11 - Dysmenorrhea & PMS Flashcards
Dysmenorrhea
Defined as pain during menstruation
When does dysmenorrhea occur?
Only during the ovulatory cycles - follicular phase of the menstrual cycle
When does dysmenorrhea usually begin?
With the onset of menses (within the first 6-12 months of menarche)
How long do the symptoms occur?
With the onset of menses (several hours prior) and lasts 2-3 days
Symptoms of dysmenorrhea?
Cramping in lower abdomen, pelvic pain may radiate to back and legs (thighs)
- Other symptoms associated:
- headache
- nausea
- vomiting
- fatigue
- IBS
Dysmenorrhea can be primary or secondary:
Define primary
Uterine contractions often involving increased PGs
Primary is though to be due to prostaglandins:
- Concentration of PGE2 and PGF2 alpha are increased in the endometrium. This increase correlates with pain severity.
- PGs result in an increase in uterine activity, strength and frequency of contractions
- *So if we decrease PGs, we decrease dysmenorrhea.
Dysmenorrhea can be primary or secondary:
Define secondary
Due to pelvic pathology such as endometriosis, uterine polyps or uterine fibroids.
*Fibroids can cause secondary dysmenorrhea: they are benign growths within the muscle tissue of the uterus
What does estrogen cause in the menstrual cycle?
causes the lining to build up
*building the house LOL
What does progesterone cause in the menstrual cycle?
causes glycogen, mucus and prostaglandins to build up in the endometrial tissue
*decorating the house LOL
Knowing that PGs are the issue, how should we treat dysmenorrhea?
NSAIDs
Primary dysmenorrhea:
Age of onset
Typically 6-12 months after menarche
Secondary dysmenorrhea:
Age of onset
Mid to late 20’s through 30’s and 40’s
Primary dysmenorrhea:
Menses
More likely to be regular with normal blood loss
Secondary dysmenorrhea:
Menses
More likely to be irregular, menorrhagia (menstruation with prolonged or abnormally heavy bleeding) more common
Primary dysmenorrhea:
Pattern & Duration
Onset just before or coincidental with menses, pain with each or most menses, lasting 2-3 days
Secondary dysmenorrhea:
Pattern & Duration
Vary with cause, change in pain pattern or intensity may indicate secondary disease
Primary dysmenorrhea:
Pain at other times of menstrual cycle?
No way jose
Secondary dysmenorrhea:
Pain at other times of menstrual cycle?
Yes - May occur before, during or after menses
Primary dysmenorrhea:
Response to NSAIDs and/or OC (oral contraception)?
Yes
Secondary dysmenorrhea:
Response to NSAIDs and/or OC (oral contraception)?
No
Primary dysmenorrhea:
Other symptoms?
N, V, fatigue, dizziness, irritability, diarrhea, and headache may occur at the same time as dysmenorrhea
Secondary dysmenorrhea:
Other symptoms?
Vary with cause, may include dyspareunia and pelvic tenderness
Dysmenorrhea will only occur during ______ cycles
ovulatory
*that’s why birth control can help because it prevents ovulation
Risk factors for dysmenorrhea?
- < 30 years old
- BMI < 20
- smoking
- menarche before 12 years old
- longer menstrual cycles/duration of bleeding
- irregular or heavy menstrual flow
- history of sexual assault
- PMS or pelvic inflammatory disease
- sterilization
What is endometriosis?
the lining that normally is formed on the inside of the uterus occurs on the outside of the uterus
Red Flags for Dysmenorrhea
- Onset of pain > 2 years post-menarche (i.e. secondary dysmenorrhea)
- Symptoms occur outside the first 3 days of menses
- Change in severity or pattern of pain
- Change in characteristics of menstrual fluid
- If trial of OTC treatment fails
List some non-pharms for dysmenorrhea
- Heat therapy (warm baths, heating pads, etc.)
- Lifestyle modifications: Stop smoking or exposure to smoke, regular exercise, decrease fat intake
- Relaxation
Is acetaminophen effective for dysmenorrhea?
No - doesn’t affect prostaglandins
You can still recommend it if they are unable to take NSAIDs if they really want it.
*Always recommend heat therapy tho - VERY EFFECTIVE
Describe the non-prescription treatment for dysmenorrhea
1st line: NSAIDs
- one agent at a time
- ibuprofen or naproxen
- start at onset of pain or menses and continue on a scheduled basis for 72 hours
-3 month trial may be done before referring or if symptoms not relieved or pain worsens
- very important to schedule it to prevent further prostaglandin release
- no PRN dosing
- routine scheduling
Would you ever recommend ASA/Acetaminophen?
They do not affect PG’s so they are not affective
-Can recommend if NSAIDs are not appropriate therapy to provide patient comfort.
Describe the prescription treatment for dysmenorrhea
- NSAIDs: propionic acids (ex. naproxen, ibuprofen) or fenamates (ex. mefenamic acid) or acetic acids (indomethacin)
- Mefenamic acid unique as it both inhibits prostaglandin synthase and blocks the action of prostaglandins that have already been formed.
- Clinical efficacy is similar for all NSAID options
- OC (oral contraceptives) are 90% effective because they block ovulation
- Low dose agents provide lighter, shorter and less painful periods, or no periods at all (i.e. progestin only)
Treatment for secondary dysmenorrhea?
Referral and treat the underlying causes such as:
- endometriosis
- IUD use
- cervical stenosis
- PID
- infection
Monitoring parameters for dysmenorrhea
For Improvement:
-May take up to 3 cycles for improvement of dysmenorrhea issues/symptoms overall
For SEs:
-Depends on the self-tx approach. Most self-tx products are unlikely to the clinically significant SE’s
Max duration of Tx for dysmenorrhea?
3 days - treat cyclically
When do you refer dysmenorrhea?
If symptoms are severe, if endometriosis or other secondary causes are suspected
What is PMS (Premesntrual syndrome) ??
- Cyclic disorder affecting 40% of women of reproductive age
- “Recurrent physical, psychological and behaviour symptoms which occur during the luteal phase of the cycle (day 14-28) and which are relieved by menstruation with a symptom free week. The symptoms have a negative impact on the QOL of the woman”
PMS:
Onset ?
anytime after puberty, typically in mid-twenties
PMS:
When do symptoms start, improve, and disappear ?
Symptoms start anywhere from 7-14 days before menstruation; symptoms ‘peak’ just a few days before.
Symptoms improve significantly (or disappear) within the 1st several days of menstruation.
Symptoms disappear (or resolve) during events that interrupt ovulation (i.e. pregnancy or menopause)
PMS: See table 1 for PMS symptoms
bitchin
Describe the ethology of PMS
-Remains unknown & may be complex and multi-factorial
Possible etiologies:
1-Exaggerated response to normal hormonal changes
-Fluctuations in estradiol and progesterone cause an abnormal response
2-Serotonin deficiencies
-Women with PMS have been found to have decreased serotonin concentration and decreased platelet uptake of serotonin during the late luteal phase
-Decreased serotonin may lead to depressed mood, irritability, anger, aggression, poor impulse control and appetite disturbances
3-Abnormalities in catcholaminergic, GABA and opioid neurotransmitter systems
Risk factors for PMS
- Lower intake of vitamin D
- Genetic predisposition
- High body mass index
- Stress
- Traumatic life events
What is Premenstrual Dysphoric Disorder (PMDD) ?
- Severe form of PMS affecting 5% of women of reproductive age
- Formerly ‘Late Luteal Phase (Dysphoric) Disorder’
- Considered a mental disorder ??
- Symptoms are usually severe enough to cause functional impairment/disruption
- Symptoms usually peak in 3rd or 4th decade
- During perimenopause (5-10 yrs prior to menopause) it may become severe
- If suspected; refer
Negative outcomes associated with PMDD?
- Marital issues
- Physical/verbal abuse of others
- Difficulties in parenting
- Criminal behavior
- Poor work or school performance
- Work absenteeism
- Social Isolation
- Accidents
- Hospitalization
- Suicidal ideation
Key information gathering assessment (in addition to SCHOLAR and MAPPL)
Type of symptoms and severity?
-Most distressing symptoms?
Timing of symptoms:
- Nature - cyclic or not
- When during the menstrual cycle does the patient experience symptoms?
Smoker?
Validated scales (ex. PRISM or COPE) ^^don't know what these are
Patients should prospectively report symptoms in luteal phase of cycle for at least 2 cycles
Red flags for PMS?
- Severe cases of PMS (PMDD)
- Uncertain or unusual patterns of symptoms or symptoms inconsistent with PMS
- Affective disorder (depression, anxiety)
- Onset of symptoms associated with OCP & HRT
- Symptoms related to other medical conditions
- Other conditions: Anemia/thyroid disorder/diabetes/endometriosis/chronic fatigue syndrome/psychiatric disorders
- Peri-menopause
- Signs of infection, ovarian cysts
- Individuals who do not respond to Tx or symptoms become worse
Treatment philosophy for PMS?
PMS is a multi-symptom disorder:
- Behavioral, psychological and physical symptoms
- Tx approach should be selected to address the Pt’s most bothersome symptoms
- Generally combined Tx approach is necessary
Treatment goals for PMS?
- To have a good understanding of PMS
- Relieve symptoms
- Reduce impact on activities and interpersonal relationships
Non-pharm treatment for PMS?
- Education
- Supportive
- Behavioral
- Dietary
Pharmacological treatment for PMS?
- PG inhibitors and other analgesics (1st line are ibuprofen/naproxen)
- Diuretics (pamabrom)
- Antihistamine (pyrlimaine)
- Natural Health Products (NHPs): Herbal
- Calcium
- Vitamin B6
- Magnesium
- Evening Primrose
- Chasteberry
Describe non-pharm treatment for PMS:
Cognitive
Behavioral therapy emphasizes relaxation techniques & stress reduction:
- Assist individual to cope or deal with the changes
- Smoking cessation (if applicable)
- Sleep hygiene
Describe non-pharm treatment for PMS: Nutritional therapy (unproven)
- Balanced diet
- Decreased salt intake
- Decreased caffeine
- Small, frequent intake of carbs
- Dietary changes are recommended 7-14 days before the menses begins (minimum)
Describe non-pharm treatment for PMS:
Exercise
Women who practiced aerobic exercise (3-4x/week) experience fewer symptoms compared to those with no exercise
Rationale:
- Exercise reduces symptoms of depressive illness
- Luteal-phase of endorphin secretion appears to be altered in women with PMS
- Exercise boosts “feel-good” endorphins
- Structured sleep schedule - consistent sleep/wake times, especially during luteal phases
Describe the pharmacological treatment for PMS:
Evening Primrose Oil (EPO)
- EPO contains 72% linoleic acid (PGE1 precursor)
- Trials have found no effect of this product
- Do not recommend this
Describe the pharmacological treatment for PMS:
Chasteberry
- Not proven
- Don’t recommend
- Lots of bad side effects
Describe the pharmacological treatment for PMS:
Pyridoxine (Vitamin B6)
- Cofactor in synthesis of dopamine and the metabolism of tryptophan (serotonin precursor)
- A meta-analysis found that pyridoxine may be beneficial for the treatment of PMS
- Dose should be recommended from 50-100 mg daily due to potential neuropathy
- Risk of neuropathy (toxicity) is associated with as low dose as 200 mg/day
Describe the pharmacological treatment for PMS:
Magnesium
- Mg2+ in dosage 200-400mg/day - minimal benefit in alleviating fluid retention
- Mg deficiency is rare - diet enough usually
- American College of Obstetrics & Gynaecology (ACOG) does not recommend Mg
- Too much = diarrhea, dizziness, weakness, fatigue
**Evidence not definitive
Describe the pharmacological treatment for PMS:
Calcium
- Historic data indicates that lower plasma Ca2+ levels premenstrually compared week following menses
- Symptoms of hypocalcemia similar to PMS
- Ca helps with mood, abdominal pain, water-retention (bloating), cramps and food cravings
- ACOG recommends Ca2+ supplementation
*Also good for bone health - hitting 2 birds with 1 stone man
- Has strongest evidence amongst herbs, vitamins, and minerals
- Take with food/watch for DI’s (2-3 hours window minimum)
*Ca is considered a preventative or corrective option rather than a FAST treatment option
Should we recommend combined OTC products (such as Midol, Pamprin, Tylenol XS Menstrual) ?
No - they all contain acetaminophen which has no effect for dysmenorrhea or PMS
**Remember - NSAIDs are better !!
Pamabrom is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.
- Very uneffective
- Derivative of theophylline that promotes diuresis
- Use in the tx of physical symptoms (bloating, weight gain, water retention)
- 50 mg QID (max dose 200mg/day)
*not found to add benefit over treatment with an analgesic
Pyrilamine is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.
*Dose in these products is below the recommended 100 mg adult dose
MOA: sedative effects for women experiencing emotional symptoms? Anxiety, nervous tension and irritability
- Will simply help you sleep
- not found to add benefit over treatment with an analgesic
Are NSAIDs helpful in PMS treatment?
- May be helpful due to theory that PMS is due to an abundance of prostaglandins
- Provides pain relief for symptoms of headache, breast pain, and muscle aches
- Ibuprofen or naproxen may be started when the pain begins and used short term at lowest effective dose
Rx treatment for PMS?
- PG inhibitors - NSAIDs (naproxen, megenamic acid)
- SSRIs (citalopram, fluoxetine, sertraline)
- Diuretics (spironolactone)
- Androgens (danazol)
- Oral contraceptives (OCP)
- Gonadatropin Releasing hormone(GnRH) ex. leuprolide
What is the bottom line for PMS treatment?
- Follow Figure 1 for Treatment of PMS in CTMA
- Begin with non-pharms
- Then consider options such as Calcium
- Add on a pain reliever, such as NSAIDs, which may help with symptom relief o headache, muscle and breast pain if required.
Monitoring parameters for PMS?
Improvement:
- Symptoms should be improved or alleviated within 1-3 cycles
- SEs: depends on the self-Tx approach. Most self-tx products are unlikely to have clinically significant SEs
When do you refer PMS?
If symptoms do not alleviate within 1-3 months or worsen at any point.
Also refer for symptoms that are disruptive to personal relationship, or inability to engage in usual activities or function productively at work - see physician.
Or any of the symptoms associated with negative outcomes of PMDD
