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PHARM 130 - Exam > Disorders of Menstruation > Flashcards

Disorders of Menstruation Flashcards

1
Q

What is the first day of the menstrual cycle?`

A

The first day of menses, all hormone levels are relatively low

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2
Q

How many days of the cycle is actual bleeding occuring?

A

between 3-7, anything >7 is irregular

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3
Q

What hormone does the hypothalamus release?

A

GnRH

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4
Q

What hormones does the anterior pituitary release?

A

LH and FSH

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5
Q

What happens ~day 13?

A

Estradiol levels have reached a peak which stops the anterior pituitary from releasing FSH and start releasing LH which causes ovulation

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6
Q

What does the corpus luteum do?

A

Secretes progesterone to stabilize the growth of the uterine lining and gets it ready for implantation

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7
Q

What happens around day 21 if pregnancy has not occurred?

A

Corpus luteum starts dying and secreting lower amounts of progesterone

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8
Q

When progesterone levels start dropping what happens?

A

menses

**results from the corpus luteum dying which only takes 14 days; this is why the luteal phase is the same for everyone

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9
Q

When is basal body temperature the highest?

A

ovulation

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10
Q

When does breast tenderness usually happen?

A

the end of the luteal phase

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11
Q

What is the phase that ranges the most in women?

A

follicular phase ranges from days to weeks thus determining the length of the cycle

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12
Q

What is dysmenorrhea?

A

Painful menstruation

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13
Q

What is the difference between acute and chronic pain?

A

Acute lasts <3 months

Chronic lasts >3 months

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14
Q

What are some causes of cyclic pelvic pain? (3)

A
  • dysmenorrhea
  • endometriosis
  • mittelschmerz
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15
Q

What is the difference between primary and secondary dysmenorrhea?

A

Primary: starts 6-12 months after menarche, only happens during ovulatory cycles and is not associated with pelvic pathologies

Secondary: starts 2 or more years after menarche, happens at times other than menarche and typically associated with pelvic pathology

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16
Q

Explain the pathophysiology of dysmenorrhea

A

After ovulation, progesterone is being released from the corpus luteum which increases arachidonic acid levels

When there is no pregnancy, the corpus luteum dies and arachidonic acid is metabolized into prostaglandins and leukotrienes.

Both increase myometrial contractions, alter blood flow by vasoconstriction and cause uterine ischemia which = pain.

Prostaglandins can also sensitize afferent nerves and cause pain.

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17
Q

What is the relationship between progesterone and prostaglandins?

A

inversely related

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18
Q

What does nitric oxide do?

A

Decreases myometrial contractions

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19
Q

What are the risk factors for dysmenorrhea?

A
  • young age
  • nulliparity
  • early menarche
  • smoking
  • stress
  • positive family history
  • heavy flow or long cylce
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20
Q

What patient history information is important to collect for a patient presenting with dysmenorrhea?

A
  • medical and gynecologic
  • medication history
  • medication allergies or sensitivities
  • social history
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21
Q

What are the red flags warranting referral of a patient presenting with dysmenorrhea?

A
  • fever, chills, sign of systemic infection
  • IUD inserted in last 6 months
  • pain occurs outside first 3 days of menses or persists for 5 days
  • sudden onset of pain with bleeding
  • unilateral abdominal or pelvic pain
  • patient reports palpable lump
  • changes in severity or pattern of pain and menstrual fluid
  • gynecological symptoms
  • new onset of pain in patient with previously pain-free periods
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22
Q

What are the goals of therapy for dysmenorrhea?

A

1) symptom resolution or improvement
2) minimize disruption of normal activities
3) suppress disease progression
4) identify patients with underlying issues requiring further evaluation

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23
Q

What are the first line treatments for patients presenting with dysmenorrhea?

A

NSAIDs and hormonal contraceptives

24
Q

What are the adjunctive non-pharmacological options for the management of dysmenorrhea?

A
  • exercise, low impact
  • tobacco cessation
  • topical heat therapy
  • transcutaneous electrical nerve stimulation
25
Q

What are the first line non-Rx options for mild primary dysmenorrhea? List the recommended dose and MDD

A

Ibuprofen
200-400mg every 6-8 hours
1200mg/day MAX

Naproxen
220mg every 8-12 hours
440mg/day MAX

26
Q

What are the second line non-Rx options for mild primary dysmenorrhea? List the recommended dose and MDD

A

Acetaminophen
650-1000mg every 4-6 hours
4000mg/day MAX

Aspirin
325-650mg every 4-6 hours
4000mg/day MAX

27
Q

What is the generic name for pamprin?

A

Acetaminophen

28
Q

List the recommended adult dose and MDD for the following Rx NSAIDs:

  • Ibuprofen
  • Mefanamic acid
  • naproxen base
  • naproxen sodium
  • ketoprofen
  • diclofenac
  • flurbiprofen
A

Ibuprofen: 600-800mg Q8H OR loading dose 800mg and 400-800mg Q8H
MDD = 2400mg

Mefanamic acid: loading dose 500mg, then 250mg Q6H
MDD = 1250mg; 1000mg

Naproxen base: loading 500mg then 250mg q6-8h OR 500mg BID
MDD = 1250mg;1000mg

Naproxen sodium: 550mg loading, 275mg q6-8h OR 550mg BID
MDD = 1375mg

Ketoprofen: 25-50mg TID-QID
MDD = 50mg/dose or 300mg/day

Flurbiprofen: 50mg QID
MDD = 200mg

29
Q

What are the progestin only medications for the management of dsymenorrhea?

A

Levonorgestrel IUD

Etonogestrel implantable rod - used off label for dysmenorrhea

Depot medroxyprogesterone - option for women who cannot tolerate estrogen and >35 years, or women who smoke

30
Q

What is the one NHP that has sufficient evidence to say it might be effective in the management of dysmenorrhea?

A

Thiamine/vitamin B1 100mg/day for 3 months

No contraindications

31
Q

What are the options for the management of dysmenorrhea if it does not improve within 6 months of NSAIDs and/or COCs?

A

Refer - medical evaluation necessary to assess for possible causes of secondary dysmenorrhea

32
Q

If someone is trying to conceive, what can you recommend them for management of dysmenorrhea?

A

Second line agents (acetaminophen or aspirin)

Avoid using NSAIDs –> may impair implantation of conceptus

33
Q

What are the product selection guidelines for women who are breastfeeding and experiencing dysmenorrhea?

A
  • acetaminophen and ibuprofen are safe
  • avoid use of high dose aspirin (>325mg)
  • naproxen is less optimal, medication has a long half life and serious AEs have been reported in neonates
34
Q

Who should avoid NSAIDs?

A
  • renal impairment (CrCl <30mL/min)
  • breastfeeding
  • uncontrolled HTN, CV disease, heart failure
  • patients taking anticoagulants
35
Q

What is methocarbamol indicated for?

A

Backaches and muscle spasms –> make sure if you see the Midol product with this, it isn’t being used for dysmenorrhea

36
Q

What are some important counselling points when recommending/prescribing NSAIDs for dysmenorrhea?

A
  • optimal dose, frequency
  • should be started at symptom or bleeding onset
  • pain relief should be 30-60 minutes
  • take with full glass of water
  • don’t lay down for 20-30 minutes after ingestion
  • take with food to prevent GI symptoms
  • use lowest effective dose for the shortest possible duration
37
Q

What is necessary for a pharmacist to do when writing prescriptions for patients?

A

MANDATORY to notify patient’s primary care provider of the treatment and follow-up plans

38
Q

What are the steps to take if there is only partial relief after one cycle of NSAIDs versus no benefit after one cycle?

A

Partial relief: continue for 2 more cycles, try different NSAID or consider COC

No benefit: change NSAID, consider COC

39
Q

When is full therapeutic benefit seen when NSAIDs are used in the management of dysmenorrhea?

A

3 months of cyclic treatment using only 2-3 days of the cycle

40
Q

When does PMS occur?

A

ONLY in the luteal phase; high fluctuation of progesterone and estradiol

41
Q

When is the typical onset of PMS?

A

average age is 26 (late 20s to early 40s)

42
Q

What are the possible causes of PMS?

A

Normal shifts in estrogen and progesterone

Dysregulation of neurotransmitter systems; serotonin

43
Q

What are some of the most common physiological, behavioural and psychological symptoms of PMS?

A

Physiological: bloating, breast pain/tenderness/swelling, headache

Behavioural: fatigue, food cravings or overeating

Psychological: anxiety, dysphoria, irritability and mood lability

44
Q

What is the diagnostic criteria for PMS?

A

NIMH: 30% increase in intensity of PMS symptoms from days 5-10 compared to 6 days before menses AND documentation of these changes in a daily symptom diary for 2 consecutive cycles at least

UCSD: at least one of the affective and somatic symptoms during 5 days before menses in 3 consecutive cycles AND symptoms relieved from days 4-13 of menstrual cycle

45
Q

What are the risk factors for PMS?

A
  • age
  • tobacco use
  • alcohol
  • stress
  • diet (not enough omega 3s)
  • lack of exercise
  • vitamin D
  • identical twins>fraternal twins
  • high BMI
  • traumatic life events
46
Q

What are the protective factors for PMS? (4)

A
  • low parity
  • COC use
  • menstrual cycle characteristics
  • socioeconomic or lifestyle variables
47
Q

What are the red flags to look for when assessing a patient presenting with PMS?

A
  • severe, debilitating symptoms with a strong affective or psychological component
  • severe symptoms or interruption of daily functioning
  • lack of symptom free period
  • symptoms absent in luteal phase
  • unresponsive to self treatment
48
Q

What are the goals of therapy for a patient with PMS? (4)

A
  1. ensure that symptoms are not related to another disorder or disease
  2. relieve symptoms
  3. minimize functional impairment
  4. educate patients about PMS
49
Q

What is the RPh process for diagnosing PMS?

A
  1. Occurs in the luteal phase
  2. Resolves near start of menstruation
  3. Creates problems or impairment
  4. Not better explained by another diagnosis

***diagnosis is confirmed through prospective monitoring of a woman’s symptoms from 2 of more menstrual cycles

50
Q

What are the first line options for management of PMS?

A

Non-pharmacological options and vitamins

51
Q

What are the non-pharm measures that can be taken to help with PMS?

A

Education and support from pharmacist

Stress reduction

  • exercise
  • sleep hygiene
  • COT, relaxation, stress management

Dietary modifications:

  • complex carbs
  • water
  • nutritional supplements
  • decrease salt, refined sugar, caffeine, alcohol and smoking
52
Q

What are the first line options for nutritional supplementation? What do they help with, at what doses and what level of evidence supports it? (4)

A

Calcium + Vitamin D (600mg BID + 400IU)

  • effective for mood and physical symptoms
  • STRONG EVIDENCE

Magnesium (200-500mg QD)

  • may decrease bloating and irritability
  • low evidence, may cause diarrhea

Vitamin B6 (50-100mg QD)

  • overall PMS symptoms
  • low evidence

Vitamin E (400-600 IU)
- may help with breast tenderness
- low evidence
-

53
Q

What are the second line herbal remedies for the management of PMS? (5)

A

STRONG EVIDENCE: Vitex agnus-castus (Chasteberry)

  • 30-40mg/day; through cycle or through month
  • effective for improving PMS symptoms overall
  • similar efficacy to fluoxetine
  • SE: nausea, HA

NO EVIDENCE:

  • evening primrose oil
  • St. John’s Wort
  • Ginkgo
  • Chinese medicine
54
Q

Why would oral contraceptives be used to treat PMS and what are the concerns associated with them?

A

Rationale:

  • PMS symptoms occur almost exclusively in ovulatory cycles
  • efficacious in improving mood and physical symptoms
  • only 1 cycle until onset of effect

Concerns:

  • cause hormonal fluctuations; efficacy for cognitive symptoms?
  • symptoms occur in the hormone free interval
55
Q

How are SSRIs part of the treatment of PMS and PMDD?

A

Efficacious in reducing mood and physical symptoms

Onset of effect within 1 month; most major depressive disorders take 3 months

56
Q

Is there a clinical difference between dosing SSRIs continuously and only during the luteal phase?

A

NO

PHARM 130 - Exam (10 decks)

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