50: Endometriosis and PMS Flashcards by Brooke Thornburg

Endometriosis

-Pelvic inflammatory condition associated w growth of endo tissue found outside uterus

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Endometriosis presentation

-asymptomatic
-dysmenorrhea
-infertility
-dyspareunia
-pelvic pain
-heavy bleeding
-fatigue
-painful bowels
-ab bloating
-flank pain

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Risk factors for endometriosis

-under 20yo
-weight loss attempts
-depression/anxiety
-heavy menses
-menarche before 12
-nulliparity
-smoking
-fam history

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Endometriosis pathophysiology

-most likely retrograde menstrual flow
?

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Goals of therapy for endometriosis

-minimize endometrial lesions
-prevent progression
-minimize pain
-treat infertility

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Nonpharmacologic treatments for endometriosis

-exercise
-acupuncture
-massage
-CBT
-surgery

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First line treatment of endometriosis

-NSAIDs
-CHCs
-Progestins

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Second line treatment of endometriosis

-GnRH agonists/antagonists
-Danazol

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third line treatment of endometriosis

-aromatase inhibitors

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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

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Danazol dosing

-PO BID

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Danazol side effects

-weight gain
-acne
-hirstuism
-lipid abnormalities
-liver probs
-change in blood sugar

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Danazol black box warning

-thromboembolism

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Danazol contraindication

-preg
-breastfeeding

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Endometriosis monitoring and follow up

-assess symptom improvement

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Uterine Fibroids (leiomyomas)

-common non cancerous growths in uterus
-developing in up to 70-80% by age 50

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Fibroid anatomy

-smooth muscle cells and fibroblasts of myometrium
-classified based on location
-vary in size and number

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Fibroid classification

-intramural
-submucosal
-subserosal

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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)

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Risk factors for fibroids

-black race
-age
-family history
-time since last birth
-premenopausal
-HTN
-early menarche before 10 yo

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protective factors against fibroids

-smoking
-more than 3 pregnancies
-hormonal contraception use

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Symptoms of uterine fibroids

-asymp
-heavy bleeding (anemia and fatigue)
-dysmenorrhea
-noncyclic pain
-ab protrudance
-painful sex
-bladder/bowel dysfunction
-repro probs

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Fibroid treatment considerations

-severity of symptoms
-patient age
-reproductive plans

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Goals of therapy for fibroids

-reduce size or remove
-reduce symptoms
-respect fertility wishes
-improve QOL

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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