29 Menstrual Disorders/Suppression Besinque Flashcards
What are some characteristics of a normal menstrual cycle?
Menstruation lasts on average of 4-7 days. Average blood loss is 35 mL. 90% of menstrual blood loss is completed by the end of the third day. Chronic menstrual blood loss > 80 mL per cycle leads to anemia
What phase do the majority of menstrual disorders take place?
Luteal
What are some common menstrual disorders?
Disorders associated with menstruation (primary dysmenorrhea, menonrrahgia). Disorders associated with cyclic patters (pre-menstrual syndrome (PMS, PMDD). Menstrual migraine. Catamenial disorders (epilepsy, asthma)). Other disorders (endometriosis, PCOS)
What is Menorrhagia?
Bleeding occurs at normal intervals but is prolonged or excessive (can be > 7 days)
What is Metrorrhagia?
Irregular, noncyclic bleeding that is prolonged or excessive
What is Polymenorrhea?
Bleeding interval is less than 21 days (short cycle)
What is Oligomenorrhea?
Bleeding interval greater than 35 days (long cycle)
Whay is Hypermenorrhea/Hypomenorrhea?
Amount of menses is abnormally high (hyper) or low (hypo)
What may be the most common gynecological problem in menstruating women?
Primary Dysmenorrhea
Who is affected by Primary Dysmenorrhea?
Onset in early adolescence. Usually begins within 3 years of menarche (start of menstruation)
What is the Etiology of Primary Dysmenorrhea?
Symptoms may be related to increased PGF-2 alpha released by sloughing of the endometrial cells. PGF-2 alpha stimulates myometrial contractions, ischemia and sensitizes nerve endings
During menstruation, what happens that can lead to Dysmenorrhea?
Increased prostaglandin synthesis. Increased markers of inflammation
What are the actual causes of dysmenorrhea?
Decreased uterine blood flow. Increased uterine contractility. Peripheral nerve hypersensitivity. All of these happen because of the increase in prostaglandins
What does progesterone withdrawal lead to?
Arachidonic acid is made, which can be converted by COX, which eventually turns into PGF2-alpha, which causes myometrial contraction and vasoconstriction, and eventually pain
What is the DOC for dysmenorrhea?
NSAIDs (only used during actual menstrual phase)
What are the other treatment options for dysmenorrhea?
Hormonal contraceptives (second line; suppres ovulation and lower prostaglandin levels, which lead to decreased menstrual blood loss). Danazol. GnRH agonists. Complementary and alternative approaches
How should NSAIDs be used for dysmenorrhea?
Begin the day before menses or as soon as flow begins. Scheduled doses for 3-5 days (not PRN). OTC doses are insufficient, take higher doses
What is secondary dysmenorrhea?
Dysmenorrhea that is due to genital tract pathology
What duration of bleeding is considered heavy menstrual bleeding?
> 7 days
What amount of blood loss is considered heavy menstrual bleeding?
> 80 mL
What are some risk factors for heavy menstrual bleeding?
Age. Uterine fibroids. Endometrial polyps. Bleeding disorders
What is the prevalence and consequence of heavy menstrual bleeding?
Affects many women. Common indicator for hysterectomy. Important cause of anemia. Affects quality of life
What are some therapy options for heavy bleeding?
NSAIDs (if bleeding doesn’t improve, consider possible coagulation disorder, or liver or kidney disease). Combination oral contraceptives. Progestins (Levonorgestrel IUD highly effective (~90% less bleeding)). Tranexamic acid (Lysteda) is highly effective (~50% reduction) but expensive
What tests should be done in all women with heavy menstrual bleeding?
History and general exam, pelvic exam, thyroid function test (hypothyroidism can increase bleeding)
What hormonal therapy can be used for heavy menstrual bleeding?
Combined oral contraceptives. Oral progestins. LNG-IUS. DMPA. Combination non-oral contraceptives
What non-hormonal therapy can be used for heavy menstrual bleeding?
NSAIDs. Tranexamic acid (Lysteda). These can be used in combo with hormonal therapy
What surgical therapy can be used for heavy menstrual bleeding?
Endometerial ablation. Hysterectomy
What is Tranexamic Acid (Lysteda)?
An antifibrinolytic drug for heavy menstrual bleeding. Synthetic amino acid derivative that prevents binding of fibrin and plasmin in a reversible manner, which helps prevent the breakdown of blood clots
How is Tranexamic Acid (Lysteda) dosed?
1,300mg (2 tablets) three times a day for a maximum of five days during menstruation. Requires adjustment for renal function
What are the ADRs associated with Tranexamic Acid (Lysteda)?
Nausea, vomiting, diarrhea, back pain, and musculoskeletal pain. Can cause thrombosis
When should Tranexamic Acid (Lysteda) not be used?
Women taking COC. History of blood clots
How does the Levonorgestrel Intrauterine system for DUB work?
Releases 20 ug of levonorgestrel every 24 hours. Decreases amount of menstrual blood loss. Used to treat heavy bleeding. Consider a bleeding disorder to be present if the patient is unresponsive to treatment
What are disorders with cyclic pattern?
PMD. PMDD. Menstrual migraine. Catamenial disorders (asthma, epilepsy)
When are the signs and symptoms of PMS/PMDD usually relieved?
Onset of menstruation
What is a treatment option for mild PMS?
Dietary changes. Increase complex carbs, water, nutritional supplements. Decrease salt, refined sugar, caffeine, alcohol, smoking. Eat frequent and smaller portions of foods high in complex carbohydrates
What nutritional supplements have been studied and shown to work?
Calcium carbonate with vitamin D. Magnesium, up to 500 mg per day. Vitamin B-6 and vitamin E have not been studied as much, but may work
What pharmacologic therapy has been shown to help with PMS/PMDD?
SSRIs. Can actually be effective if just taken during luteal cycle (7-14 days)
How can Diuretics help with PMS treatment?
Diuretics for fluid retention and bloating are effective. Spironolactone is preferred, in addition to being a diuretic it also interferes with testosterone synthesis. May treat other symptoms of PMS as a result. Dose 50-100mg/day during luteal phase
What are three treatment strategies to eliminate or decrease hormone-free intervals with OCs in the treatment of PMS/PMDD?
Omit 7-day inert pills from monophasics. Extended or continuous regimen pills. Reduced hormone-free interval pill
How can evening primrose oil help?
Helps with breast tenderness/pain
What should be done when PMS/PMDD symptoms are occurring outside of the luteal phase?
Refer
What is Endometriosis?
Growth of endometrial cells outside uterus. Most commonly found: on ovaries, on exterior of uterus, on bowel, on bladder, within abdominal cavity
What is the prevalence of endometriosis?
15-25% of all female surgical patients have endometriosis. 30-40% of women with endometriosis experience fertility problems. 20% of infertile women are diagnosed with endometriosis
What is the etiology of Endometriosis?
Blood and endometrial cells back up through uterus and tubes and implant or attach to other sites. May have genetic contributions
What are the key components in the development of endometriosis?
Local overproduction of prostaglandins by an increase in COX-2 activity and overproduction of local estrogen by increased aromatase activity. Progesterone resistance dampens the anti-estrogenic effect of progesterone and amplifies the local estrogenic effect
What is the presentation of endometriosis?
May be asymptomatic. Endometrial implants respond to hormone level fluctuation similar to normal endometrial lining and may bleed during menstruation. Endometriomas (chocolate cysts) may form. Usually reaches maximum severity in 30-40s. Pain throughout cycle, with menses or intercourse (severity of pain does not correlate with severity of disease - might correlate with depth of lesions). Lower abdominal cramps. Heavy and/or irregular periods. Rectal pain with defecation. Urinary discomfort. Infertility
What is the etiology of PCOD?
Genetic defect. Associated with insulin resistance
What is the presentation of PCOP?
History of irregular menstrual cycles. Hirsutism on the face, breasts, abdomen. Infertility. Obesity. Enlarged or multicystic ovaries. Elevated androgen levels
What are the treatment options in PCOS?
Lifestyle modification (weight loss). Androgen suppression (anti-androgens (spironolactone, flutamide, finasteride), oral contraceptives). Insulin lowering agents (metformin, pioglitazone, rosiglitazone)
What are some extended hormonal contraception methods?
Pills/patches/rings. Implants. Mirena. Injection (DepoProvera)
What is unique about Seasonique?
Has 7 days of lower level estrogens that help w/ estrogen withdrawal symptoms during placebo period
What is unique about Lybrel?
365 days with no cycle
What is Depot Medroxyprogesterone Acetate (Depo-Provera, Depo-SubQ Provera 104)?
Highly effective contraception. Noncontraceptive benefits include: reduced menorrhagia, reduced dysmenorrhea
How is Depot Medroxyprogesterone Acetate (Depo-Provera, Depo-SubQ Provera 104) dosed?
150mg administered IM every 3 months OR 104mg administered subQ every 3 months. IM and SQ route are not interchangable
What are some negatives about Depot Medroxyprogesterone Acetate (Depo-Provera, Depo-SubQ Provera 104)?
Amenorrhea common with long-term use. Return to fertility takes some time to become fertile again after use (6-9 months)
What hormone withdrawal induces bleeding?
Progesterone
