47: Abnormal Uterine Bleeding Flashcards by Brooke Thornburg

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Normal bleeding

-22-35 day cycle
-35mL blood/day
-menstruation 3-7 days

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Types of abnormal bleeding

-dysmenorrhea
-amenorrhea
-oligomenorrhea
-polymenorrhea
-heavy menstrual bleeding (HMB)
-metrorrhagia

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Dysmenorrhea

-painful menstruation
-17-90%

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primary dysmenorrhea

-normal ovulatory cycles and pelvic anatomy

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secondary dysmenorrhea

-underlying anatomic or physiologic cause

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Pathophysiology of dysmenorrhea

-buildup of fatty acids in cell membranes, then released
-prostaglandins and leukotrienes released in uterus
-inflammatory response causes symptoms

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Risk factors of dysmenorrhea

-<20 y/o
-weight loss attempts
-depression/anxiety
-heavy menses
-menarche before 12 y/o
-nulliparity
-smoking
-family history

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Symptoms of dysmenorrhea

-crampy pelvic pain
-nausea/vomiting
-diarrhea
-headache
-muscle cramps
-dizziness

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Goals of therapy for dysmenorrhea

-provide symptomatic relief
-reduce lost productivity
-improve QOL

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First line treatment for dysmenorrhea

-NSAID
-oral contraceptives
-non-pharmacologic

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second-line treatment for dysmenorrhea

-DMPA
-LNG IUD

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Nonpharmacologic treatment of dysmenorrhea

-heating pad
-exercise
-omega 3, vit B, ginger
-smoking cessation
-acupuncture

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NSAID therapy mech

-inhibits COX 1 and 2
-dec prostaglandin production

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NSAID dosing

-taken around the clock 1-2 days before cycle start
-short-term use

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Pros of NSAID therapy

-good for those wanting to conceive
-short-term
-pain relief within hours
-cheap, otc

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cons of NSAID therapy

-intolerable side effects
-not great for CV risk

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NSAID side effects and precautions

-GI bleeding/ulcers
-renal injury
-onset of CV, inc HTN

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NSAID counseling

-take w food or milk to minimize GI upset
-monitor for abnormal bleeding
-scheduled dosing vs PRN

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Oral contraceptive therapy mech

-inhibit endometrial tissue proliferation
-dec endometrial production of prostaglandins and leukotrienes

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oral contraceptive therapy dosing

-CHCs
-efficacy noted w cyclic vs continuous regimens (one isn’t better than the other)

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Pros of hormone therapy

-appropriate for those seeking contraception
-can be used w NSAIDs

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cons of hormone therapy

-not appropriate for pt wanting pregnancy
-Rx needed
-delayed relief (1-2 months)

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side effects and precautions of hormone therapy

-inc BP
-weight gain
-fluid retention
-risk of clots and stroke

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pt counseling and education

-monitor for nausea, HA, boob hurt, mood swings

LNG IUD or DMPA therapy

-related to amenorrhea side effect -beneficial in those who want contraception -delayed relief -try IUD before DMPA

Dysmenorrhea monitoring and follow up

-asses symptom improvement -if symptoms have not lessened or resolved in 3-6 months, REFER

Amenorrhea

-absence of menstrual cycle

primary amenorrhea

-no menses by 15 -less than 0.1%

secondary amenorrhea

-no menses x 3 months in previously menstruating women -3-4%

Amenorrhea symptoms

-often asymptomatic -can be accompanied by weight loss/gain -often a symptom itself rather than condition

Some causes of amenorrhea

-PCOS, low BMI, ED, excessive exercise -medications

Tests to preform if amenorrhea

-preg test -FSH/LH levels -TSH -prolactin -estrogen

Amenorrhea pathophysiology

-abnormalities in uterus or ovaries -disruption to pituitary hormones -stress and ED effect hypothalmus

Drug induced amenorrhea

-some antipsychotics (Prochlorperazine, chlorpromazine, haloperidol, risperidone) -some antidepressants -MAOIs -anti-HTN (verapamil) -GI promotility agents (metoclopramide)

Goals of therapy for amenorrhea

-ovulation restoration -bone density preservation -bone loss prevention

First-line treatment of amenorrhea

-rule out pregnancy -determine underlying cause

Treatment for ED related ammenorrhea

-gain weight -cut back on exercising -go to therapy

treatment for medication induced amenorrhea

-may consider alternative agents that do NOT inhibit dopamine receptor or inc prolactin levels -OR initiate dopamine agonist

Treatment of hypoestrogenic amenorrhea

-provide supplemental estrogen -must include progestin component

dopamine agonists

-bromocriptine (muliple x day) -cabergoline (weekly or twice weekly)

contraindications of dopamine agonists

-breastfeeding -uncontrolled HTN

side effects of dopamine agonists

-N/D -HA -orthostatic hypotension -fatigue

Monitoring and follow up of dopamine agonists

-side effects -take BP, HR, liver/kidney function, preg status, prolactin level -should take 6-8weeks to resolve -if not, try the other agent

Oligomenorrhea

-cycle >35 days but less than 90 -overlaps with amenorrhea

oligomenorrhea causes and treatment approaches

-similar to amenorrhea

Polymenorrhea

-menstrual cycle less than 21 days -may cause challenges in conceiving

Common causes of polymenorrhea

-stess -STDs -endometriosis -menopause

Heavy menstrual bleeding

-more than 80mL of blood OR lasting more than 7 days -18-30% of gyno visits

heavy menstrual bleeding pathophysiology

-bleeding/clot disorders -cirrhosis -HYPOthyroidism -uterine abnormalities -uterine fibroids (most ofteN)

Symptoms of heavy menstrual bleeding

-heavy flow -with or without pain -possibly fatigue and lightheadedness

Goals of therapy for heavy menstrual bleeding

-reduce flow -correct iron-deficiency anemia or underlying disorders -improve QOL

heavy menstrual bleeding treatment options

-acute vs chronic -hormonal vs nonhormonal

Hormonal treatment of heavy menstrual bleeding

-CHC -progestin -LNG IUD -Danazol -GnRH agonists

nonhormonal treatment of heavy menstrual bleeding

-NSAIDs -tranexamic acid -iron to treat anemia

Tranexamic acid mech of action

-antifibrinolytic -prevents degradation of blood clots

Tranexamic acid dosing

-1,300mg PO TID for 5 days at onset of menses -use only during menses

tranexamic acid contraindications

-DVT or pulmonary embolism -h/o seizure

side effects of tranexamic acid

-not too bad -maybe HA or nasal symptoms

Drug class ranking by reduction in blood loss

-LNG IUD -oral progestin -CHCs -tranexamic acid -NSAIDs

Metrorrhagia

-irregular bleeding between cycles

Metrorrhagia causes

-hormone inbalance -fibroids, polyps, endometriosis -meds -IUDs -infections

treatment of metrorrhagia

-target underlying cause -hormonal contraceptive