Clinical Pearls

When one encounters cycle abnormalities, the key is to identify the substance that is elevated or reduced.
A systematic review of the HPO axis will frequently elucidate a cause.

Women with primary dysmenorrhea should start NSAIDs before the onset of menses and take them for 3-
5 days

Clinical studies of women with hypothalamic amenorrhea have demonstrated that it is possible to
stimulate ovulation with primarily FSH, and that only passive amounts of LH are needed.

Abnormalities in the thyroid, pituitary, and adrenal glands can result in irregular periods in reproductive-
age women. Check TSH, Prolactin, and 17-OHP as part of the workup.

Progesterone suppresses ovulation and is the key component of combined birth control pills. The
estrogen also contributes to negative feedback that prevents ovulation too, but if taking a test and having
to pick one, its progesterone

Delayed puberty in a boy is often due to constitutional delay, whereas in a girl it is often pathologic.

Progesterone causes a small rise in body temperature; therefore, women can track the phases of their
menstrual cycle by consistently checking and documenting their basal body temperature. If a woman is
tracking her temperature to time intercourse either to improve chances of conception or to avoid
pregnancy, it is important that she is aware that the temperature only goes up after ovulation has already
occurred. Another, and perhaps more accurate, way to track ovulation is by following over-the-counter
ovulation predictor kits. These kits work by detecting LH in the urine. There are many apps available to
help women track their ovulation and menses by entering cycle length, temperature, and LH surge kit
data.

You can often limit your differential diagnosis be determining if estrogen is present or not. You can tell this
clinically by looking for signs of breast development. Remember though that testosterone can be
converted to estrogen so in cases where testosterone levels are very high (androgen insensitivity
syndrome) you will get conversion of testosterone to estrogen resulting in breast development.

You can often limit your differential diagnosis by determining if estrogen is present or not. In the case of
secondary amenorrhea, you can often test this clinically by giving the woman progesterone (either orally
or by injection). In general, if she bleeds in response you know that she is producing estrogen. If she does
not, you have limited your differential to conditions in which she may not be producing estrogen or she
has a disorder of the outflow tract of the uterus. Often times this can be further distinguished through
imaging of the uterine cavity or by giving the woman combined (estrogen and progestin-containing) oral
contraceptive pills.

Making the distinction between amenorrhea with estrogen being produced vs. estrogen not being
produced is important for a number of reasons. In addition to determining how you might help someone
conceive, it is also important for women who are not trying to conceive. If someone is making estrogen
and not ovulating (therefore no progesterone, e.g., unopposed estrogen), you worry about her
endometrial lining and long-term risk of endometrial cancer. If someone is not making estrogen, you worry
about her bone health and long-term risk for osteoporosis. In either case, if the woman is not trying to
conceive oral contraceptive pills may be a reasonable treatment if the underlying disease has been
addressed.

Clomiphene citrate is an estrogen agonist/antagonist commonly used to induce ovulation for treatment of
infertility in women with polycystic ovary syndrome. It requires an intact communication/normal
communication between the hypothalamic compartment and the pituitary compartment to work, therefore
it is not typically useful in cases such as hyperprolactinemia, functional hypothalamic amenorrhea, or
other hypothalamic or pituitary etiologies of secondary amenorrhea or anovulation. In such cases the
underlying pathology needs to be addressed, or "overridden" with injectable gonadotropins (FSH and LH).

LARC methods are more than 20 times more effective at preventing pregnancy than pills, the patch, or
the ring.

Combined hormonal contraception is popular with many women because they have regular and lighter
periods.

Almost all women, including those with medical co-morbidities can use progestin-only contraception.

History of an ectopic pregnancy is NOT a contraindication to IUD use.

Barrier methods are the only contraceptive methods that protect against sexually transmitted infections.

Ectopic pregnancy MUST be ruled out in a woman with a positive pregnancy test who has a history of
sterilization.

There can be a physiologic suppression of TSH by hCG (same -subunits). Also, total T4 increases in
pregnancy because of estrogen-stimulated increase in thyroid binding globulin. Thus, need to check free
T4 to rule out hyperthyroidism.

Vitamin B
6
25 mg po BID and Unisom 1 tab at night (and if needed tab in the morning) is a safe, easy,
and relatively effective over-the-counter remedy for EG and mild HG.

If HG is refractory to other medical Rx, methylprednisolone 16 mg po TID x 3 days and then 2-week taper
may provide improved control of symptoms.

In early losses, the most common chromosome anomaly (a.k.a. aneuploidy) is monosomy X (45,X), a.k.a.
Turner Syndrome. The most common trisomy is trisomy 16, followed by trisomies 22 and 21. In general,
the recurrence risk for future fetal aneuploidy is increased (usually 1-2%) except for monosomy X and
triploidy which appear to maintain baseline risk.

Very recently clinical researchers and professional organizations recommended using more conservative
(i.e., higher) ultrasound measurement cutoffs for diagnosing a non-viable pregnancy because specificity
is improved to essentially 100% (no false positives). With the newly proposed criteria, a mean sac
diameter (MSD) >25 mm without a visible yolk sac or crown rump length (CRL) >7 mm is needed to
diagnose a nonviable pregnancy (a.k.a. missed abortion).

The definition of abnormal fetal heart rate (FHR) varies with gestational age. FHR is abnormal if:

< 100 bpm @ < 6 wks.

< 120 bpm @ 6-8 wks.

Most common dosing of Misoprostol in clinical practice is 400-800 mcg per vagina every 4-6 hours. Most
patients have successful expulsion of the pregnancy loss within 24-48 hours.

Intrauterine contraceptive devices (IUD) appear to increase relative risk for ectopic pregnancy in
observational studies, but IUDs DO NOT increase the absolute risk of ectopic pregnancy. This statistical
misrepresentation occurs because IUDs are very effective at preventing intrauterine pregnancy and if an
IUD user becomes pregnant they will most likely have a pregnancy outside of the uterus (i.e., ectopic).
Therefore, DO NOT counsel patients that IUD use will increase ectopic pregnancy relative to patients not
using an IUD.

If serum -hCG is > 1500 mlU/ml and no pregnancy is seen in the uterus on transvaginal ultrasound,
assume there is an ectopic until proven otherwise.

Medical therapy has an unacceptably higher failure rate for treatment of ectopic pregnancies that are
large (> 4 cm) and with fetal heart motion.

An increased heart rate in a pregnant woman with mitral stenosis limits left ventricular filling time during
diastole, which may create new symptoms not apparent outside of pregnancy.

Pregnant women undergoing surgical procedures are especially susceptible to hypoxia as their functional
residual capacity is limited.

A pregnant woman with an acute asthmatic attack and a pCO
2
report from an arterial blood gas in the
"normal" non-pregnant range should raise the possibility of impending respiratory failure. The patient
should be hypocarbic during the attack.

A single umbilical vein and two umbilical arteries ramify over the chorionic surface, with the arteries
passing over the veins. As the placenta is rarely circular in shape, the umbilical cord inserts eccentrically
into most placentas.

Highly sensitive mechanisms for detection of fetal cells and DNA in maternal blood are key technical
innovations in non-invasive prenatal genetic diagnosis. Fast-moving progress is being made in
implementing such technology in the clinic, and uses of this technology include detection of genetic
disorders and fetal sex determination.

When labor is not progressing as expected, a simple way to evaluate the problem is to consider problems
with the power (uterine contractions or maternal pushing), passenger (fetal lie, size, and position), or
passage (maternal pelvis)

Pregnant women with prior low transverse Cesarean section are offered TOLAC or repeat Cesarean. The
reason for the prior Cesarean is often taken into account when counseling these patients. For example, if
the Cesarean occurred because the pelvis was suspected to be small and the current fetus is similarly
sized or bigger than the last, then Cesarean may be encouraged. If the prior fetus did not tolerate labor
and Cesarean had to be performed early in labor, then the chance of success is much higher.

The most significant risk factor is a history of a prior preterm delivery, approximately 2 fold. However, risk
is decreased with a subsequent term delivery.

An acute increase in the amount of vaginal discharge may be a sign of cervical dilation and warrants
evaluation.

No studies have shown that any tocolytic can reduce the rate of preterm birth. The main rationale for use
of tocolytic agents is to allow transport of the patient and to administer steroids to reduce neonatal
mortality and morbidity.

The National High Blood Pressure Education Program Working Group recommends that the term
"gestational hypertension" replace the term "pregnancy-induced hypertension" to describe elevated
blood pressure without proteinuria in women after 20 weeks gestation.

There is no screening test that predicts preeclampsia reliably. Have a high level of suspicion in at-risk
populations, in patients with labile blood pressures, or with new onset proteinuria in the absence of a UTI.

Cascade testing is best patient care and saves costs.

Beware of headaches independent of blood pressure levels. Headache as an indicator of severe
preeclampsia reflects an abnormal vascular response to increasing systemic blood pressures, reflecting
dysregulation cerebral perfusion.

Virtually all aspects of the management of mild gestational hypertension, including hospitalization,
bedrest, and use of anti-hypertensives, are controversial because of inadequate controlled trials. This
leads to a wide range of approaches, most of which are based on "expert opinion."

In managing hypertensive emergencies, the IV route is safer than oral or IM because it is easier to
combat inadvertent hypotension by stopping the IV infusion.

Low estrogen from any cause can cause menopausal signs and symptoms. If it is associated with
elevated FSH it is menopause, i.e., ovarian failure.

Many of the emotional signs and symptoms of menopause fatigue, irritability, apprehension, decreased
libido, headache, and feelings of inadequacy are often due to lack of sleep, a common problem in
menopause.

A decrease of 1 SD in bone density is associated with a 2-fold increase in fracture risk.

The best method to screen and monitor therapy for osteopenia and osteoporosis is DEXA (dual-energy
x-ray absorptiometry) of the lumbar spine and proximal femur.

Treatment of estrogen alone increases the risk of endometrial hyperplasia by up to 50% and the relative
risk for endometrial carcinoma by 3 to 15.

Since the progestin component of HT appears to contribute to an increased risk of breast cancer, ET
rather than HT should be used in women without a uterus if estrogen is used for the treatment of
menopausal signs and symptoms.