Ex. 5 L5 -Abnormal Bleeding (47) Flashcards
Normal Bleeding
35mL of blood per day
Cycle length of 22-35 days
Menstruation lasting 3-7 days
Median age of mearche: 12.4 years (starting period)
Types of abnormal bleeding
Dysmenorrhea
Amenorrhea
Oligomenorrhea
Polymenorrhea
Heavy Menstrual Bleeding (HMB)
Metrorrhagia
Dysmenorrhea
Pain associated with menstruation
Primary:
-Normal ovulatory cycles and pelvic anatomy
Secondary:
-Underlying anatomic or physiologic cause
Occurring in 17-90% of women
About 6-12 months after cycle - more immediate
One of the key symptoms of endometriosis is
Dysmenorrhea
Pathophysiology of Dysmenorrhea
-Buildup of fatty acids in cell membranes, then released
-Prostaglandins and leukotrienes released in uterus
-Inflammatory response causes symptoms
Risk Factors - Dysmenorrhea
< 20 years old
Weight loss attempts
Depression/anxiety
Heavy Menses
Menarche before <12YO
Nulliparity
Smoking
Family History
Symptoms of Dysmenorrhea
Diarrhea
Vomiting
Nausea
Crampy Pelvic Pain
Dizziness
Muscle Cramps
Headache
Goals of therapy for patients with Dysmenorrhea
Provide symptomatic relief
Reduce lost school/work productivity
Improve QOL/ADLs
Dysmenorrhea - Treatment Overview
First-Line
-Non-steroidal anti-inflammatory (NSAID), +/-
Oral Contraceptives +/-
Non-pharmacologic
Second-Line
-Depot Medroxyprogesterone acetate (DMPA)
-Levnorgestrel-releasing IUD
Treatment for Dysmenorrhea - Non-Pharmacologic
-Heating Pad
-Exercise
-Nutritional Supplementation: Omega-3-fatty acids, vitamin B, Ginger
-Smoking Cessation
-Acupuncture
NSAID Therapy: Dysmenorrhea
MOA: Inhibits COX enzyme (1 and 2), leading to decrease in prostaglandin production
-Dosing can be taken around the clock 1-2 days before cycle start
-Intended for short-term use
No NSAID found to be more efficacious than another
Dysmenorrhea NSAID drugs and dosing
Celecoxib
(COX2 specific)
-Rx only
-400mg x 1, then 200mg PO Q12h
Diclofenac
-Rx only
-100mg x 1, then 50 mg PO q8h
Ibuprofen
-Rx and OTC
-800mg x 1, then 400-800mg PO Q8h
Naproxen
-Rx and OTC
-500mg x 1, then 220-550mg PO Q12h
Pros and Cons of NSAID therapy
Pros:
-Good option for those wanting to conceive
-Short term use
-Pain relief within hours
-Cheap, non-Rx
Cons:
-SE can be intolerable
-Not a great option for those with CV history
NSAIDs SE and precautions & counseling
SE and Precautions
-GI bleeding/ulcers and upset
-Renal injury
-Onset of CV events, exacerbate HTN
Counseling and Education:
-Take w/food or milk to minimize GI upset
-Monitor for abnormal bleeding
-Scheduled dosing vs. PRN
NOT RECOMMENDED FOR PATIENTS WITH CV HISTORY
Oral contraceptive therapy
MOA: Inhibition of endometrial tissue proliferation, leading to decreased endometrial production of prostaglandins and leukotrienes
Multiple options:
-Combined hormonal contraceptives (CHCs)
Can use ethinyl estradiol component up to 35 mcg (or 50 mcg)
Dosing: efficacy noted with cyclic and continuous regimens
-No regimen found to be more efficacious than another
Hormone therapy pros and cons
Pros:
-Appropriate for those seeking contraception
-Can be used in conjunction w/NSAIDs
Cons:
-Not appropriate for patient desiring pregnancy
-RX needed
-Delayed relief *1-2 months)
Hormone therapy SE and Precautions & Counseling and Education
SE and Precautions
-Increased BP
-Weight gain
-Fluid retention
-Risk of blood clots/stroke (increased w smoking)
Patient ED and counseling
-Monitor for nausea, HA, breast discomfort and changes in mood
Levonorgestrel IUD and Depot Medroxyprogesterone Acetate (DMPA)
MOA: related to amenorrhea SE
-Beneficial in those desiring contraception
-Delayed Relief, often with initial months of therapy
-Recommended to try levonorgestrel IUD before DMPA
Levonorgestrel recommended to try BEFORE depot
Monitoring and Follow Up
Assess patient symptom improvement (pain rating scales, self reported symptoms, etc)
-If symptoms have not lessened in severity or resolved in ** 3-6 months of traditional therapy, REFER**
Amenorrhea
The absence of a menstrual cycle
Primary:
-No menses by age 15
Secondary:
No menses x3 months in previously menstruating women
Amenorrhea traits
Characteristics and Symptoms
-Often asymptomatic
-Can be accompanied by weight loss/gain
Often a symptom rather than a condition itself
-Lab tests: pregnancy test, FSH/LH levels, TSH, prolactin, estrogen
-PCOS, low BMI, eating disorders, excessive exercise
-MEDICATIONS
(IUD, Depotshot, etc)
Prevalence
Primary: <0.1%
Secondary: 3-4%
Drug induced amenorrhea
First gen antipsychotics
-Prochlorperazine, chlorpromazine
-Haloperidol
-Chloprothixene
Second-gen antipsychotics
-Risperidone
-Molindone
Antidepressants
-Clomiphene
Monoamine oxidase inhibitors
-Pargyline
-Clorgyline
Antihypertensives
-Verapamil
GI promotility agents
-Metoclopramide
-Domperidone
Goals of therapy amenorrhea
Ovulation restoration
(especially if fertility desired)
Bone density preservation
Bone loss prevention
Amenorrhea treatment - first line
RULE OUT PREGNANCY
-Determine underlying cause
Treatment for amenorrhea, non pharmacologic
If cause if Anorexia
-Weight gain
-Consider work-up for eating disorder
-Cognitive behavioral therapy (CBT)
If cause is Excessive Exercise
-Reduction in exercise quantity and intensity
If cause is Medications
-May consider alternative agents that do NOT inhibit dopamine receptor or increase prolactin levels
OR -> initiate dopamine agonist
Monitoring and follow-up Dopamine agonists:
SE
Monitoring:
-BP
-HR
-Hepatic/renal function
-Pregnancy status
-Prolactin level
Average time to resolution of menses: ~6-8 weeks
-If no resolution seen with one agent, try other!!
Pharmacologic Tx for Amenorrhea: cause is hypoestrogenic
-If cause is hypoestrogenic - provide supplemental estrogen
-Must include a progestin component
Agent:
-Conjugated Equine Estrogen
(Common brands: Premarin, Cenestin, Enjuva)
Regimen:
Take 0.625 - 1.25mg PO daily on days 1-25 of cycle
Agent:
Estradiol (patch)
(Common brands: Climara, Vivelle-Dot)
Regimen:
Apply 0.1 mg patch to the skin once or twice weekly
Pharmacologic Tx for Amenorrhea: cause is Medications
If cause is medications that increase prolactin levels…provide Dopamine agonist
Bromocriptine
-Multiple daily dosing (short half life)
Cabergoline
-Weekly or twice weekly dosing (long half life)
Contraindications
-Breast feeding, uncontrolled HTN,
Mild SE: N/D, HA, orthostatic hypotension, fatigue
Oligomenorrhea
Menstrual cycle interval >35 days (but less than 90 days)
Overlaps with amenorrhea
-Similar causes and tx approaches
Polymenorrhea
Menstrual cycle interval <21 days
Common Causes
-Stress
-Infections (STDs)
-Endometriosis
-Menopause
MAY CAUSE CHALLENEGES IN CONCEIVING
Heavy Menstrual Bleeding (HMB)
-Previously called “menorrhagia”
Bleeding >80mL OR lasting > 7 days
“Excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, or maternal quality of life”
Prevalence
-Accounts for 18-30% of gynecologic visits
HMB - pathophysiology
-Multiple Etiologies
-MUST RULE OUT: pregnancy, ectopic pregnancy, miscarriage
Hematologic
-Bleeding/clotting disorders
Hepatic
-Cirrhosis
Endocrine
-Hypothyroidism
Uterine
-Structural abnormalities
-Uterine fibroids(up to 40%)
HMB - symptoms
Heavy blood flow w/menstruation
-With or without pain (dysmenorrhea)
-Possibly: fatigue and lightheadedness
HMB Goals of therapy
-Reduce menstrual blood flow
-Correct iron-deficiency anemia or underlying disorders (if applicable)
-Improve QOL/ADLs
HMB - Chronic management (monthly)
Hormonal
-CHC
-Progestins
-Levonorgestrel IUD
-Danazol
-GnRH
Nonhormonal
-NSAIDs
-Tranexamic Acid
-Iron*
*not indicated to lessen bleeding, but to treat iron-deficient anemia if applicable
Tranexamic Acid
MOA - antifibrinolytic - prevents the degradation of blood clots
Dosing:
1,300 mg PO TID x 5 days (at onset of menses)
-Intended for short-term use (duration of menses)
-Nonhormonal; usually reserved for those unable to take CHCs or wanting to conceive
Contraindications
-Active and/or h/o DVT or Pulmonary embolism
H/o seizure
SE
-Generally well tolerated
-Can cause HA, nasal symptoms
Metrorrhagia
Hemorrhage of the uterus
-Irregular menstrual bleeding Between cycles
Causes:
-Hormone imbalance
-Fibroids, polyps, endometriosis
-Medications
-IUDs
-Infections
Treatment
-Target underlying cause
-Hormonal contraceptive
Comparing AUB conditions
Which conditions are related to cycle length?
-Oligomenorrhea (>35 days)
-Amenorrhea (Cycle >90 days)
-Polymenorrhea (Cycle <21 days)
-Bleeding occurring between cycles: Metrorrhagia
Which conditions are descriptors of blood flow?
