A 21-year-old woman presents to you for management of menstrual migraines. She has no other medical problems, does not smoke, and does not take any medications routinely. Her periods are regular and last 5 days. She says the flow is moderate and she does not have dysmenorrhea. She is sexually active with her partner of 1 year, and she uses condoms for contraception. She says she develops a debilitating migraine for the first 2 days of her period every month. She describes her headaches as unilateral, throbbing, and associated with nausea and photophobia. She has missed work due to these symptoms.
What change in her management would be indicated if she reported that 2 days before the onset of her migraine, she develops an aura consisting of bright spots in her vision?
A visual aura may present as an area of vision loss, bright spots in the vision, or flashing lights. There is some data that migraines with visual aura are associated with an increased risk of stroke, and therefore estrogen should be avoided.
A 16-year-old P0 presents to your office accompanied by her mother to discuss options for management of heavy menstrual bleeding. She has been on oral contraceptives for the last 9 months, but admits she often forgets to take her pills and develops breakthrough bleeding. They have both researched the options on the Internet, and are interested in depo provera (depot medroxyprogesterone acetate, or DMPA) because of the possibility of amenorrhea and the ease of use.
How should you counsel this patient?
DMPA inhibits secretion of pituitary gonadotropins, resulting in anovulation and decreased estrogen production. It is a highly effective contraceptive that affords privacy and a convenient dosing schedule (once every 12 weeks). In addition, the mechanism of action results in approximately 50% rate of amenorrhea, making it a reasonable option for management of heavy menses in the adolescent population. DMPA has been associated with bone loss, but not with an increase in fracture risk. The FDA issued a “black box” warning in 2004 regarding the prolonged use of DMPA causing significant bone loss. The stance of ACOG is that practitioners should notify patients about this potential side effect of long-term use of DMPA, but it should not prevent the use of this medication in the adolescent population.
You ask a patient to call your office during her next menstrual cycle to schedule an HSG as part of her infertility evaluation.
Which day of the menstrual cycle is best for performing an HSG?
An infertility evaluation should be initiated in women younger than 35 years after 1 year of infertility (regular unprotected intercourse), and after 6 months in women older than 35 years. An HSG is performed in the mid-follicular phase, around day 8, in order to evaluate the patency of the fallopian tubes and the contour of the uterine cavity; it should not be done while the patient is menstruating or after ovulation has occurred. In women with normal menstrual cycles, ovulation may be confirmed with a day 21 serum progesterone level. Serum progesterone levels greater than 3ng/mL is consistent with ovulation. Ovarian reserve may be tested with a day 3 FSH. Women with adequate ovarian function will have sufficient production of ovarian hormones early in the menstrual cycle to keep the FSH at a low level, thus indicating an adequate pool of follicles and oocytes.
You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked.
Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation?
Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her FSH level be tested.
Which is the best day of the menstrual cycle to check an FSH in this situation?
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