DIT 37 Gyn 1

● 12 mos of amenorrhea in a women >45 yrs is diagnostic & requires no additional workup
● a woman >45 with irregular menses (oligomenorrhea) and menopausal symptoms (hot flashes, mood changes, sleep disturbances) can be assumed to be going thru perimenopause
● Serum FSH levels increase in the perimenopausal period & after menopause, but it is of little diagnostic value beyond obtaining a hx of menses and symptoms
● if younger than 45, other etiologies for oligo/amenorrhea must be excluded (TSH, serum hCG, prolactin, FSH)

● control of menopausal symptoms (hot flashes, vaginal dryness/atrophy, urinary incontinence, emotional lability)
● reduced risk of osteoporosis
● reduced risk of colorectal cancer

● not indicated for the prevention of chronic disease, stroke, heart disease, and osteoporosis
● HRT doubles risk of invasive breast cancer (+8 per 100,000; but not non-invasive breast cancer), endometrial cancer, & venous thromboembolism (+8 PEs per 10,000)
● ↑ risk of stroke by up to 32-41% (+8 per 10,000)
● ↑ risk of heart disease by 29% (+7 per 10,000) - however, if taken at ages 50-59, HRT results in less coronary calcification on CT scan (NEJM 2007). This may or may not correlate with less risk of heart dz in women taking HRT during ages 50-59
● ↑ risk of biliary dz & need for biliary surgery

● Desvenlafaxine (Pristiq) - 100mg qd. only non-hormonal FDA approved for hot flashe. also works as an antidepressant
● Venlafaxine (Effexor) - 37.5mg BID reduces frequncy 52-62% and severity 57-67%, and results begin in the 1st wk of therapy. Good choice if any depression, axiety, fatigue or isolation. Good 1st line drug
● Clonidine - reduces freq 22% and severity 48%. Good choice if BP control is also needed. SE of dry mouth, constipation, and drowsiness
● Gabapentin (neurontin) - about 50% reduction seen in a small trial. Good choice if insomnia, restless leg syndrome, seizure d/o, neuropathy, chronic pain
● Time - ~30-40% of women have symptom improvement within a few mos, and most have resolution w/in 4-5 yrs
● Placebo effect is ~20-25% effective in reducing hot flashes

Clonidine

reduces freq of hot flashes 22% and severity 48%

AE: dry mouth, constipation, drowsiness

● pregnancy (altho accidental use in early preg is not a/w congenital anomalies)
● Hx of thromboembolism (DVT, PE) or inherited thrombophilia
● Hx of estrogen-dependent tumor (endometrial or breast carcinoma)
● Cerebrovascular disease (hx of stroke) or CAD
● Poorly controlled HTN
● smoker >35yrs
● Hepatic disease/ neoplasm (adenoma, cancer, hepatitis, cirrhosis)
● abnormal vaginal bleeding of unknown etiology
● Migraine w/ aura, neurologic symptoms, or vascular involvement (↑ risk of stroke)

● Reliable (<3% failure rate)
● ↓ risk of endometrial & ovarian cancer
● ↓ incidence of ectopic pregnancy
● menses more predictable, lighter, less painful

● daily dosing
● doesn't protect against STDs
● breakthrough bleeding
● Estrogen SE: bloating, weight gain, breast tenderness, nausea, headaches
● Progesterone SE: depression, acne, HTN
● ↑ risk of DVT
● ↑ triglycerides

bloating, weight gain, breast tenderness, nausea, headaches

depression, acne, HTN

● reversible liver cholestasis
● Hepatic adenoma (benign tumor which may undergo malignant transformation; incidence is 3-4 per 100k long-term users vs o.1 per 100k in the general population; development typically requires high dose estrogen for >5yrs)
● Budd-chiari syndrome from hepatic vein thrombosis or IVC thrombosis
● Veno-occlusive disease of the terminal hepatic venules and hepatic sinusoids (similar to Budd-chiari)
● hepatocellular carcinoma
● resulting cirrhosis, portal HTN or liver failure from one of the above

● Antibiotics (Rifampin, griseofulvin to lesser degree)
● Anti-epileptics (ie phenobarbital, phenytoin, carbamazepine, topiramate, oxcarbazepine, primidone)
● Other: St. John's wort

● current vaginal or cervical infection
● high risk for STDs/PID including multiple sex partners or hx of recurrent STDs
● known pregnancy or desire for preg in the near future
● severe uterine distortion (bicornate uterus, cervical stenosis, fibroids distorting the uterine cavity)
● uterine bleeding that has not yet been worked-up
● Copper allergy or Wilson's disease -- avoid copper IUD
● Breast cancer -- avoid progesterone IUD

● Thorough hx & PE -
- congenital defects identified: imperforate hymen, transverse vaginal septum, vaginal agenesis
- if signs of hyperandrogenism → serum testosterone and DHEA-S to assess for an androgen-secreting tumor
- if galactorrhea → serum prolactin & thyrotropin to assess for prolactinoma
● Pelvic sonogram if uterus does not appear to be present or is difficult to assess
● if uterus is absent → karyotype and serum testosterone
- if beta-hCG high → pregnancy
- if FSH high → karyotype for Turner syndrome (45, XO)
-if FSH low → cranial MRI for hypothalamic or pituitary disease
-if FHS normal → serum prolactin & thyrotropin

imperforate hymen

● serum beta-hCG to rule-out pregnancy
● thorough hx & PE
● serum prolactin (r/o hyperprolactinemia), serum TSH (r/o thyroid disease), serum FSH (r/o ovarian failure)
● if signs of hyperandrogenism → serum DHEAS and total testosterone
● if all of the above are normal or h/o D&C → progestin withdrawal test (r/o Asherman's)

Kallman Syndrome

first, always check beta-hCG
-check TSH & prolactin

● beta-hCG
● Prolactin
● TSH
● FSH
● testosterone & DHEA-S
● Progestin withdrawal test

● TRUE/CENTRAL: ↑ LH/FSH, wen you give GnRH = further ↑ FSH
● PSEUDO: ↓LH/FSH, no response when you give GnRH

absence of menses for >6mos in a woman <40yrs old

● exogenous hormones
● adrenal hormones
● CAH
● hormone secreting tumors
● McCune ALbright Syndrome

homone - progesterone
BBT rises 24-48 hrs after ovulation

1. combination OCPs
2. Progestin only
3. Copper IUD
4. selective progesterone receptor modulators

● Pregnancy
● hx of thromboemabolism
● hx of estrogen-dependent tumors
● poorly controlled HTN
● smoker >35yr
● Liver disease
● abnormal vaginal bleeding of unknown etiology
● migraines w/ aura or neurologic symptoms or vascular involvement

Rifampin, Griseofulvin, antiepileptics, St John's wort

age 13

Tanner stage 2, seen earlier in AA & Hispanics

before menarche

pubertal changes in <8yr in girls or <9 yrs in boys

1. congenital adrenal hyperplasia
2. exogenous androgens
3. androgen-secreting neoplasms

1. CNS lesions
2. trauma
3. thyroid disorders

use GnRH analogs in continuous fashion to suppress gonadotropin release

luteal phase

estradiol

↓ progesterone level = corpus luteum will degrade & menstruation occurs

age 40

1 yr of amenorrhea in a woman >40

● ↓ ovarian response to LH & FSH
● ↑ FSH & LH levels
● estrogen levels fluctuate

● SNRIs
● Clonidine
● Gabapentin
● time

those with osteopenia & those with high risk factors for osteoporosis (note- need to supplement with Ca2+ & Vit D)

● inhibit follicle development & ovulation
● change endometrial quality
● ↑ cervical mucus viscosity

ovarian cancer

● Estrogen = weight gain, nausea, breast tenderness, headache
● Progesterone = acne, depression, hypertension