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Clinical 1 (Part B) > 11 - Dysmenorrhea & PMS > Flashcards

11 - Dysmenorrhea & PMS Flashcards

1
Q

Dysmenorrhea

A

Defined as pain during menstruation

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2
Q

When does dysmenorrhea occur?

A

Only during the ovulatory cycles - follicular phase of the menstrual cycle

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3
Q

When does dysmenorrhea usually begin?

A

With the onset of menses (within the first 6-12 months of menarche)

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4
Q

How long do the symptoms occur?

A

With the onset of menses (several hours prior) and lasts 2-3 days

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5
Q

Symptoms of dysmenorrhea?

A

Cramping in lower abdomen, pelvic pain may radiate to back and legs (thighs)

  • Other symptoms associated:
  • headache
  • nausea
  • vomiting
  • fatigue
  • IBS
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6
Q

Dysmenorrhea can be primary or secondary:

Define primary

A

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.
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7
Q

Dysmenorrhea can be primary or secondary:

Define secondary

A

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

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8
Q

What does estrogen cause in the menstrual cycle?

A

causes the lining to build up

*building the house LOL

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9
Q

What does progesterone cause in the menstrual cycle?

A

causes glycogen, mucus and prostaglandins to build up in the endometrial tissue

*decorating the house LOL

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10
Q

Knowing that PGs are the issue, how should we treat dysmenorrhea?

A

NSAIDs

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11
Q

Primary dysmenorrhea:

Age of onset

A

Typically 6-12 months after menarche

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12
Q

Secondary dysmenorrhea:

Age of onset

A

Mid to late 20’s through 30’s and 40’s

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13
Q

Primary dysmenorrhea:

Menses

A

More likely to be regular with normal blood loss

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14
Q

Secondary dysmenorrhea:

Menses

A

More likely to be irregular, menorrhagia (menstruation with prolonged or abnormally heavy bleeding) more common

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15
Q

Primary dysmenorrhea:

Pattern & Duration

A

Onset just before or coincidental with menses, pain with each or most menses, lasting 2-3 days

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16
Q

Secondary dysmenorrhea:

Pattern & Duration

A

Vary with cause, change in pain pattern or intensity may indicate secondary disease

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17
Q

Primary dysmenorrhea:

Pain at other times of menstrual cycle?

A

No way jose

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18
Q

Secondary dysmenorrhea:

Pain at other times of menstrual cycle?

A

Yes - May occur before, during or after menses

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19
Q

Primary dysmenorrhea:

Response to NSAIDs and/or OC (oral contraception)?

A

Yes

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20
Q

Secondary dysmenorrhea:

Response to NSAIDs and/or OC (oral contraception)?

A

No

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21
Q

Primary dysmenorrhea:

Other symptoms?

A

N, V, fatigue, dizziness, irritability, diarrhea, and headache may occur at the same time as dysmenorrhea

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22
Q

Secondary dysmenorrhea:

Other symptoms?

A

Vary with cause, may include dyspareunia and pelvic tenderness

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23
Q

Dysmenorrhea will only occur during ______ cycles

A

ovulatory

*that’s why birth control can help because it prevents ovulation

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24
Q

Risk factors for dysmenorrhea?

A
  • < 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
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25
Q

What is endometriosis?

A

the lining that normally is formed on the inside of the uterus occurs on the outside of the uterus

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26
Q

Red Flags for Dysmenorrhea

A
  • 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
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27
Q

List some non-pharms for dysmenorrhea

A
  • Heat therapy (warm baths, heating pads, etc.)
  • Lifestyle modifications: Stop smoking or exposure to smoke, regular exercise, decrease fat intake
  • Relaxation
28
Q

Is acetaminophen effective for dysmenorrhea?

A

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

29
Q

Describe the non-prescription treatment for dysmenorrhea

A

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
30
Q

Would you ever recommend ASA/Acetaminophen?

A

They do not affect PG’s so they are not affective

-Can recommend if NSAIDs are not appropriate therapy to provide patient comfort.

31
Q

Describe the prescription treatment for dysmenorrhea

A
  • 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)
32
Q

Treatment for secondary dysmenorrhea?

A

Referral and treat the underlying causes such as:

  • endometriosis
  • IUD use
  • cervical stenosis
  • PID
  • infection
33
Q

Monitoring parameters for dysmenorrhea

A

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

34
Q

Max duration of Tx for dysmenorrhea?

A

3 days - treat cyclically

35
Q

When do you refer dysmenorrhea?

A

If symptoms are severe, if endometriosis or other secondary causes are suspected

36
Q

What is PMS (Premesntrual syndrome) ??

A
  • 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”
37
Q

PMS:

Onset ?

A

anytime after puberty, typically in mid-twenties

38
Q

PMS:

When do symptoms start, improve, and disappear ?

A

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)

39
Q

PMS: See table 1 for PMS symptoms

A

bitchin

40
Q

Describe the ethology of PMS

A

-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

41
Q

Risk factors for PMS

A
  • Lower intake of vitamin D
  • Genetic predisposition
  • High body mass index
  • Stress
  • Traumatic life events
42
Q

What is Premenstrual Dysphoric Disorder (PMDD) ?

A
  • 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
43
Q

Negative outcomes associated with PMDD?

A
  • 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
44
Q

Key information gathering assessment (in addition to SCHOLAR and MAPPL)

A

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

45
Q

Red flags for PMS?

A
  • 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
46
Q

Treatment philosophy for PMS?

A

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
47
Q

Treatment goals for PMS?

A
  • To have a good understanding of PMS
  • Relieve symptoms
  • Reduce impact on activities and interpersonal relationships
48
Q

Non-pharm treatment for PMS?

A
  • Education
  • Supportive
  • Behavioral
  • Dietary
49
Q

Pharmacological treatment for PMS?

A
  • 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
50
Q

Describe non-pharm treatment for PMS:

Cognitive

A

Behavioral therapy emphasizes relaxation techniques & stress reduction:

  • Assist individual to cope or deal with the changes
  • Smoking cessation (if applicable)
  • Sleep hygiene
51
Q 
Describe non-pharm treatment for PMS:
Nutritional therapy (unproven)
A
  • Balanced diet
  • Decreased salt intake
  • Decreased caffeine
  • Small, frequent intake of carbs
  • Dietary changes are recommended 7-14 days before the menses begins (minimum)
52
Q

Describe non-pharm treatment for PMS:

Exercise

A

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
53
Q

Describe the pharmacological treatment for PMS:

Evening Primrose Oil (EPO)

A
  • EPO contains 72% linoleic acid (PGE1 precursor)
  • Trials have found no effect of this product
  • Do not recommend this
54
Q

Describe the pharmacological treatment for PMS:

Chasteberry

A
  • Not proven
  • Don’t recommend
  • Lots of bad side effects
55
Q

Describe the pharmacological treatment for PMS:

Pyridoxine (Vitamin B6)

A
  • 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
56
Q

Describe the pharmacological treatment for PMS:

Magnesium

A
  • 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

57
Q

Describe the pharmacological treatment for PMS:

Calcium

A
  • 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

58
Q

Should we recommend combined OTC products (such as Midol, Pamprin, Tylenol XS Menstrual) ?

A

No - they all contain acetaminophen which has no effect for dysmenorrhea or PMS

**Remember - NSAIDs are better !!

59
Q

Pamabrom is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.

A
  • 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

60
Q

Pyrilamine is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.

A

*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
61
Q

Are NSAIDs helpful in PMS treatment?

A
  • 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
62
Q

Rx treatment for PMS?

A
  • PG inhibitors - NSAIDs (naproxen, megenamic acid)
  • SSRIs (citalopram, fluoxetine, sertraline)
  • Diuretics (spironolactone)
  • Androgens (danazol)
  • Oral contraceptives (OCP)
  • Gonadatropin Releasing hormone(GnRH) ex. leuprolide
63
Q

What is the bottom line for PMS treatment?

A
  • 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.
64
Q

Monitoring parameters for PMS?

A

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
65
Q

When do you refer PMS?

A

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

Clinical 1 (Part B) (11 decks)

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