Dysmenorrhea Flashcards
Define dysmenorrhea
Painful menstruation
When does dysmenorhhea occur?
Occurs before and/or during the beginning of menstruation
What is the most common gynaecological sx reported by people who menstruate?
Dysmenorhhea
Describe the prevalence of dysmenorrhea
The most common gynaecological sx reported by people who menstruate
Affects 50–90%
Highest incidence in late adolescence and early 20’s
1/3 to ½ report moderate to severe sx’s
10 –15% are incapacitated for 1-3 days/month
Describe the impact on life of dysmenorhhea
Leading cause of absenteeism from school and work for young women yet still largely goes untreated
Describe the impact of dysmenorhhea on academics
The severity of menstrual pain correlated with academic performance (concentration, absenteeism, performance, and lower grades during dysmenorhhea)
Describe the basic etiology of dysmenorhhea
Primary Dysmenorhhea
Secondary Dysmenorhhea
Describe primary dysmenorhhea
Painful menstruation with normal pelvic anatomy
– > Absence of pathology
Associated with normal ovulatory cycles
Typically begins in adolescence once ovulatory cycles established (within first few years after menarche; on average 6-12 months later)
Describe secondary dysmenorrhea
Painful menstruation associated with underlying anatomic or pathologic pelvic abnormalities
More likely to experience other symptoms like:
Irregular uterine bleeding
Chronic pelvic pain
Mid-cycle pain
Dyspareunia
Describe the differences between primary and secondary dysmenorhhea
Describe the underlying pathophysiology
Although the exact cause is unknown, prostaglandins (PG) are known to have a significant role
People with dysmenorrhea have increased production of endometrial PGs prior to menstruation
PG’s results in stronger, more frequent uterine contractions (and vasoconstriction)
Increased vasopressin and leukotriene levels
End result: Increased myometrial contractions, reduced uterine blood flow, which leads to PAIN
Risk factors for primary dysmenorhhea
Early menarche (<12yo)
Age <30yo
Family history of dysmenorrhea
Heavy menses / longer menstrual periods
Smoking
Weight (BMI <20)
Nulliparity (never have birthed a baby)
Describe the symptoms of dysmenorhhea
Spasmodic (cramping) pain in lower abdominal region
May radiate to lower back or thighs
May also experience:
Headache
N/V/D
Fatigue or trouble sleeping
Dizziness
Bloating
Describe the timeline of symptoms of dysmenorhhea
Few hours before menstruation –> peaks –> lasts 2-3 days
Pain comes and goes in cycles – Not constant
Describe the diagnosis of primary dysmenorhhea
Primary dysmenorrhea:
Based upon:
1) symptoms
2) response to therapy
3) clinical history
4) physical exam
Requires a thorough medical history evauluating:
Pain: onset, severity, type, location, duration
Associated sx’s
Family hx of endometriosis
Sexual activity
Menstrual history: age at menarche, cycle regularity, time since menarche, estimated menstrual flow
Describe why a thorough medical history is required for diagnosis of primary dysmenorhhea
Requires a thorough medical history to rule out 2 dysmenorhhea
Symptoms of secondary dysmenorhhea overlap with other conditions so a thorough history necessary
When should secondary dysmenorhhea be considered in the diagnosis of dysmenorhhea?
Menstrual pain after several years of painless periods
Sudden occurrence when normally have mild to no pain
Complaints of heavy bleeding
Dyspareunia
Rectal pain
Pain at times other than during menstruation
Pain persists beyond first couple days of menstruation
Little to no response to drug therapy
Goals of therapy for dysmenorhhea
Relive symptoms
Minimize time lost from work, school, etc
Identify patients with possible secondary dysmenorrhea for further assessment
Describe the treatment of dysmenorhhea? What type of diagnosis is it?
If history does not suggest a secondary cause, a presumptive diagnosis of primary dysmenorrhea may be made and confirmed with a 3 month trial of pharmacotherapy (empiric therapy is initiated – generally NSAIDs)
A history suggestive of 2o dysmenorrhea requires referral to a physician
Describe the treatment duration of NSAIDs and pharmacist prescribing
Can prescribe 6 months of therapy but must follow up at 3 months
No improvement at 3 months – referral to phsycian for assessment
What are some non pharmacological strategies for dysmenorhhea? Describe them.
What are some of the OTC agents that can be used for dysmenorhhea?
Acetaminophen
Pamabrom
Pyrilamine
NSAIDS
Describe acet usage in dysmenorhhea
Analgesic effect may be effective for mild cramping pain
Acetaminophen sometimes combined with caffeine/pamabrom/pyrilamine
Describe pamabrom usage in dysmenorhhea
Mild, short-acting diuretic
Is found combined with acetaminophen/pyrilamine (PMS Midol® Complete, Pamprin® Extra Strength)
Describe pyrillamine usage in dysmenorhhea
Acet-caffeine-pyrilamine (Menstrual Midol® Complete, Teen Midol Complete)
Pyrilamine has not been proven to be effective for menstrual sx’s
Describe NSAID Therapy and the synthesis of prostaglandins
Describe NSAIDs place in therapy
1st line therapy for pain relief & improved daily activity
Describe the MOA of NSAIDS and its relation to dysmenorrhea
Inhibit cyclooxygenase leading to a reduction in PG synthesis
PG’s increase leading up to menstruation – Taken sooner, more efficacy
Inter-individuality – Which NSAID works the best and is best tolerated
Describe the efficacy of NSAIDs in dysmenorhhea. Is any NSAID more efficacious than another? What is the choice based on?
Efficacious in ~80% of patients (if taken early enough)
In addition to pain relief, they: help relieve cramps, headache and muscle aches
Are all equally efficacious (as a class) for dysmenorrhea sx’s
Base choice on:
Availability, adverse effects, cost, use/indications
Describe the dosing of NSAIDs in dysmenorhhea
Initiate with onset of symptoms OR with onset of bleeding – dose continuously (whichever comes first)
Continue using for ~3 days
May begin with a loading dose
~3 cycles is a reasonable treatment trial
Describe an appropriate trial of NSAIDs and its timing of dosing
~3 cycles is a reasonable treatment trial
Regular dosing for 72 hours (PG concentrations peak in first 48 hours)
Loading dose – If individual needs it for faster releief
Reasonable Trial – 3 months
What are some common initial NSAIDs and their corresponding doses? Risks?
Ibuprofen: 800mg q8h or 400mg Q4-6h (OTC)
Naproxen base: 500mg stat; 250mg q6-8h or 500mg BID
Naproxen Na: OTC max 440mg/d vs. Rx dosing of 1375mg/d with a loading dose
Mefenamic acid: 500mg stat; 250 q6h or 500mg bid (RX only)
Can recommend OTC Ibuprofen and naproxen
Used for a short duration – Side effects are low here; not a major concern
What are some side effects of NSAID’s? When are side effects a concern or not a concern?
Mild: GI irritation, h/a, dizziness, drowsiness
Severe: PUD and bronchospasm in hypersensitive patients; caution in renal dx
Short-term use: typically not an issue
Describe the prescribing authority of pharamcists regarding dysmenorrhea?
Describe the mechanism of action of combined hormonal contraceptives in dysmenorrhea?
Suppresses endometrial proliferation and ovulation; this prevents PG and LT production in the late luteal phase and decreases the volume of menstrual fluid
Estrogen and progestin containing products
Decsribe the efficacy of combined hormonal contraceptives in dysmenorrhea
50-90% achieve pain control within 3-6 months
As a group, all CHCs are similarly effective
Continuous-use / extended cycle CHC’s and cyclical are all effective
Some evidence to suggest more effeicacy for continuous dosing (not menstruating at all, sx/pain is less likely)
What are some of the formulations of combined hormonal contraceptives?
Oral, transdermal, vaginal
Describe the combined hormonal contraceptives place in therapy?
1st or 2nd line, depending on the situation
Can combine with NSAIDs
Useful if individual is wanting contraception – Not apart of tx algorithm for minor ailments
Trial period required
Describe the advantages of combined hormonal contraceptives
Contraceptive and non-contraceptive benefits
Address many factors relevant to adolescents
Always remember to provide comprehensive counseling when dispensing (ensure appropriate contraception even if not taking for that purpose)
Can progestin only products be used in dysmenorhhea? If not why? If so, MOA?
Provide progestin only and inhibit ovulation and decrease menstrual flow
Can be considered if C.I. to estrogen
Efficacy due to amenorhhea
Describe the efficacy of progestin only products?
Progestin-only products are not as well studied, and no head-to-head studies, but have also been proven efficacious
Describe the progestin only products that can be used for dysmenorhhea
Depo medroxyprogesterone acetate IM (Depo-Provera®)
Levonorgestrel intrauterine system (e.g. Mirena®)
Etonogestrel (Nexplanon®)
Subdermal implantable rod
Norethindrone 0.35mg (progestin-only pill)
Drosperinone 4mg (progestin-only pill)
DEPO, IUD, PILL formulations
How can treatment resistance of dysmenorhhea be managed?
Requires an extensive work-up
Treatment is generally guided by laparoscopic findings
Use is reserved due to risks
Summarize the workup and treatment of dysmenorrhea?
Very common and sometimes debilitating condition
A thorough history is critical prior to recommending treatment
Initial tx: NSAIDs or CHCs
Observe for a few menstrual cycles to see effect
–> If patient has not responded to therapy, investigate its use and evaluate for other options or potential for secondary dysmenorrhea
Describe why NSAIDS are the empiric therapy for primary dysmenorhhea? Which NSAID’s?
Primary dysmenorhhea is caused by abnormal uterine contractions as a result of increased PG production by the endometrium in ovulatory cycles
NSAID’s inhibitn PG production and are the tx of choice
All NSAID’s except ASA have been shown to be effective with minimal difference in efficacy
Describe the risk of side effects of NSAID usage in dysmenorhhea
With short term usage, side effects of all NSAIDs are generally minor
All NSAIDs demonstrate an increased risk of CV events (MI, stroke) studies indicate that diclofenac and high dose ibuprofen are associated with the highest risk of CV events
CV events are likely to be extremely rare in young women using NSAIDs on an intermittent basis
Describe acetaminophen role in the treatment of dysmenorhhea
Demonstrates minimal analgesic effect in dysmenorhhea
Inferior pain relief compared to NSAID’s
Consider acetaminophen only for patients with contraindications to NSAIDs
Why are combined hormonal contraceptives useful in dysmenorhhea?
CHC’s inhibit ovulation, which limits endometrial growth and decraeses menstrual blood flow, thereby supressing PG production at menses
Describe th dosing regimens that can be used in dysmenorhhea
Continous or extended cycle regimens may decrease the frequency of menstrual periods and the prevalence of pain
Continous use of COC’s is often sucessful if cyclic fails
Extended or continous use of the contraceptive ring or patch may be another alternatives
Describe the usage of the levonorgesterol intrauterine system (LNG IUS)
Reduces menstrual bleeding and is highly effective for dysmenorhhea associated with heavy menstrual flow
A low dose of lenorgesterol is released continously over a period of atleast 3 years, causing the endometrium to become atrophic and inactive
Describe the usage of depot medroxyprogesterone (DMPA) in dysmenorhhea? Main risk and management?
Intramuscular injections supress ovulation, induce endometrial atrophy and produce ammenorhhea
Consider DMPA as a tx option in the mangement of primary dysmenorhhea in women who cannot tolerate estrogen and in women over the age of 35 years old who smoke
Although BMD may return to baseline upon dc of tx, use DMPA with cuation in adolescents 12-18 years as they have not yet attained their peak bone mass
To promote overall bone health, encourage adequate calcium ( total of 1200 mg daily from all sources, preferably dietary) and vitamin D (1000 IU) in women on DMPA tx
