47: Abnormal Uterine Bleeding Flashcards
Drug chart study guide
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Normal bleeding
-22-35 day cycle
-35mL blood/day
-menstruation 3-7 days
Types of abnormal bleeding
-dysmenorrhea
-amenorrhea
-oligomenorrhea
-polymenorrhea
-heavy menstrual bleeding (HMB)
-metrorrhagia
Dysmenorrhea
-painful menstruation
-17-90%
primary dysmenorrhea
-normal ovulatory cycles and pelvic anatomy
secondary dysmenorrhea
-underlying anatomic or physiologic cause
Pathophysiology of dysmenorrhea
-buildup of fatty acids in cell membranes, then released
-prostaglandins and leukotrienes released in uterus
-inflammatory response causes symptoms
Risk factors of dysmenorrhea
-<20 y/o
-weight loss attempts
-depression/anxiety
-heavy menses
-menarche before 12 y/o
-nulliparity
-smoking
-family history
Symptoms of dysmenorrhea
-crampy pelvic pain
-nausea/vomiting
-diarrhea
-headache
-muscle cramps
-dizziness
Goals of therapy for dysmenorrhea
-provide symptomatic relief
-reduce lost productivity
-improve QOL
First line treatment for dysmenorrhea
-NSAID
-oral contraceptives
-non-pharmacologic
second-line treatment for dysmenorrhea
-DMPA
-LNG IUD
Nonpharmacologic treatment of dysmenorrhea
-heating pad
-exercise
-omega 3, vit B, ginger
-smoking cessation
-acupuncture
NSAID therapy mech
-inhibits COX 1 and 2
-dec prostaglandin production
NSAID dosing
-taken around the clock 1-2 days before cycle start
-short-term use
Pros of NSAID therapy
-good for those wanting to conceive
-short-term
-pain relief within hours
-cheap, otc
cons of NSAID therapy
-intolerable side effects
-not great for CV risk
NSAID side effects and precautions
-GI bleeding/ulcers
-renal injury
-onset of CV, inc HTN
NSAID counseling
-take w food or milk to minimize GI upset
-monitor for abnormal bleeding
-scheduled dosing vs PRN
Oral contraceptive therapy mech
-inhibit endometrial tissue proliferation
-dec endometrial production of prostaglandins and leukotrienes
oral contraceptive therapy dosing
-CHCs
-efficacy noted w cyclic vs continuous regimens (one isn’t better than the other)
Pros of hormone therapy
-appropriate for those seeking contraception
-can be used w NSAIDs
cons of hormone therapy
-not appropriate for pt wanting pregnancy
-Rx needed
-delayed relief (1-2 months)
side effects and precautions of hormone therapy
-inc BP
-weight gain
-fluid retention
-risk of clots and stroke
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
