ic16 EE and Norethindrone + ic18 menstrual cycle disorders + menopause Flashcards
Definition of Amenorrhea
Classification?
no bleeding for 3 months
Primary: no menses by age 15
Secondary: no bleeding for 3 cycles (3 months)
Who does Secondary Amenorrhea usually occur in?
< 25yo with history of menstrual irregularities
Competitive sports
Massive weight loss
3 causes of Amenhorrea
1) Anatomical
Pregnancy
Uterine structure abnormalities
2) Endocrine disturbances
3) Ovarian insufficiency / failure
Definition of Menorrhagia
Heavy bleeding
> 80ml per cycle OR bleeding > 7 days per cycle
Pharmacological Treatment for Menorrhagia
Contraception desired:
1) COC / Progestin only (IUD, Oral, Injection)
- Estrogen-only NOT USED
- (recap) Progestin causes endometrial atrophy
No contraception desired:
1) NSAIDs
2) Tranexamic acid
Slow breakdown of blood clots
3) Cyclic progesterone
Non-pharmacological treatment for Menorrhagia (2 points)
1) Endometrial ablation
Remove endometrial lining
2) Hysterectomy
Remove entire uterus
What is Dysmenorrhea
Crampy pelvic pain with or just before menses
MOA for Primary Dysmenorrhea and Secondary Dysmenorrhea
Primary:
Release Prostaglandins and Leukotrienes → vasoconstriction → Cramp
Secondary:
Endometriosis
Pharmacological treatment for Dysmenorrhea (1st, 2nd, 3rd line)
NSAIDs (1st line)
Inhibit production of Prostaglandins
Pain relief
COC (2nd line)
Progestin IUD (Levonorgestrel), injections (3rd line)
Progestin causes thinning of endometrial / atrophy → Less prostaglandins produced → Lesser vasoconstriction → Less pain
Cause of Polycystic Ovary Syndrome (PCOS)?
Ovaries producing more androgens (male hormones) → Cysts form in ovaries
Symptoms of PCOS
Menstrual irregularities
Amenorrhea
Menorrhagia
Androgenic symptoms
Acne
Hirsutism
Metabolic disorder / Insulin resistance
Treatment for PCOS (2 Points)
COC
Drospirenone (4th gen. cos antiandrogenic)
Metformin
Counter insulin resistance by increasing glucose uptake of muscle cells (secondary MOA)
What happens during Perimenopause?
How to detect Perimenopause?
Estrogen production starts to decrease → causing menses to become unpredictable
Can test FSH level
FSH high if Estrogen is reduced
Symptoms of Menopause (4 points)
1) Vasomotor symptoms (most common)
Hot flushes
Night sweats
Fast, irregular HR
Cold sweats, perspiration
2) Genitourinary syndrome (GSM)
Genital dryness
Burning, irritation, pain
Lubrication difficulty
Impaired libido, painful intercourse
Dysuria
Urinary urgency
Recurrent UTI
3) Psychological
Depression, anxiety
Mood swings
4) Bone fragility
Lower estrogen → More bone loss
↑ risk of osteoporosis, fractures, joint pain
Non-pharm treatment for Menopausal symptoms
When should non-pharm be used?
1) Mild Vasomotor
Lower room temp
Less spicy food, caffeine, hot drinks
More exercise
Isoflavones, Black cohosh
2) Mild Vulvovaginal
Non hormonal vaginal lubricants, moisturisers
Should be used only if VMS or GSM symptoms are mild
Pharm treatment for Menopausal symptoms (3 points)
Menopausal Hormone Therapy (MHT)
Antidepressants
Gabapentin
2 types of MHT, and when should they be used?
Estrogen only
use only for patient without uterus
Estrogen + Progesterone
use if patient has intact uterus
When should Estrogen-only be given?
When should Progestin-only be given?
Estrogen-only given for:
- Menopause (MHT) patients without intact uterus to supplement the low Estrogen and reduce symptoms
- Amenhorrhea
Progestin-only given for
- Menorrhagia (heavy bleeding)
- cannot tolerate N/V of estrogen
- breastfeeding
- VTE, migraine w aura
Purpose of Progestin in MHT?
To prevent overgrowth of endometrium and reduce risk of endometrial cancer
Goal of MHT vs Goal of COC?
MHT: Supplement endogenous estrogen to alleviate symptoms
→ hence use lower dose of estrogen
COC: Suppress HPO axis to avoid ovulation
→ hence use higher dose of estrogen
Types of Estrogen only MHT (3 points)
Which are used for Vasomotor symptoms, which are used for Genitourinary symptoms?
1) Systemic oral tablets
for both
2) Systemic gel / patch
for both
3) Local vaginal pessary, creams
only for Genitourinary symptoms, NOT for Vasomotor symptoms (cos no systemic absorption)
What is the difference between Continuous-cyclic and Continuous-combined? (bold and underline)
Continuous cyclic:
Progestin taken for 10-14 days
Progestin added on 1st or 15th day
Withdrawal bleeding occurs when progestin is stopped
Suitable for:
Perimenopausal women, where menstrual cycle becomes irregular
Continuous-combined:
Estrogen + Progestin taken everyday
No withdrawal bleeding
Breakthrough bleeding may occur initially
Suitable for:
Post menopausal women, since they are not experiencing anymore periods
Role of Progestins in Menopausal Hormone Therapy
Reduce risk of endometrial cancer (AKA counters Estrogen by causing endometrial atrophy, wont overgrow)
Progestins used are mostly 1st and 2nd generation
Counselling points for patients on MHT
What kind of monitoring is needed (2 points)
Takes 2-3 months to see improvement in symptoms
Let patient understand risks and benefits of MHT, and the need for monitoring for breast cancer and bleeding
Annual mammography
Monitor for breast cancer
Endometrial surveillance
Any bleeding or bleeding heavier than normal
Similarities between Norethisterone / Norethindrone and Ethinyl Estradiol (Distribution and Metabolism)
Highly bound to albumin
Undergo phase 2 glucuronidation and sulfation
Why does EE have high half life (13-27hrs)?
After sulfation, EE sulfate can undergo enterohepatic circulation
Why can VTE still occur in Norethindrone?
Norethindrone can be converted to EE via metabolism in the liver, resulting in estrogen adverse effects eg. VTE
