinsulinemia: Increased insulin level increase artherosclerosis •Mood disorders especially in adolescents
A female patient is 35 years old. She has never had an abnormal PAP smear and has had regular screening since age 18. If she has a normal PAP smear with HPV testing today, when should she have the next cervical cancer screening? A) One year B) 2-3 years C) 3 years D) 5 years
D) 5 years Explanation: American College of Obstetricians and Gynecologists recommends screening for women over age 30 years no more frequently than every 5 years if both tests are negative and adequate screening has taken place. If she had been screened with PAP only, the recommendation for screening would be in 3 years. US Preventive Services Task Force recommends screening this patient in 5 years. Human papilloma virus (HPV) testing in combination with cervical cytology has been shown to be more sensitive than cytology alone. However, HPV alone is not recommended as a lone screening modality. Finally, HPV testing is more specific in women over age 30 years.
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 21-65 years of age? A) 1 year B) 2 years C) 3 years D) 5 years
D) 5 years Explanation: Women ages 21-65 who have a cervix should be screened for cervical cancer. Screening intervals every 3 years should take place for women of average risk who are aged 21-29 years. Women aged 30-65 of average risk should take place every 3 years if only cytology is performed; or every 5 years if cytology plus HPV screening takes place. Women who are at increased risk of cervical cancer should be screened more frequently. Increased risk includes females who have had cervical cancer, those who are immunocompromised, or have infection with HIV.
The frequency for cervical screening depends on the patient and her age. What is the longest recommended time interval between cervical screens for patients who are 65 years-old or younger? A) 1 year B) 2 years C) 3 years D) 5 years
D) 5 yearsExplanation: Cervical screening for women aged 21-29 years should take place every 3 years with cytology only. Women aged > 30 years should be screened every 5 years with cytology and HPV. Generally, women who have been adequately screened do not need screening beyond age 65 years.
A 50 year-old female believes that she is "menopausal". She complains of "hot flashes" and has not had menses in 12 months. Which of the following test results may be helpful for confirmation of menopause? A) Increased thyroid stimulating hormone B) Decreased follicle stimulating hormone C)Hypoestrogenemia D) Increased follicle stimulating hormone
D) Increased follicle stimulating hormone Explanation: Follicle stimulating hormone (FSH) begins to rise during menopausal transition. This stage of menopause begins with variation in menstrual cycle length and ends 12 months after the final menses. If the patient is older than 45 years and menstrual cycle dysfunction has been ruled out, menopause should be considered. Possibly the best approach to diagnosing menopause is to ask and observe clinical manifestations. An elevated FSH is not necessary to make a diagnosis of menopause but is commonly done in clinical practice. Diagnosis entails a review of her symptoms. Specifically, changes in bleeding patterns, hot flashes, sleep disturbances, and genitourinary symptoms are characteristic of menopause.
A woman who is 65 years old presents to your clinic with a breast lump. She has had only normal annual mammograms and her last one was 6 months ago. What is true about this lump? A) It is probably breast cancer. B) It may not be a lump at all. C) It is likely a fibroadenoma. D) It is probably a benign lesion.
D) It is probably a benign lesion. Explanation: The vast majority of breast lumps, even in older women are benign. However, because of the risk of breast cancer in any female patient, especially an older patient, she must be evaluated for breast cancer. Fibroadenomas are common in younger women. Cysts are common throughout the lifespan. Sometimes women identify a lump, but, instead it is the lumpiness of the breast tissue and not a distinct lump.
What recommendation should be made to a 70 year-old female regarding mammograms? A) She should continue to have them annually. B) She should have them annually until age 75 years. C) She should have them every three years. D) She should have them annually as long as she has a reasonable life expectancy.
D) She should have them annually as long as she has a reasonable life expectancy. Explanation: Breast cancer is more prevalent in older women. In fact, 85% of breast cancer occurs in women after age 50 years. Older women profit from screening with mammograms and should continue to receive screening. No age limit has been established for discontinuing mammograms.
A female patient who takes oral contraceptives has just completed her morning exercise routine. She complains of pain in her right calf. Her blood pressure and heart rate are normal. She is not short of breath. Her calf is red and warm to touch. What is NOT part of the differential diagnosis? A) Deep vein thrombosis B) Cellulitis C) Calf muscle strain D) Trochanteric bursitis
D) Trochanteric bursitis Explanation: Trochanteric bursitis does not produce pain in the calf. Pain is concentrated in the affected hip. While it is not likely that someone who exercises regularly would have a DVT, this patient does take oral contraceptives. Therefore, DVT should always be part of the differential given the potential risks associated with untreated DVT (pulmonary embolism).
What choice below has no precautions for oral contraceptive pill use? A) Gallbladder disease B) 5 months post-partum and lactating C) Blood pressure 160/100 D) Varicose veins
D) Varicose veins Explanation: One of the major components of gallstones is estrogen. A patient with underlying gallbladder disease should not receive oral contraceptives (OC) since they will increase estrogen exposure and theoretically, formation of gallstones. Patients who are less than 6 months post-partum should avoid OCs until they are 6 months post-partum because OCs can decrease the quantity of breast milk produced. Hypertension is a contraindication to OC use because of the increased risk of stroke. Varicose veins are not a contraindication.
Possible complications with PCOS
Endometrial cancer (due to d eficient progesterone secretion) •Postmenopausal breast cancer •Ovarian cancer •Hyperlipidemia •Hyperinsulinemia and insulin resistance •Diabetes mellitus ; metabolic syndrome •Cardiovascular disease •Infertility (due to infrequent ovulation)
Secondary Dysmenorrhea
Get a good history (medical and menstrual) • Physical exam Purpose: Rule out a secondary cause (pelvic pathology-endometriosis, adhesions, fibroids, PID) • Pelvic exam (consider deferral for young, non-sexually active adolescents with mild symptoms) • Consider pelvic US to look for adnexal masses, fibroids, other pelvic pathology
Pharm Management
NSAIDs: 80-86% response rate (Start at onset of menses for 1-2 days or for duration of pain) •Hormonal contraceptive therapy (OK for first line tx) •If treatment with NSAIDs or hormonal contraceptives fails, try the other •Consider treatment with both •Consider secondary cause for failure of first and second line tx
Once Primary Dysmenorrhea is established...
Non-Pharm Management • Exercise improves symptoms • Heat to the lower abdomen is as effective as oral analgesics for relief
DYSMENORRHEA
Painful cramping associated with menstruation secondary to excessive uterine muscle contraction • Most common GYN problem in adolescents and many adult females • Get a good HISTORY!!! • Primary vs. Secondary
Differential Diagnosis
Pregnancy! •Congenital adrenal hyperplasia •Thyroid dysfunction •Cushing's syndrome •Androgen secreting tumors • Others
Diagnostic Studies
Testosterone: increased (but < 150 ng/dL), most sensitive measure of hyperandrogenemia •Pregnancy test •Lipid studies (decreased HDL s;elevated trigs, LDLs) •OGTT (oral glucose tolerance test) (more sensitive /specific than FBG/A1C) •Doppler ultrasound of ovaries (string of pearls)
If pregnancy not desired
To Treat Androgen Exces: Estrogen/progestin contraceptive (first line treatment) treats acne, hirsutism and protects the endometrium OR drospirenone ( analogue of spironolactone) OR Both •Metformin if needed for glucose regulation, reduces insulin secretion (BUT no longer routinely recommended -not supported by the data
If pregnancy desired
Weight loss should always be attempted initially; this may restore ovulation •REFER -Clomiphene first line (Clomid®) OR Letrozole (more effective in obese women)
Management for PCOS
Weight loss(may restore ovulation) , exercise, stress management
