50: Endometriosis and PMS Flashcards
Endometriosis
-Pelvic inflammatory condition associated w growth of endo tissue found outside uterus
Endometriosis presentation
-asymptomatic
-dysmenorrhea
-infertility
-dyspareunia
-pelvic pain
-heavy bleeding
-fatigue
-painful bowels
-ab bloating
-flank pain
Risk factors for endometriosis
-under 20yo
-weight loss attempts
-depression/anxiety
-heavy menses
-menarche before 12
-nulliparity
-smoking
-fam history
Endometriosis pathophysiology
-most likely retrograde menstrual flow
?
Goals of therapy for endometriosis
-minimize endometrial lesions
-prevent progression
-minimize pain
-treat infertility
Nonpharmacologic treatments for endometriosis
-exercise
-acupuncture
-massage
-CBT
-surgery
First line treatment of endometriosis
-NSAIDs
-CHCs
-Progestins
Second line treatment of endometriosis
-GnRH agonists/antagonists
-Danazol
third line treatment of endometriosis
-aromatase inhibitors
Danazol
-androgen that supresses FSH and LH
-previously widely used now reserved for later treatment consideration
-bad side effects
-do NOT take if preg/breastfeeding
Danazol dosing
-PO BID
Danazol side effects
-weight gain
-acne
-hirstuism
-lipid abnormalities
-liver probs
-change in blood sugar
Danazol black box warning
-thromboembolism
Danazol contraindication
-preg
-breastfeeding
Endometriosis monitoring and follow up
-assess symptom improvement
Uterine Fibroids (leiomyomas)
-common non cancerous growths in uterus
-developing in up to 70-80% by age 50
Fibroid anatomy
-smooth muscle cells and fibroblasts of myometrium
-classified based on location
-vary in size and number
Fibroid classification
-intramural
-submucosal
-subserosal
Fibroid pathophysiology
-not well understood
-inc estrogen and progesterone = inc mitotic rate and prob mutations
-genetic factors
-response to injury (inc prostaglandins and vasopressin with onset of menses)
Risk factors for fibroids
-black race
-age
-family history
-time since last birth
-premenopausal
-HTN
-early menarche before 10 yo
protective factors against fibroids
-smoking
-more than 3 pregnancies
-hormonal contraception use
Symptoms of uterine fibroids
-asymp
-heavy bleeding (anemia and fatigue)
-dysmenorrhea
-noncyclic pain
-ab protrudance
-painful sex
-bladder/bowel dysfunction
-repro probs
Fibroid treatment considerations
-severity of symptoms
-patient age
-reproductive plans
Goals of therapy for fibroids
-reduce size or remove
-reduce symptoms
-respect fertility wishes
-improve QOL
Non-pharmacologic treatment of fibroids
-expectant therapy
-myomectomy (remove fibroids but keep fertility)
-hysterectomy
Treatment overview for fibroids
-NSAIDs
-hormonal contraceptives
-tranexamic acid
-GnRH agonists
-SPRM
GnRH agonist use for fibroids
-only for 3-6 months near menopause
-decrease size
-sec blood loss, surgery and recovery time
GnRH agonist disadvantages
-long-term use more $$, menopausal symptoms and bone loss
-inc recurrence risk w myomectomy
GnRH agonist fertility impact
-dependent on subsequent procedure
SPRM use in fibroids
-short-term pre-op or near menopause
-decrease size
-dec blood loss and recovery time
-NOT associated with HYPO estrogenic effects
SPRM disadvantages
-HA and breast hurt
-PRM-associated endometrial changes
-inc fibroid recurrence risk with myomectomy
SPRM fertility impact
-dependent on subsequent procedure
SPRM regimens
-mifepristone 10-50mg
-ulipristal 5-10mg
-not FDA approved for fibroids
Complications of fibroids in pregnancy
-miscarriage
-premature labor and delivery
-abnormal fetal postition
-placental abruption
Treatment of fibroids in pregnancy
-avoid myomectomy unless it cannot be safely delayed
-pain management w acetaminophen, NSAID, or opioid
Premenstrual syndrome (PMS)
-at least one symptom x 3 cycles
Premenstrual Dysphoric Disorder (PMDD)
-DSM-5
-at least 5 symptoms with at least on in 2 dif critera x 2 consecutive months
PMS and PMDD similarities
-onset 5-7 days before period
-end at onset of menses
-require symptom-free period for diagnosis
-some level of impairment to QOL
-no definitive test
-more than 200 symptoms
PMDD diagnostic symptoms (need at least one)
-affective lability
-irritability
-depression
-anxiety
PMDD diagnostic symptoms (need at least one)
-dec interest in activities
-hard to concentrate
-lethargy
-change in appetite
-hyper or insomnia
-overwhelming feelings
-physical symptoms
Pathophysiology of PMS and PMDD
-reduce levels of serotonin, GABA, and allopregnanolone
-fluctuations in estrogen and progesterone
Goals of therapy for PMS/PMDD
-improve/resolve symptoms
-improve productivity and relationships
-improve QOL
Nonpharmacologic treatment of PMS and PMDD
-limit sodium, caffeine, alcohol
-aerobic exercise
-relaxation techniques
-sleep schedule
-calcium (1200mg/day)
-magnesium (200-400mg/day)
-vitamin B, D, E
First line treatment of PMS/PMDD
-SSRIs
-NSAIDs
-spironolactone
Second line treatment of PMS/PMDD
-venlafaxine
-Duloxetine
-Clomipramine
-Alprazolam
-COCs
last line treatment of PMS/PMDD
-GnRH agonists
-surgery
Complementary therapy treatment of PMS/PMDD
-Ginkgo
-St. John’s Wort
SSRIs FDA approved for PMDD
-Fluoxetine 20mg daily
-Sertraline 50-150mg daily
-Paroxetine CR 12.5-25mg daily
SSRI intermittent dosing
-start day 14
-stop 1-2 days after onset of menses
SSRIs not FDA approved but can treat PMDD
-citalopram 20-30mg daily
-escitalopram 10-20mg daily
Continuous/daily dosing of SSRIs for PMDD
-mood symptoms outside of luteal phase
-irreg cycle
-intolerable side effects upon discontinuation
-difficulties with on/off schedule
SSRI black box warning
-inc risk of suicidal thinking and behavior in children, adolescents, and young adults with depression
SSRI side effects
-nausea
-drowsiness
-sex sydfunction
-sweating
-insomnia
-diarrhea
-HA
-weight gain
improvement of symptoms after SSRI treatment
-within 2-3 cycles
Spironolactone
-non FDA approved indication for PMDD
-antimineralocorticoid and antiandrogenic effects interfere w testosterone synthesis
Spironolactone dose
-100mg daily days 15-28
Spironolactone advantages
-dec weight gain
-somatic symptoms (breast and bloating)
-negative mood
Spironolactone side effects
-hyperkalemia
-somnolence
-irreg menses
-diarrhea
-nausea
-headache
SNRIs for PMS/PMDD
-Venlafaxine 75-112 mg during luteal phase or 50-200 mg daily
-Duloxetine 60mg daily
-try before other second line options
SNRI side effects
-headache
-inc BP
COCs for PMS
-EE 20mcg/drospirenone 3mg qd for 24days
-use if they want contraception
-use before clomipramine and alprazolam
Clomipramine
-2nd line
-25-75mg daily
-consider before alprazolam
Clomipramine side effects
-blurred vision
-dry mouth
-constipation
-fatigue
-Headache
Alprazolam
-2nd line for PMS
-0.23-1mg TID-QID during luteal phase
-try other 2nd lines first
Alprazolam side effects
-sedation
-drowsiness
-risk of dependence
SSRI relieve which symptoms
-mood
-physical
-social functioning
-work performance and QOL
Spironolactone relieves which symptoms
–breast tenderness
-bloating
-mood
COCs relieve which symptoms
-physical but it can also cause these
-social functioning and productivity
Alprazolam relieves which symptoms
-depression
-tension
-anxiety
-irritability
-hostility
-social withdrawal
Monitoring and follow up of PMS treatment
-evaluate symptoms
