GYN - PMS / Menopause / Sexuality

*** not done

What condition is atleast one sx associated with economic or social dysfunction that occurs during the 5 days before sunset of menses & is present in atleast 3 consecutive menstrual cycles?

Premenstrual Syndrome (PMS)

When does PMS regularly onset?

luteal phase - 1-2 wks before menses

must completely resolve w/ menses & cannot present before menarche

How is PMS relieved?

chronic ovarian suppression (hormonal birth control, GNRH inhibitor, pregnancy, menopause)

What are theories about the pathophysiology of PMS?

Nutritional deficiencies - folate, B6, calcium, magnesium

Abnormal response to progesterone in luteal phase

Hypersensitivity to dec serotonin in luteal phase

Abnormal interaction bt ovarian steroids & CNS neurotransmitters

What appetite changes and cravings happen with PMS?

increased metabolism during luteal phase → increased hunger

cravings for sugar/salt

How is PMS diagnosed?

1-4 sx that ma bye physical, behavioral, or psychological in nature

must onset during luteal phase and remit after menses

If a woman has ≥5 sx, with one being an affective sx (mood swings, anger, etc), is it more accurate to diagnose her with PMDD or PMS?

PMDD

What are non pharmacological treatment options for PMS?

exercise, improve nutrition, mange stress, improve sleep quality

cyclic NSAIDs for pain

What is the first line treatment option for PMS?

SSRIs - sertraline, fluoxetine, escitalopram, paroxetine (cyclical or continuous dosing)

What is required for a patient to have cyclic dosing of SSRIs to treat PMS?

must be sx free during follicular phase

What is the 2nd line (and more common) treatment option for PMS?

OCP- drospirenone or norgestimate

What can be used to treat PMS if first and second line options failed?

GnRH agonists/antagonists- can add estrogen to prevent menopausal sx

(*dont use long term bc affects bone density)

What area treatment options for PMS if bloating is the main concern?

trial Midol + low dose diuretic

add cyclical or continuous diuretic (ex- spironolactone)

What drug?

• K sparing diuretic w/ anti-androgenic (male hormone) effects

• must get CMP to r/o K irregularities & monitor

• pregnancy category C → feminization of male fetus (use contraception)

Spironolactone

What condition?

• severe PMS w/ occupational/social impairment

• more intense symptoms: anger, rage, depression, hopelessness, out of control, SI/HI

• impaired ability to cope

• disabling

Premenstrual dysphoric disorder (PMDD)

What is the DSM-5 criteria for PMDD?

documentation of sx atleast 1 yr

≥5 sx that onset atleast 1 wk before menses & resolve 2-3 days after (brain fog, anhedonia, bloating, etc)

out of the 5 sx, 1 or more core affective sx must be present

What are the affective symptoms associated with PMDD?

mood swings, sudden sadness, sensitivity to rejection

anger, irritability

depressed mood, self critical thoughts

tension, anxiety

What are non-RX treatment options for PMDD?

exercise (endorphins), improve nutrition, manage stress, improve sleep, cyclic NSAIDs

psych: CBT, light therapy, relaxation therapy

What are pharmaceutical treatment options for PMDD?

SSRI ± OCP (Drospirenone + Ethinyl estradiol [YAZ])

SSRI ± Alprazolam

SNRIs (venlafaxine), Buspirone

GnRH (limit 1-2 yrs)

Danazol (modified testosterone → suppresses ovarian cycle)

What are surgical treatment options for PMDD?

TAH w/ BSO

Perimenopause or Menopause?

• transition from normal ovulatory cycling to cessation of menses

• avg age of onset - 46 y/o

• can last 2-8 yrs & be asx or sx

Perimenopause

Perimenopause or menopause?

• spontaneous amenorrhea x 1 yr due to natural ovarian failure

• age related & genetic component

• avg age - 50-52 y/o

• mildly dependent on age of menarche

Menopause

Premature menopause happens before what age?

40 y/o

What are RF for premature menopause?

DM, vegetarian/vegan, malnourishment, smokers

*stronger genetic component

What can cause medically induced premature menopause?

chemo/XRT damage to ovaries, GnRH agonists/antagonists, aromatase inhibitors

Which of the following alone can be considered surgically induced menopause?

BL Oophorectomy

What factors are protective against early menopause?

Pregnancies & breastfeeding

What is the most common first symptom of menopause?

menstrual changes; usually in this order

• heavier or lighter flow

• longer or shorter cycles

• irregularity

Are mood disturbances more associated with perimenopause or menopause?

Perimenopause

What symptoms are associated with menopause?

dude alot there’s like 3 slides on it but here’s what’s bolded

• Inc CV risk → CAD MCC of death in women

• greater central obesity (visceral fat → metabolic disturbances)

• hour glass figure → shot glass

• osteopenia, osteoporosis, inc fx risk

• atrophic vagintiis

When does 20% of lifetime bone loss occur in women?

first 5-7 years of menopause

What condition?

• thin, translucent, yellow discharge

• pruritus

• pH > 5.5

• parabasal cells on pap smears

• associated with menopause

Atrophic vaginitis

How is menopause diagnosed?

1 year w/o period, elevated FSH & LH, decreased estradiol,

diagnostics to monitor RF (DEXA, mammogram, lipid panel, cardiac workup)

What is the most sensitive marker and best initial test for menopause?

elevated FSH (> 30 IU/mL)

What are non-RX treatment options for menopause?

improve nutrition, exercise (WB to protect bone health), sleep hygiene

What natural OTC supplements can be used for menopause treatment?

Phytoestrogens / Isoflavones: use consistently > 6 mos for max effect

Omega 3s: fish oil & grown flaxseed

Vit D3 & Ca2+

What medications can be used to treat mood changes associated with menopause?

SSRIs, SNRIs, anxiolytics

Which type of HRT should be used in those without a uterus?

Estrogen only (ET or ERT)

Which HRT should be used in those with an intact uterus?

Estrogen and progesterone combo therapy

Which dosage form of ERT is preferred in those with increased triglycerides?

Transdermal- gels / creams / patches (less liver metabolism)

What are benefits to ERT for menopause treatment?

most effective for sx & dec risk of CV, stroke, osteoporosis, & dementia

not a significantly inc risk of breast cancer compared to general population

What are risks of ERT for menopause treatment?

inc risk of endometrial cancer, VTE, liver dz, gallbladder complications

What are benefits to estrogen & progesterone combined therapy for menopause?

sx relief, dec risk of CV, stroke, osteoporosis, dementia

protective against endometrial cancer

What are risks to estrogen & progesterone combined therapy for menopause?

slight increased risk of breast cancer, VTE, liver dz, gallbladder complications

Which women experience less vaginal atrophy due to regular stimulation of tissue, sexually active or sexually inactive?

Sexually active

What can be used to treat vaginal atrophy/dryness?

Transdermal / PV estrogen, vaginal lubricants/moisturizers

What can be used to treat hot flashes & night sweats associated with menopause?

TD or PO estrogen +/- progesterone

Clonidine (caution- hypotension)

Gabapentin (caution- drowsiness)

What are contraindications for use of HRT?

Hx estrogen sensitive breast CA, endometrial CA, VTE, thrombophilic d/o

Undx breast lesions

Unexplained uterine/vaginal bleeding

Confirmed CVD, CAD

Active liver disease

Migraine w/ aura

Smoker

*caution w/ HTN, DM, HLD, autoimmune (SLE), obesity, Fhx breast CA

What HRT provides the lowest dose of progestin that protects the endometrium (20 mcg/day)?

Mirena IUD

How must Flaxseed (Linseed oil) be taken to achieve full anti-inflammatory & anti-oxidant effects?

use the seed & must be ground for bioavailability

(oil does not contain the lignans)

True or false: HT & ET regimens should be used for primary or secondary prevention of CHD?

False

What are the 4 stages of the sexual response cycle?

Desire, Arousal, Orgasm, Resolution

What stage of the sexual response cycle?

• Libido/sex drive- lasts mins-hrs

• highly influenced by hormones, meds, alcohol, & substances

Desire

What stage of the sexual response cycle?

• excitement brought on by physiological stimulation → vasocongestion

• inc HR, RR, BP

• F: nipples erected, breasts swell, clitoris erected & sensitive, inc vaginal lubrication

• M: nipples erected, testicles swell, erection

Arousal

What stage of the sexual response cycle?

• continued elevation & peak in HR, RR, BP

• shortest phase

• F: involuntary contractions f uterus & lower 1/3 of vagina

• M: ejaculation

Orgasm

What stage of the sexual response cycle?

• sense of relaxation, calm, & vitals return to normal after completion of orgasm

• longer in men vs women

Resolution

True or false: Women often do not go through the stages of the sexual response cycle in order.

True

What are the MCCs of sexual dysfunction in women?

reduced libido, dyspareunia, vulvodynia, vaginismus, female arousal or orgasmic disorder, body or self image

What classification of sexual dysfunction?

• expectations are never met

Primary

What classification of sexual dysfunction?

• all phases used to function in the past but 1+ phases don’t anymore

Secondary

What classification of sexual dysfunction?

• stages / responses function sometimes

• often psychogenic or relationship related

Situational

What is the MCC of orgasm disorders in women?

psychogenic

What are examples of common substances that disrupt sexual function?

alcohol, antidepressants (esp SSRIs), tranquilizers, BBs, diuretics (esp spironolactone), steroids, contraceptives (high dose or ultra low doses or containing progestin or drospirenone)

How do you diagnose sexual dysfunction?

no diagnostic measure can confirm; R/O other causes (comobidities, stressors, meds, etc)

What are treatment options for sexual dysfunction?

lifestyle mods, psychotherapy, pelvic floor therapy (if dyspareunia/vaginismus), lubricants or PV estrogen, HRT (testosterone replacement), Flibanserin or Addy, Bupropion (Wellbutrin), eros clitoral therapy device (increases circulation)

What drug is a centrally acting serotonin receptor agonist/antagonist that results in transient decreases in serotonin & increases in DA & NE in certain regions of the brain, which increases sex drive?

Flibanserin / Addyi