Dysmenorrhea and PMS Flashcards
Dysmenorrhea only occurs during ______ cycles
ovulatory (during the follicular phase of the menstrual cycle)
When does dysmenorrhea usually begin?
usually begins with the onset of menses (within the first 6-12 months of menarche)
The onset and severity of dysmenorrhea often mimics what?
menstrual flow
What are the other associated symptoms with dysmenorrhea?
- headache, nausea, vomiting, fatigue and IBS
What is the difference between primary and secondary dysmenorrhea?
Primary: uterine contractions involving increased PGs
Secondary: PID, endometriosis
Primary dysmenorrhea is often thought to be due to what?
to to prostaglandins
- concentration of PGE2 and PGE2-alpha are increased in the endometrium. This increase correlates with pain severity
- results in an increase in uterine activity, strength and frequency of contractions (dysrhythmic)
What is the difference of age of onset between primary and secondary dysmenorrhea
1: typically 6-12 months
2: mid to late 20s through 30s and 40s
What is the difference in menses between primary and secondary dysmenorrhea?
1: more likely to be regular with normal blood loss
2: more likely to be irregular, menorrhagia more common (increased amount of blood loss)
What is the patten and duration of primary and secondary dysmenorrhea?
1: onset just before or coincidental with menses, pain with each or most menses, lasting 2-3 days
2: vary with cause, change in pain pattern or intensity may indicate secondary disease
Will both primary and secondary menorrhea respond to NSAIDs?
1: yes it will
2: no it will not
What are the other symptoms associated with both primary and secondary dysmenorrhea?
1: N/V, fatigue, dizziness, irritability, diarrhea, and headache may occur at same time of dysmenorrhea
2: vary with cause, may include dyspareunia and pelvic tenderness
What are that main risk factors of dysmenorrhea?
- under 30 y/o
- BMI under 20 kg/meter squared
- smoking
- menarche before 12 y/o
- longer menstrual cycles/duration of bleeding
- irregular or heavy menstrual flow
- history of sexual assault
- PMS or pelvic inflammatory disease
- sterilization
What are the red flags for dysmenorrhea?
- onset of pain > 2 years post-menarche
- symptoms occur outside the first 3 days of menses
- change in severity of pattern of pain
- change in characteristics of menstrual fluid
- if trial of OTC treatment fails (because we know that dysmenorrhea is caused by the production of PGs, and NSAIDs block the production of these)
What are the non-pharm options for dysmenorrhea
- heat therapy
- lifestyle modifications
(stop smoking, regular exercise, decreased fat intake) - other non-pharm measures: TENS, CBT, relaxation, etc
- regular aerobic exercise throughout the cycle should decrease how painful periods are
- decrease saturated fat - fish oil supplements can also be beneficial-high in omega 3 polyunsaturated fatty acids. Thought to decrease the severity of pain
What is the first line therapy for treating dysmenorrhea?
- ibuprofen or naproxen (ASA and acetaminophen do not reduce PGs in menstrual fluid)
- first choice to decrease prostaglandin concentrations in endometrial and menstrual fluid
- start at onset of pain or menses and continue on a schedules basis for 72 hours
- – there will be a 3 month trial before referring or if symptoms are not relieved or pain worsens
What are the rx options available for treating primary dysmenorrhea?
- NSAIDs: propionic acids (naproxen, ibuprofen) or fenamates (e.g. mefenamic acid) or acetic acids (indomethacin)
- mefenamic acid is unique because it inhibits PG synthase and blocks the action of PG that have already been formed
- clinical efficacy is similar for all NSAID options
- oral contraceptives are 90% effective, levonorgestrel IUS- modification of the menstrual cycle (blocks ovulation); low dose agents provide lighter, shorter and less painful periods, or no periods at all
When should a patient se improvement in symptoms?
- may take up to 3 cycles for improvement of dysmenorrhea issues/symptoms overall
What is the maximum duration of treatment for self-treatment approaches?
- 3 days each cycle
What is the definition of PMS?
- recurrent physical, psychological and behavioural symptoms which occur during the luteal phase of the cycle (day 14-28) and which are relieved by menstruation with a symptom free week. The symptoms have a negative impact on the quality of life of the woman
When is the typical onset of PMS in a woman?
anytime after puberty, typically in the mid-twenties
When are the symptoms of PMS usually experienced?
- anywhere from 7-14 days before menstruation, symptoms peak just a few days before
- usually improve significantly or disappear just a few days of menstruation
Will a woman get symptoms of PMS during pregnancy or menopause?
no they will not
What ar the three most supported aetiologies of PMS?
- Exaggerated response to normal hormonal changes
- fluctuations in estradiol and progesterone cause an abnormal response - 5HT deficiencies
- women with PMS have been found to have decreased 5HT concentrations and decreased platelet uptake of 5HT during the late luteal phase
- decreased 5HT may lead to depressed mood, irritability, anger, aggression, poor impulse control and appetite disturbances - Abnormalities in catcholaminergic, GABA and opioid NT systems
What are some of the risk factors associated with PMS?
- lower intake of vitamin D
- genetic predisposition
- high BMI
- stress
- traumatic life events
What is premenstrual dysphoric disorder? (PMDD)
- severe form of PMS
- symptoms are usually severe enough to cause functional impairment/disruption
- sx usually peak around 3rd and 4th decade
- may become severe in perimenopause (5-10 yr prior to menopause)
What are the negative outcomes associated with PMDD?
- marital issues
- physical/verbal abuse of others
- difficulties in parenting
- criminal behaviour
- poor work or school performance
- work absenteeism
- social isolation
- accidents
- hospitalization
- suicidal ideation
What are the red flags for PMS?
- severe cases of PMS- unrelenting of progressive symptoms
- uncertain or unusual patterns of symptoms or symptoms inconsistent with PMS
- affective disorder
- onset on symptoms associated with OCP and HRT
- symptoms related to other medical conditions
- other conditions such as anemia, thyroid disorder, diabetes, endometriosis, chronic fatigue syndrome, psychiatric disorder
- peri-menopause
- signs of infection or ovarian cysts
- individuals who do not respond to treatment
What are some of the cognitive non-pharmacological tx options for PMS?
- behavioural therapy emphasizes relaxation techniques and stress reduction
- assist individual to cope or deal with the changes
- smoking cessation, if applicable
- sleep hygiene
What are some of the nutritional non-pharm tx options for PMS?
- balances diet
- decrease salt intake
- decrease caffeine intake
- small, frequent intake of carbs
- dietary changes are recommended 7-14 days before the menses begins (minimum)
What are some of the exercise non-pharm tx options for PMS?
- women who practice aerobic exercise (3-4x/week) experience fewer symptoms compared to those with no exercise
Why do women that exercise have less PMS sx?
- exercise reduces the symptoms of depressive illness
- luteal phase of endorphin secretion appears to be altered in women with PMS
- exercise boosts “feel good” endorphins
- structured sleep schedule- consistent wake/sleep times, esp during the luteal phase
What is the efficacy of evening primrose oil in treating PMS?
efficacy similar to placebo
What is the efficacy of chasteberry in treating PMS?
- can help reduce breast discomfort and other symptoms of PMS
- preparations are different in each formulation however - WATCH for this
What are the main SE of chasteberry?
- can cause GI problems, acne like rashes, headache, fatigue, dry mouth and dizziness
Who should not take chasteberry?
women who are pregnant or taking birth control pills or who have hormone sensitive condition (such as breast cancer) should not use chasteberry
- people taking dopamine-related medications, such as selegiline, amantadine, and levodopa, should avoid using chasteberry
What is the efficacy of pyridoxine (vitamin B6) in
cofactor in synthesis of dopamine and the metabolism of tryptophan (5HT precursor)
- a meta analysis found that peroxide may be beneficial for the treatment of PMS
- dose should be recommended from 50-100 mg daily due to potential neuropathy
What is the efficacy of magnesium in treating PMS?
not beneficial
- there is minimal benefit in alleviating fluid retention
- too much Mg - can lead to diarrhea, dizziness, weakness and fatigue
Is calcium recommended as a supplement to treat PMS?
- helps with mood, abdominal pain, water retention (bloating), cramps and food craving
- recommended for supplementation
- premenstrually there are lower plasma calcium levels
- ** if you start calcium supplementation and continue it on, the next period should have some improvement
Is midol generally recommended?
NO
- it has acetaminophen, pamabrom, pyrilamine, methocarbamol, caffeine, etc in it
What is pamabrom?
- derivative of theophylline that promotes diuresis (use in the physical symptom treatment for things such as bloating, weight gain and water retention)
What is pyrilamine used for in PMS products?
- MOA: sedative effects for women experiencing emotional symptoms - anxiety, nervous tension and irritatbility
What are the common rx treatments for PMS?
- PG inhibitors- NSAIDS
- SSRIs
- Diuretics (spironolactone)
- androgens
- oral contraceptives
- GnRH - leuprolide
What are the treatment options available for PMS?
- begin with non-pharm changes
- then consider an option such as calcium
- add on a pain reliever, such as NSAIDs, which may help with symptom relief of headache, muscle and breast pain if required
What are the time lines that patients should notice improvement for treatment of PMS?
- symptoms should be improved or alleviated within 1 to 3 cycles
