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PHRM 825 - Exam 5 > LECTURE 47 - AUB, endometriosis, UFs > Flashcards

LECTURE 47 - AUB, endometriosis, UFs Flashcards

1
Q

Describe “normal” period averages

A

First period (age of menarche) ~~ age 12-13
Cycle lengths → 22-35 days
Menstruation → 3-7 days
Average blood lost → 35 mL/day

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2
Q

Describe Dysmenorrhea

A

pain associated with menstruation

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3
Q

Differentiate between primary & secondary dysmenorrhea

A

Primary → normal ovulatory cycles & pelvic anatomy

Secondary → underlying anatomic or physiologic cause

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4
Q

Describe the pathophysiology of dysmenorrhea

A

inflammatory response to prostaglandins & leukotrienes

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5
Q

List risk factors for dysmenorrhea

A
  • < 20 YO
  • Weight loss attempts
  • Depression/anxiety
  • Heavy Menses
  • Menarche < 12 YO
  • Nulliparity (haven’t given birth)
  • Smoking
  • Family History
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6
Q

List symptoms of dysmenorrhea

A
  • Dizziness
  • Crampy pelvic pain
  • N/V
  • Diarrhea
  • Headache
  • Muscle Cramps
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7
Q

List the goals of therapy for dysmenorrhea

A

Symptomatic relief
Improved school/work productivity
Improve QOL/ADLs

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8
Q

When should a patient be referred based on their responsiveness to traditional therapy?

A

If symptoms have not lessened in severity in 3-6 months of traditional therapy, REFER !!

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9
Q

List the “first-line” treatment options for dysmenorrhea

A

NSAIDs
Oral Contraceptive
Non-Pharmacological treatment

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10
Q

Describe which NSAIDs can be used to treat dysmenorrhea & how they are used

A

How it works:
- MOA leads to decrease in PG production
- Dosing → around the clock 1-2 days before start of cycle
- Intended for short-term use

Drug options:
- Celecoxib (Rx)
COX-2 specific
- Diclofenac (Rx)
- Ibuprofen (Rx & OTC)
- Naproxen (Rx & OTC)

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11
Q

Describe which oral contraceptives can be used to treat dysmenorrhea & how they are used

A

How it works:
MOA leads to decreased endometrial production of PGs & LKTs

Dosing / type of OCs:
efficacy noted with cyclic & continuous regimens

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12
Q

Describe which non-pharmacological options can be used to treat dysmenorrhea

A

Options:
- Heating pad
- Exercise
- Nutritional supplementation (omega-3-FA, vitamin b, ginger)
- Smoking cessation
- Acupuncture

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13
Q

List the “second-line” treatment options & describe why they are second-line

A

Delayed relief with these options → often within initial months of therapy

Options:
Levonorgestrel-releasing IUD
Recommended to try before DMPA
- DMPA (depot medroxyprogesterone acetate)

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14
Q

Describe Amenorrhea

A

the absence of a menstrual cycle

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15
Q

Differentiate primary & secondary amenorrhea

A

Primary → no menses by age 15

Secondary → no menses x3 months
(in prev. menstruating pt.)

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16
Q

Describe the characteristics / symptoms of amenorrhea

A

Often asymptomatic
Can be accompanied by weight loss/gain

often a SYMPTOM rather than a condition itself

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17
Q

List lab test that should potentially be run for a patient with amenorrhea

A

Pregnancy test, FSH/LH levels, TSH, prolactin, estrogen

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18
Q

List potential causes of amenorrhea

A

PCOS, low BMI, eating disorders, excessive exercise
MEDICATIONS !!!

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19
Q

Describe the pathophysiology of amenorrhea

A
  • uterus & ovaries
    (anatomic abnormalities)
  • pituitary gland
    (disruption to GnRH, LH, FSH, and prolactin hormones)
  • hypothalamus
    (anorexia nervosa, bulimia, intense exercise, stress)
  • drug-induced amenorrhea
    (more on a different card)
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19
Q

List drugs that can induce amenorrhea

A
  • First-gen antipsychotics
    prochlorperazine, chloropyrazine
    haloperidol
  • Second-gen antipsychotics
    risperidone
  • Antihypertensives
    verapamil
  • GI promotility
    metoclopramide
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20
Q

List the goals of therapy for amenorrhea

A
  • Ovulation restoration → especially if fertility is desired
  • Bone density preservation
  • Bone loss prevention
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21
Q

What is the first step for choosing a treatment for amenorrhea?

A

rule out pregnancy
determine underlying cause

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22
Q

List non-pharmacological treatment options for patients experiencing amenorrhea due to anorexia

A
  • weight gain
  • consider work-up for ED
  • Cognitive Behavioral Therapy (CBT)
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23
Q

List non-pharmacological treatment options for patients experiencing amenorrhea due to excessive exercise

A

Reduction in exercise quantity & intensity

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24
List non-pharmacological treatment options for patients experiencing amenorrhea due to medications
- May consider alternate agents that do NOT inhibit dopamine receptor/increase prolactin levels - OR initiate dopamine agonist
25
List pharmacological treatment options & dosing regimens for patients experiencing amenorrhea due to being hypoestrogenic (low/no estrogen)
supplement estrogen (WITH progestin component) OPTIONS - conjugated equine estrogen (Premarin, Cenestin, Enjuva) - dosing: take 1 (0.65-1.25 mg) PO daily on days 1-25 of cycle - Estradiol patch (Cimara, Vivelle-Dot) - dosing: apply (0.1 mg) patch to the skin once or twice weekly
26
List pharmacological treatment options & dosing regimens for patients experiencing amenorrhea due to taking medications that increase prolactin levels
Provide dopamine agent - Bromocriptine - dosing: multiple daily dosing - Cabergoline - dosing: weekly or twice weekly dosing
27
List contraindications for dopamine agents (bromocriptine, cabergoline)
breastfeeding uncontrolled hypertension
28
List mild side effects for dopamine agents (bromocriptine, cabergoline)
nausea / diarrhea headache orthostatic hypotension fatigue
29
Define oligomenorrhea
menstrual cycle interval > 35 days (but < 90 days)
30
Describe the treatment options for oligomenorrhea
Overlaps with amenorrhea Similar causes & treatment approaches
31
Define polymenorrhea
menstrual cycle *interval* < 21 days
32
List common causes of polymenorrhea
Stress Infections (STDs) Endometriosis Menopause
33
What is a potential complication with polymenorrhea?
May cause challenges in conceiving
34
Define heavy menstrual bleeding (HMB)
Bleeding > 80 mL OR lasting > 7 days (previously called menorrhagia)
35
Describe the pathophysiology of HMB
Hematologic --Bleeding/clotting disorders Hepatic --Cirrhosis Endocrine --Hypothyroidism Uterine --Structural abnormalities --Uterine fibroids (up to 40%)
36
What must be ruled out before diagnosing a patient with HMB?
pregnancy ectopic pregnancy miscarriage
37
List the symptoms of HMB
Heavy blood flow with menstruation With or without pain (dysmenorrhea) Possible - fatigue and lightheadedness
38
List the goals of therapy for HMB
- Reduce menstrual blood flow - Correct iron-deficiency anemia or underlying disorders (if applicable) - Improve QOLs/ADLs
39
List the categories of the treatment options
Acute vs Chronic & Hormonal vs Nonhormonal
40
List hormonal treatment options
- Combined Hormonal Contraceptive (CHC) - Progestins - Levonorgestrel IUD - Danazol - GnRH agonists
41
List non-hormonal treatment options
NSAIDs Tranexamic Acid Iron (for iron deficiency, not for less bleeding)
42
What is the reduction in blood loss for NSAIDs?
10% - 51%
43
What is the reduction in blood loss for CHCs?
30% - 60%
44
What is the reduction in blood loss for oral progestins?
up to 80%
45
What is the reduction in blood loss for tranexamic acid?
up to 50%
46
What is the reduction in blood loss for IUDs?
up to 97% *after 1 year of treatment*
47
What HMB treatment categories is tranexamic acid in?
Acute (short-term) - duration of menses & non-hormonal - for those who are unable to take CHCs / want to conceive
48
List the contraindications for tranexamic acid
Active &/or history of DVT or pulmonary embolism (PE) History of seizure
49
List the side effects of tranexamic acid
*Generally well-tolerated* Can cause headache (HA), nasal sx
50
List the preferred agents for acute management of HMB
high dose estrogen (EE): - conj. equine estrogens (25mg IV Q4-6h x 24 hrs) - monophasic OC (30-35mcg EE po Q6-8h until bleeding stops)
51
List the preferred agents for acute management of HMB - IF - the patient has a contraindication to estrogen therapy
Medroxyprogesterone (20mg PO TID x 7 days)
52
List the preferred agents for acute management of HMB - IF - the patient has a contraindication to hormone therapy
Tranexamic acid (1,300 mg PO TID (Q8h) x 5 days)
53
Define metrorrhagia
irregular bleeding between cycles
54
List possible causes of metrorrhagia
- Hormone imbalance - Fibroids, polyps, endometriosis - Medications - IUDs - Infections
55
Describe the treatment options for metrorrhagia
*target underlying cause* hormonal contraceptive
56
Define endometriosis
Pelvic inflammatory condition associated with growth of endometrial tissue found outside the uterus
57
List the characteristics of endometriosis
Asymptomatic → → Severe Symptoms Most common: - dysmenorrhea - infertility - dyspareunia
58
List the risk factors for endometriosis
- < 20 YO - Weight loss attempts - Depression/anxiety - Heavy Menses - Menarche < 12 YO - Nulliparity (haven’t given birth) - Smoking - Family History
59
List common symptoms of endometriosis
- *Dysmenorrhea* - *Chronic pelvic pain* - Dyspareunia - Infertility (common complication) - Heavy bleeding - Chronic fatigue - Dyschezia - Dysuria - Painful bowel movements - Abdominal bloating - Flank pain the non-specific symptoms often lead to delayed diagnosis
60
List the goals of therapy for endometriosis
- Minimization of endometrial lesions - Prevention of endometriosis progression - Minimization of pelvic pain - Prevention/correction of infertility (if desired)
61
List non-pharmacologic treatment options
Exercise Acupuncture Massage CBT Surgery
62
List "first-line" treatment options for endometriosis
NSAIDs CHCs Progestins
63
List "second-line" treatment options for endometriosis
GnRH agonists / antagonists Danazol
64
Describe danazol
- second-line treatment for endometriosis - androgen that suppresses FSH & LH production
65
What is the limiting factor of Danazol?
intolerable side effect profile BLACK BOX WARNING: thromboembolism - weight gain - acne - hirsutism - lipid abnormalities - liver dysfunction - changes in blood glucose CONTRAINDICATED in pregnancy & breastfeeding
66
List "second-line" treatment options for endometriosis
aromatase inhibitors
67
What monitoring & follow-up should be done for patients being treated for endometriosis?
Assess patient symptom improvement (pain rating scales, self-reported symptoms, etc.)
68
Define Uterine Fibroids ("leiomyomas")
common noncancerous growths in the uterus (most common pelvic tumor)
69
List risk factors for uterine fibroids
- Black Race - Age - Family history - Time since last birth - Premenopausal - HTN - Early menarche (< 10 YO)
70
List protective factors for uterine fibroids
- Smoking (*do NOT tell pts*) - Pregnancies (>/= 3) - Hormonal contraception use
71
List symptoms of uterine fibroids
Can be asymptomatic - Heavy menstrual bleeding → anemia & fatigue - Dysmenorrhea - Non-cyclic pain - Abdominal protuberance - Painful intercourse or pelvic pressure - Bladder or bowel dysfunction - Reproductive problems
72
List the goals of therapy for uterine fibroids
- Reduce size (or completely remove) fibroids - Reduce symptoms (pain, HMB) - if applicable - Respect patient’s fertility wishes - Improve QOL/ADLs
73
List considerations that are used to determine treatment
Severity of symptoms Patient aga Reproductive plans
74
List types of non-pharmacological treatment
expectant therapy myomectomy hysterectomy
75
Describe expectant therapy (uterine fibroids)
- no action unless condition changes - used if patient is asymptomatic or mildly symptomatic - fertility IS preserved
76
Describe myomectomy (uterine fibroids)
- removal of fibroids (surgical / endoscopic) - used for resolution of symptoms while preserving uterus - fertility IS preserved
77
Describe hysterectomy (uterine fibroids)
- removal of uterus - used because it is a DEFINITIVE treatment - fertility is NOT preserved
78
List options for pharmacological treatments of uterine fibroids
- NSAIDs - CHCs - Levonorgestrel IUD - Tranexamic Acid - GnRH agents - Selective progesterone receptor modulators (SPRM)
79
Which pharmacological treatments for uterine fibroids reduces the fibroid size?
Levonorgestrel IUD GnRH agents SPRMs
80
Which pharmacological treatments for uterine fibroids helps with dysmenorrhea?
- NSAIDs - CHCs - Levonorgestrel IUD - GnRH agents
81
Which pharmacological treatments for uterine fibroids helps with HMB?
NSAIDs CHCs Levonorgestrel IUD Tranexamic Acid GnRH agents SPRMs

PHRM 825 - Exam 5 (10 decks)

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