ࡱ> /1.i%` $bjbjNN J,,! 55555\ Ђ`X6X6X6X6n6Q8Q8Q8OQQQQQQ$0hxuQ8/8"Q8Q8Q8uX6n6===Q88X6n6O=Q8O==x~n6L6 0G5:z6O0Ђz<l~~@Q8Q8=Q8Q8Q8Q8Q8uu=Q8Q8Q8ЂQ8Q8Q8Q8    $$   $    Last Class Menopause: Definition and interpretation of a T score? T score- bone mass comparison to pre-menopausal mean peak reference value 0 to -1 = bone mass normal -1 = bone mass 10% below normal -1.5 = bone mass 15% below normal -2.0 = bone mass 20% below normal Screening recommendations for DEXA? Women > 65 regardless of risk factors Post-menopausal women <65 with one or more risk factors in addition to being white, PM, and female Post-menopausal women who present with fractures Risk Factors for osteoporosis? Non-modifiable Personal history of fracture as an adult Fracture in a first degree relative Caucasian/Asian Advanced age Female sex Dementia Poor health/frailty Steroid therapy > 3 months Potentially modifiable Current cigarette smoking Low body weight (<127#) Estrogen deficiency Low calcium intake (lifelong) Alcohol intake (> 2/day) Impaired eyesight despite correction Recurrent falls Inadequate physical activity Poor health/frailty Definitions and types of incontinence? Genuine Stress Incontinence (GSI) Detrusor Instability (DI) Mixed (GSI and DI) Overflow Effect of menopause on cholesterol? Levels go up from about 95% before menopause to 105% 6 months after menopause HDL levels go down from 105% before menopause to 95% 6 months after menopause LDL levels go up from 95% before menopause to 110% 6 months after menopause Average age of menopause? 51.4 years old Perimenopausal Transition is at 46 years old and last about 5 years. Menarche = 12.7 y/o Effect of estrogen on cardiovascular system? Both Beneficial Effects Direct effect on vasculature Indirect effect on lipid metabolism CASE STUDY IN CHRONIC PELVIC PAIN: Basics of endometriosis? Endometrial glands/stroma outside the endometrial cavity Most common sites: pelvic peritoneum, posterior cul-de-sac, round ligament, uterosacral ligaments Incidence 10-15% reproductive age women 20% of women with chronic pelvic pain 40% of women with infertility Theories Halban: endometrial tissue transported via lymphatic system to ectopic sites in the pelvis Meyer: multipotential cells in peritoneal cells undergo metaplastic transformation into functional endometrial tissue Sampson: endometrial tissue transported through the tubes during retrograde menstruation Complications: Dysmenorrhea Dyspaurenia Infertility Abnormal bleeding Cyclic pelvic pain Severity of symptoms does not correlate with amount of endometriosis Definition of chronic pelvic pain? Non-cyclic 6 months or more in duration Localized to pelvis, anterior abdominal wall below the umbilicus, lumbosacral area, or buttocks Causes significant enough impairment to cause them to seek treatment How to interpret a PUF questionnaire? Pelvic Pain and Urgency/Frequency > 10 points 74% likelihood of IC 5-10 points 55% likelihood of IC Healthy women < 2 points IC = Interstitial Cystitis 80% of patients with IC have a positive Potassium Sensitivity Test (PST) COMPLICATIONS OF MENSTRUATION: Basic Evaluation of post-menopausal bleeding? It is cancer until proven otherwise! Menorrhagia Metrorrhagia Hypomenorrhea Metrorrhagia Polymenorrhea Menometrorrhagia Oligomenorrhea Cryptomenorrhea Evolution of Contraception: Oral Contraceptive: Combination of ethinyl estradiol and one of several progestins or progestin alone Mechanism of Action Inhibit the LH surge needed for ovulation (progestin) Modulating GnRH release/FSH production (estrogen) Alter cervical mucous Induce atrophic changes in the endometrium Non-contraceptive benefits of oral contraceptives? Lower incidence of endometrial and ovarian cancers Fewer ovarian cysts Decreased risk of ectopic pregnancy Minimize acne Regulation of menses lighter flow Reduction in dysmenorrhea Reduction in symptomatic fibrocystic breast disease Decrease upper genital tract infection (PID) Protect against ovarian cancer Contraindications of oral contraceptives? Migraine with aura Smokers over the age of 35 History of thromboembolic disease Coronary artery disease Diabetes or hypertension with vascular disease or older than 35 Lupus erythematosus Hypertriglyceridemia Cancer BOY MEETS GIRL INFERTILITY Effect of age on fertility? As age increases follicular phase becomes shorter and estradiol begins to rise earlier Increased rate of follicular atresia after 37-38 Increased rate of spontaneous miscarriage Intercourse on most fertile day 50% achieve pregnancy age 19-26 40% achieve pregnancy age 27-34 30% achieve pregnancy age 35-39 Methods of detecting ovulation? Basal body temperature Temperature first thing in the morning Biphasic pattern suggestive of ovulation Common to have dip the day of ovulation Temperatures rise after ovulation due to progesterone from corpus luteum If temperatures drop late in the luteal phase dont waste money on a pregnancy test! Serum progesterone (mid-luteal Day19-22) 12 - 15 ng/mL considered evidence of ovulation Ovulation predictor kits (LH surge) Ultrasound Most common Mullerian abnormality? Bicornuate uterus (37 percent) Arcuate uterus (15 percent) Incomplete septum (13 percent) Uterus didelphys (11 percent) Complete septum (9 percent) and Unicornuate uterus (4.4 percent) How to interpret basal body temperature chart? Each day mark temperature. Also note breast tenderness, sleep deprived, high stress, or headache. Each day the temperature is taken and marked on the chart. Biphasic pattern suggests ovulation How to interpret a ovulation test? GYN MALIGNANCIES: Prognostic factors for breast cancer? Risk factors for the development of breast cancer? Gyn cancer with the highest mortality? Most common cause of gyn malignancy = Endometrial Cancer Highest Mortality = Ovarian MENSTRAUL CYCLE PHYSIOLOGY: Specifics of delayed puberty? No pubertal development by age 13 Pubertal maturation not completed within 4 years or Menses not begun by age 16 Understand the physiology of the menstrual cycle and what hormones are doing what and when? Norepinephrine stimulates hypothalamus to release GnRH GnRH- gonadotropin releasing hormone from hypothalamus stimulates anterior pituitary Anterior pituitary- FSH and LH stimulate ovaries Ovaries- progesterone and estrogen A rise in LH is in ovulation Ovum lives approximately 24 hours after it is released but is fertilizable less than half that time Estrogen - proliferation of ducts Progesterone - growth of lobules & alveoli Secreted in large amounts by the corpus luteum and the placenta 2% free in circulation Important intermediate in steroid biosynthesis pathway Fluctuate widely during cycle Mastalgia = cyclic breast pain Ovary Follicular Phase Ovulation Luteal Phase Uterus Proliferative Phase Estrogen dominates Parallels follicular phase of the ovary Growth of blood vessels, mucosa and glands Secretory Phase Progesterone dominant Parallels luteal phase Mucous producing 3 types of estrogen and potency? 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