IC17 Menstrual Disorders + Menopause Flashcards
What is amenorrhea? What is primary and secondary amenorrhea? What are the possible causes?
Amenorrhea
Definition/Symptoms: No bleeding for 90 days (>= 3 months)
Primary/functional: No bleeding by age 15 for women who have never menstruated
Secondary: No bleeding for 3 cycles in women who have menstruated before
Common in:
- < 25y/o with menstrual irregularities
- Competitive athletes (lack of fats)
- Massive weight loss
Causes:
- Anatomical changes e.g. pregnancy, uterine structural abnormalities
- Endocrine disturbances chronic anovulation disrupts the cycle
- Ovarian insufficiency / failure can’t ovulate
a. E.g. GnRH/FSH/LH disrupted so E and P not produced, no menses
What are the non-pharm and pharm management of amenorrhea?
Treatment:
Non-pharmacological
- Weight gain
- Exercise less
- Stress management
Pharmacological
- COC
- Estrogen Only
- Progestin Only
- Copper IUD (intraurethral device)
What is menorrhea? What are the causes of menorrhagia?
Definition/Symptoms: bleeding >= 80mL per cycle OR >= 7 days per cycle + *affect QOL (comes with pain)
Causes:
- Uterine-related factors
a. Fibroids
b. Adenomyosis (tissue lining the uterus grows into the muscular wall of uterus)
c. Endometrial polyps
d. Gynecologic cancer
e. Alterations in HPO (hypothalamus-pituitary-ovarian) axis - Coagulopathy factors
a. Cirrhosis
b. Von Willebrand disease
c. Idiopathic thrombocytopenic purpura
What are the non-pharm and pharm management of Menorrhagia?
Treatment:
Pharmacological
Is contraception Desired:
- Yes
1. COC
2. Progestin IUD
3. Progestin only oral meds (Minipill)
4. Progestin injection - No
1. NSAIDs during menses
2. Tranexamic acid during menses e.g. slow break down clots
3. Cyclic Progesterone (not continuous so have no contraceptive effect)
Non-pharmacological
- Endometrial Ablation
- Hysterectomy
What is dysmenorrhea? What is the pathophysiology of dysmenorrhea?
Dysmenorrhea
Definition/Symptoms: crampy pelvic pain with or just before menses
Pathophysiology:
Primary: release more prostaglandins and leukotrienes –> vasoconstriction –> cramp
Secondary: endometriosis (endometrium grows outside of uterus)
What are the non-pharm and pharm management of dysmenorrhea?
Treatment:
Non-pharmacological
- Topical heat therapy
- Exercise
- Acupuncture
- Low-fat vegetarian diet (since prostaglandins and leukotrienes precursors are fats)
Pharmacological
- NSAIDs (pain management, 1st line)
- COC (2nd line)
- Progestin injections (3rd line, reduces menses and thins endometrium)
- Progestin IUD (3rd line)
What is PMS and the symptoms?
Premenstrual Syndrome (PMS)
Definition: cyclic pattern of symptoms occurring 5 days before menses, resolve on onset of menses (most do not report impairment of daily activities)
Symptoms:
Somatic (physical):
- Bloating
- Headache
- Weight gain
- Fatigue
- Dizziness / nausea
- Appetite changes
Affective (mental):
- Anxiety / Depression
- Angry outburst
- Social withdrawal
- Forgetfulness
- Tearful
- Restlessness
- Severe mood symptoms –> Premenstrual Dysphoric Disorder (PMDD)
What are the pharm and non-pharm ways to treat PMS?
Treatment:
Pharmacological
- Selective Serotonin Reuptake Inhibitors (SSRIs) –> for affective symptoms
- COC –> for somatic symptoms
Non-pharmacological
- Exercise more
- Eat more vitamins
- Less caffeine and sugar
What is PCOS? What are the symptoms? What are the possible treatment?
Polycystic Ovary Syndrome (PCOS)
Definition: ovaries produce abnormal amt of androgens + small cysts (fluid filled sacs) form in the ovaries
Symptoms:
- Menstrual irregularities
- Androgen effects
a. e.g. acne, hirsutism, obesity
b. Metabolic disorders / insulin resistance e.g increase risk for DM and CVD
Treatment:
Pharmacological
- COC (consider antiandrogenic progesterone e.g. drospirenone, cyproterone if acne/hirsutism)
- Metformin (not for everyone)
What is menopause?
Menopause
Definition: Permanent cessation of menses following loss of ovarian follicular activity
No menses for >= 12 months
What are the causes of menopause?
Causes:
- Natural –> perimenopause, menopause, post-menopause
- Induced –> any time before natural menopause e.g. ovaries removal, iatrogenic ablation e.g. chemotherapy or pelvic radiation
Describe the different stages of menopause.
Early perimenopause:
- Duration of each cycle is > 28 days
- FSH increase
- No symptoms
Late perimenopause:
- Duration of each cycle is >= 60 days (2 months or more)
- FSH increase
- Vasomotor symptoms
Menopause
- No bleeding for 12 months
- FSH increase
- Vasomotor symptoms
Post menopause
- No bleeding for >12 months
- FSH stabilizes
- Urogenital atrophy
What are the 4 symptoms?
- Vasomotor symptoms
- Genitourinary syndrome of menopause
- Psychiatric disorders
- Bone loss
What are vasomotor symptoms? What is the cause?
- Vasomotor symptoms
a. Hot flushes
b. Night sweating
c. Intense feeling of heat on face, rapid/irregular HR, flushing/reddened face, perspiration, cold sweats, sleep disturbances, anxiety
d. Occurs several times a day
Cause: estrogen withdrawal –>thermoregulatory dysfunction occurs at the hypothalamus
What are the genitourinary symptoms? What is the cause?
Genitourinary syndrome of menopause (GSM)
a. Genital dryness
b. Burning/irritation/pain
c. Lubrication difficulty
d. Libido/painful intercourse/impaired sexual function
e. Urinary urgency
f. Dysuria
g. Recurrent UTI
Cause: reduced estrogen –> vulvovaginal lose collagen and fat deposits, thus barrier protection lost and lose ability to retain water
What are the psychological effects? What is the cause?
Psychological effects
a. Anxiety and depression
b. Poor concentration / memory
c. Mood swings
Cause: multi-factorial, stress, hormonal fluctuations
What is bone fragility? What is the cause?
Bone Fragility
a. Increase risk of osteoporosis and fractures
b. Increase joint pain
Cause: reduced estrogen –> more bone loss
When is non-pharmacological treatment of menopause used?
For mild symptoms
What are the non-pharm management of menopause?
Non-pharmacological (for MILD symptoms)
Mild vasomotor symptoms
- Remove layered clothings
- Lower room temp
- Less spicy food/caffeine/hot drinks
- Isoflavones –> natural estrogen found in soybeans and legumes
- Black Cohosh –> herb from North America, serotonergic effects at hypothalamus
- Exercise
Mild GSM
- Use lubricants / moisturizers
When are pharmacological management of menopause used?
Moderate to severe symptoms, no response to non-pharm
When should HRT not be used for?
Pharmacological (for MODERATE to SEVERE symptoms)
Hormone Replacement Therapy (gold standard) –> tackle vulvovaginal & vasomotor symp
*should NOT be used solely for:
- Treatment of low libido
- CVD prevention
- Depression/anxiety/cognitive/memory issues
- Itchy skin/hair loss
- Treatment of osteoporosis
When should we use estrogen only and COC?
Estrogen:
When to use: Can only give to those who have no uterus or give local vaginal estrogen e.g. cream / pessary
COC:
When to use: Progesterone protects the endometrium from overgrowth and lowers the risk of endometrium cancer
(when have uterus)
What are the different formulations fo estrogen only and COC?
Formulation:
1. Estrogen-only
Oral
topical (patches, gel)
local (cream, pessary)
- COC
Oral
What are the pros and cons of estrogen only HRT?
- Systemic Oral tablets
Pros:
- Relatively cheap
Cons:
- High dose –> Many ADR
- Potential for missed dose –> irregular bleeding
- Systemic Topical (patches and gels)
Pros:
- Lower dose –> less ADR
- Convenient
- Continuous estrogen release
Cons:
- Expensive
- Skin irritation (rotate site)
- Gel has more variability in absorption
- Local Vaginal (Pessary and creams)
Pros:
- Lowest dose –> least ADR, no need progesterone
- Continuous estrogen release
Cons:
- Inconvenient /uncomfortable
- Vagina discharge
- Only for localized urogenital atrophy/GSM (since little to no systemic absorption)
What are the pros and cons of COC?
- Continuous-cyclic
Progestins added on either 1st or 15th day of month for 10-14 days
Pros:
- Allows regular bleeding (predictable)
–> Withdrawal bleeding when progestin is stopped (regular cycle)
Cons:
- still have bleeding
- Continuous-combined
E and P daily
Pros:
- Amenorrhea (after several months)
Cons:
- Initially breakthrough bleeding (unpredictable)
Side Note:
Progestins
- Not considered as standard therapy, mainly to reduce risk of endometrium cancer caused by unopposed estrogen
- usually NOT used alone for menopause therapy
What are the contraindications and precautions for estrogen only HRT?
Under IC16
1. VTE
2. Breast Cancer
3. MI/ischemic stroke
4. Uncontrolled HTN >160/110
5. Vascular disease
6. Peripheral vascular disease
7. Endometrium cancer
8. Smoke >= 15 sticks/day AND >=35 y/o
What to monitor when starting on HRT?
- Takes 2-3 months to see significant improvements in menopausal symptoms
- Educate patient to continue + be aware of the ADR
- Upon initiation
- Do annual mammogram
- Endometrial surveillance (below are signs that should NOT occur)
a. Unopposed estrogen: any vaginal bleeding
b. Continuous-cyclic: bleeding while still on progestins
c. Continuous-combined: bleeding is prolonged and heavier, frequent, persists for >10months after treatment started
- Upon discontinuation, 50% chance of symptoms returning
Other than HRT, what other medications can be used to manage menopause symptoms?
Antidepressants (only help with vasomotor symptoms and psychiatric symptoms)
- Selective serotonin reuptake inhibitors (SSRI) e.g. Paroxetine
- Serotonin and norepinephrine reuptake inhibitors (SNRI) e.g. Venlafaxine
- Gabapentin (help with night sweats and sleepless nights by knocking the person out)
- Tibolone
- Estrogenic, progestogenic and androgenic effects
- Benefits: help with vasomotor symptoms, GSM, psychological effects and protects against bone loss
- Risks: stroke, breasts cancer recurrence, endometrial cancer
- ONLY given to postmenopausal women (no bleeding for >12 months)
