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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
