Management of menstrual disorders 1 Flashcards
1
Q
Describe the menstrual cycle?
A
Day 1: first day of menstruation- period starts
Menstrual phase: lasts ~4-7 days
- shedding of endometrium
- 80mL of blood loss
Follicular phase
- endometrial proliferation
- FSH–> develops follicle–> increased oestrogen levels
- ends as oestrogen production peak–> surge in LH (which stimulates ovulation)
Ovulation: at ~day 14, mature egg released
Luteal phase
- production of progesterone & less potent oestrogen by corpus luteum
- endometrium maintained in case of pregnancy (implantation)
- when no pregnancy or implantation of fertilised egg, progesterone declines–> period starts again
2
Q
What is dysmenorrhoea?
A
- recurrent, significant pain associated with menstruation
- primary dysmennorrhoea- no identifiable cause
- secondary dysmennorrhoea- there is a cause
- most common gynaecoloical symptom reported
- >70% adolescent young women
- 40% adult women
3
Q
What are some causes of secondary dysmenorrhoea?
A
- endometroisis
- endometrial polyps
- fibroids
- PID, pelvic inflammatory disease
- IUD use
- malformations of the genital tract
4
Q
What makes having secondary dysmenorrhoea more likely?
A
- older women
- irregular periods
- heavy bleeding
- patterns in pain changing
- poor response to tx
5
Q
What is the pathophysiology of dysmenorrhoea?
A
- at the start of menstruation, endometrial cells release PGs to due progesterone withdrawal
- PG cause uterine contraction, vasoconstriction, nerve sensitisation which all lead to pain
- severity of pain is proportional to PG concentration
6
Q
What are some risk factors to dysmenorrhoea?
A
- early menarche- period starting
- heavy/ long duration of menstrual flow
- family hx
- smoking
- obesity
- social environment (lack of support)
- depression/ mood disorders
7
Q
What are the symptoms associated with dysmenorrhoea?
A
- cramping, suprapubic pain
- may extend to lower back, thighs
- usually begins in the first year of period
- starts several hours before menstruation
- may persist up to 2-3 days
- peak pain is with maximum blood flow
- others- diarrhoea, nausea, vomitting, light headedness, fever
- other causes of pelvic pain may worsen
8
Q
How is dysmenorrhoea diagnosed?
A
- menstrual history
- age at menarche, when did sxs start, length & regularity of cylce, dates of last few periods, duration of periods, amounts of bleeding
- pain
- type, location, radiation, timing, severity, duration
- associated symptoms
- diarrhoea
- degree of disbaility
- days off school/ work, effect on QOL
- rule out secondary dysmenorrhoea
9
Q
What is pharmacological approach to treatment?
A
- 1st line- NSAIDs
- 1st line- COCs
- 2nd line- progestins
10
Q
1st line- NSAIDs
A
- start at onset of symptoms and contnue regularly for 2-3 days
- use loading dose to start
- can start prophylactically 24-48 hours prior to menstruation if symptoms severe
11
Q
1st line- COC
How does it work?
A
- reduced endometrium= reduced PG= reduced pain
- may take 3 months for full relief
- less evidence compared with NSAIDs however used widely
- COCP containing 30mcg ethinylestradiol
- consider continuous use (extended cyles) if symptoms problematic
- can use with NSAIDs especially in the initial stages
12
Q
2nd line-progestins
Which ones?
A
- levonorgestrel IUD
- local effect on endometrium
- reduces menstrual flow, effective if heavy bleeding
- periods may be irregular, spotting can be problematic
- medroxyprogesterone depot
- induces endometrial atrophy
- reduces BMD+delayed return of menstruation
13
Q
What are some non pharmacological ways to manage dysmenorrhoea?
A
- aerobic exercise can be rlly useful
- helps to increase pelvic blood flow & induce good endorphins
- high frequency transcutaneous electrical nerve stimulation (TENS)
- acupuncture
- heat packs (may be as effective as ibuprofen)
- behavioural interventions- distraction techniques & sx awareness
14
Q
What is normal menstrual bleeding?
A
- average cycle is between 21-35 days
- average is 28 days
- bleeding is from day 1-7
- amount should be less than 1 pad or tampon per 3 hour period
15
Q
What classifies as heavy bleeding?
A
- loss of >80mL of blood
- > 7 days bleeding
- mestruation loss considered unacceptable to women
16
Q
What is heavy menstrual bleeding?
A
- menorrhagia
- heavy cyclical bleeding
- occurs over several consecutive cyles
- thought to be caused by inadequate haemostasis due to excess fibrinolytic activity & excess PG production
- haemostasis= process that prevents & stops bleeding
- presumed to be caused by hormone dysfunction
17
Q
What are some causes of heavy menstrual bleeding?
A
- endometrial polyps
- fibroids
- malignancy
- trauma
- hormonal contraceptives
- anticoagulants
- antipsychotics
- SSRIs
- tamoxifen
- danazol
- spirinolactone
- ginseng
- gingko
- phytoestrogens
18
Q
What types of heavy menstrual bleeding are there?
A
- ovulatory (more common)
- heavy but regular periods
- often accompanied by pelvic pain & PMS
- anovulatory
- irregular, unpredictable heavy bleeding
- typically occurs in <20 & >40 year olds
- also in PCOS, low body mass, excessive exercise
19
Q
How is heavy menstrual bleeding diagnosed?
A
- patient menstruation history
- age of menarche, frequency and amount of menstruation, impact
- labs- rule out secondary causes
- progesterone- FSH/ LH
- FBC & ferritin- assess anaemia
- TSH- rule out thyroid issues
- pelvic ultrasound (polyps / fibroids present in 25-50% patients)
- endometrial biopsy- rule out malignancy or pre- malignant conditions
- esp in women over 40, or if at risk of endometrial cancer
20
Q
What do we need to consider before begin treatment?
A
- need for contraception
- fertility considerations
- prescence of other symptoms/ medical conditions
- patient preference
- adverse effects
- if anovulatory- treatment must include hormonal therapy
21
Q
What pharmacological approach do we take for heavy menstrual bleeding?
A
- tranexamic acid- 1st line
- preferred if no pain (dysmenorrhoea)
- well tolerated
- NSAIDs
- start before or on 1st day of period & continuue regularly for 3-5 days or until cessation of period
- COCP
- commonly used but limited good quality evidence, may reduce blood loss by 43%
- progestin
- 21 day course if ovulatory
- 12 day course if anovulatory
- reduces blood loss by 80% however poorly tolerated and short term only
- levonorgestrel releasing IUD
- reduces blood loss by 70-90%
- medroxyprogesterone depot
- limited evidence
22
Q
What are some other pharmacological therapies that are rarely used?
A
- steroid hormones- danazol
- must be used with non hormonal contraception
- poorly tolerated- androgenic side effects- may be irreversible
- acne, oily skin, oedema, weight gain, hirsutism, voice changes, hot flushes, vagina dryness, reduced breast size
- GnRH agonists- goserelin
- induces amenorrhoeic state
- non hormonal contraception required
- A/E- hot flushes, sweating, sexual dysfunction, vaginal dryness, myalgia, oedema, mood changes
- not recommended for more than 6 months due to BMD loss
23
Q
How do we approach heavy menstrual bleeding non pharmacologically?
A
- surgery
- dilation & curettage
- can also have diagnostic role if endometrial biopsy inconclusive
- endometrial ablation- burning excessive endometrial growth
- hysterectomy- removal of uterus
- dilation & curettage
24
Q
Management of heavy menstrual bleeding, AMH
A
25
Q
How do you treat acute heavy menstural bleeding?
A
- if bleeding severe& haemodynamic instability or Hb is very low
- tranexamic acid IV 10mg q8h or PO 1-1.5g q6-8h until bleeding stops
- if TXA not tolerated or unavailable
- COCP q6h ethinylestradoil 30-35mcg
- medroxyprogesterone acetate 10mg q4h
- norethisterone 5-10mg q4h
- use until bleeding stops
- High dose estrogen may be required if bleeding continues
- COCP containing 50mcg ethinylestradiol q6h until bleeding stops
- need to taper progestin/COCP after bleeding stops
- regular hormonal therapy required to prevent further acute events
26
Q
Monitong patiets with abnormal uterine bleeding
A
- amount and frequency of flow
- breakthrough bleeding
- use of PRN analgesia
- QoL – number of days of school/work missed
- Side effects
- Complications (anaemia!!!)
- Trial therapy for 3 months, if inadequate adjust dose or change agent
27
Q
What is endometriosis?
A
- endometrial tissue grown outside of the uterus
- common in ovaries but can be in peritonium, cervix, vagina, bowel, colon, appendix
- cyclical hormonal changes lead tissue to growth and breakdown–> scarring
- cause unknown
- main concerns= pain & subfertility
28
Q
What are the symptoms of endometriosis?
A
- heavy bleeding
- abnormal bleeding
- bloating
- dysmenorrhoea
- dyspareunia
- subfertility
- pelvic pain
- painful defacation
29
Q
What are the risks associated with endometriosis?
A
- shorter cycle
- longer flow length
- family history
- higher socioeconomic status
- ?caffeine/ alcohol intake
30
Q
How is endometriosis diagnosed?
A
- symptom history
- pelvic exam, ultrasounds & MRI
- definitve diagnosis an only be made with a laproscopy
- visualise and remove lesions/ adhesions
- biopsy
31
Q
How is endometriosis treated pharmacologically?
A
- NSAIDs
- COCP
- Progestins
- Danazol
- GnRH agonists (goserilin)
32
Q
NSAIDs for endometriosis
A
- relieves pain
- best used regularly rather than prn
- option if trying to conceive
- inconclusive evidence on efficacy
33
Q
COCP for endometriosis
A
- usually well tolerated
- inhibits ovulation, less circulatory hormone, less endometrial growth
- cyclical or continuous (if sxs severe in “pill free” period)
- no evidence to support one over the other
34
Q
Progestins for endometriosis
- not suitable if woman is trying to conceive- can cause amenorrhoea
A
- levonorgestrel IUD, high dose medrocyprogesterone acetate 10mg BD oral or depot- short term only
- a/e: weight gain, irregular bleeding, mood changes
35
Q
Danazol for endometriosis
- not suitable if woman is trying to conceive- can cause amenorrhoea
A
- use limited by androgenic A/E
- limited duration: 6-9months
- non-hormonal contraception also required
36
Q
GnRH agonists (goserelin)
- not suitable if woman is trying to conceive- can cause amenorrhoea
A
- use limited by A/E (hot flushes, vaginal dryness, reduced BMD)
- “add back” therapy- giving low dose oestrogen/ progestin or tibolone- counteract BMD loss may extend treatment to 2 years
- tibolone 2.5mg daily reduces osteoporosis and vasomotor symptoms
- synthetic steroid that has estrogen effects in brain, bone, vaginal tissue- stops vaginal dryness
- non hormonal contraception required
37
Q
What is non pharmacological therapy for endometriosis?
A
- Symptoms often re-occur following cessation of medical treatment – surgery warranted
- Surgery is often necessary for large lesions
- laparoscopic ablation/removal of adhesions to total abdominal hysterectomy with bilateral salpingo-oophorectomy
- most women have at least 3 laparoscopies prior to major surgery
- medication may be used to delay surgery
- Symptoms can also re-occur following surgery
- no evidence to support any particular treatment before or after surgery to increase success
38
Q
What is PCOS- polycystic ovarian syndrome?
A
- inappropriate gonadotrophin secretion
- anovulation
- increased androgen production
- insulin resistance + hyperinsulinaemia
- LH secreted too frequently
- follicles don’t have time to develop properly so ovulation can’t occur
- LH also increases andogren production
- might be because of UP LH, no progesterone, no ovulation–> negative cycle
- no luteal phase= reduced progesterone= unopposed oestrogen
- risk of endometrial hyperplasia & cancer
39
Q
What are the clinical characteristics of PCOS?
A
- hyperandrogenism
- hirsutism- thick pigmented hair(upper lip/ lower abdomen)
- acne
- alopecia- hair loss, crown area of head
- oligomenorrhoea (infrequent) or amenorrhoea
- <9 menses per year
- central/ abdominal obesity (30-60% of PCOS sufferers)
- related to hyperandrogenism & hyperinsulinaemia
- complications
- impaired glucose tolerance & T2DM, metabolic syndrome & CV risk, OSA due to diabetes
40
Q
How is PCOS diagnosed?
A
- hyperandrogenism
- menstrual irregularity
- polycystic ovaries
- atleast 2 of these to have a PCOS diagnosis
41
Q
What are the treatment goals of PCOS?
A
- reduce hirsutism, maintain cycle regularity, decrease insulin resistance
- prevent long term complications
42
Q
How is PCOS treated?
A
- COCP- low dose estrogen & consider anti androgen progestogen (cyproterone/ dropirenone)
- regulates cycles & reduces androgenism
- reduces risk of endometrial cancer
- androgen hormones- contribute to growth & reproduction in menopausal women
- cyclical progestin- if COCP contraindicated
- 12 day cycle (e.g. MPA 10mg or norethisterone 5mg daily)
- levonorgestrel IUD- minimise endometrial overgrowth only
43
Q
What else is used to treat PCOS?
A
- metformin
- helps to improve cycle regularity
- improves insulin resistance
- minimal benefit to hirsutism c/w COCP
- spirinolactone
- hyperandrogenism symptoms only
- fertlity management
- metformin, clomiphene
44
Q
How do you manage PCOS non pharmacologically?
A
- 1st line treatment- reduce weight
- 5% weight loss helps to restore regular menstrual cycle
- possible reduces risk of endometrial cancer
- diet & exercise
- helps maintain weight
- reducing risk of T2DM & CV disease
45
Q
What is PMS & PMDD?
A
- premenstrual syndrome & premenstrual dysphoric disorder
- a cyclic recurrence of symptoms during luteal phase of menstrual cycle
- often symptoms dissipate(get worse) with onset of menses
- mixture of mood, phsycial and cognitive symptoms
- symptoms usually begin 25-35 years of age
- can exacerbate other chronic conditions (epilepsy, migraine, asthma)
- PMDD
- severe PMS
46
Q
How is PMS/ PMDD diagnosed?
A
Symptoms must be:
- characteristic of PMS/ PMDD
- limited to luteal phase (often worse few days before menses)
- impact daily life
- present for 2 consecutive cyles
- not explained by other diagnosis
- DSM5- classified as a mental health disorder
- can used GnRH therapy for 3 months diagnostically
47
Q
PMS diagnosis
A
- PMS- at least 1 affective and 1 somatic symptom during 5 days before menses
- Affective
- depression
- angry outbursts
- irrritability
- anxiety
- confusion
- social withdrawal
- Somatic
- breat tenderness
- abdominal bloating
- headache
- swelling of extremeties
- sx relieved within 4 days of menses and no not re-occur until day 13 of cycle
48
Q
PMDD diagnosis
A
- marked depressed mood
- Marked anxiety
- Marked affective lability
- Persistent anger/irritability
- Decreased interests in usual activities
- Difficulty concentration
- Lethargy, fatigue
- Changes in appetite (under/overeating)
- Hypersomnia/insomnia
- Sense of being overwhelmed
- Other physical symptoms (listed for PMS)
- sxs interfere with daily life and end a few dats after menses
49
Q
Assessing PMS & PMDD
A
- Daily symptom diary for 2-3 months
- If symptoms are not cyclical or not in luteal phase consider alternate diagnosis
- If symptoms do not interfere with daily living -> mild PMS
- If symptoms do interfere with daily living -> PMS
- What have they tried in the past?
- Anything worked? How long tried for? Including complementary therapies
- Any other medical conditions?
- Rule out potential causes – anaemia, hypothyroidism etc
- Any changes in period?
- Should not see any changes in PMS/PMDD
50
Q
How is PMS/PMDD treated?
A
1st line
COCP
- Mixed result – 50% no change, 25% better, 25% worse
- Use continuously – evidence for 168 day cycle n Consider anti-androgen progestogen if significant fluid retention
- Only COCP to be studied in RCT was ethinylestradiol with drospirenone
SSRIs
- Any SSRI can be tried
- Intermittent (2 weeks before menses until day 1-3 of period) just as effective as continuous
- If intermittent not effective switch to continuou
- Drug of choice for PMDD
51
Q
How is PMS/PMDD treated?
- 2nd line
A
2nd line
- Transdermal oestrogen and cyclical progesterone
- E.g. estradiol 100microg patch and micronised progesterone 100-200mg PV on day 17-28 of cycle
- may supress ovulation (not guaranteed)
- Higher dose SSRI
- Note: Progestogens
- Historically used but no evidence to support use
- IUD – only to reduce endometrial proliferation
- no effect on physical & mood symptoms
52
Q
What are some other ways PMS/PMDD is treated?
A
- GnRH agonists
- Effective but not routinely recommended
- Use limited by adverse effects
- Use “add-back” therapy (50-100microg estradiol patch and 100mg micronised progesterone, or tibolone)
- Diuretics – spironolactone
- 25-100mg/day during luteal phase
- Most helpful for fluid retention, bloating, breast tenderness
- NSAIDs
- Naproxen, mefenamic acid most studied although likely class effect
- May help with physical symptoms
- Complementary therapies
- Chasteberry, vitamin B6
- Ensure adequate calcium intake (1200-1500mg/day)
53
Q
How is PMS/PMDD non pharmacologically managed?
A
- Cognitive behavioural therapy – considered first line
- Patient education and symptom diary
- Knowledge can be empowering
- Exercise
- Regular aerobic exercise reduces severity of symptoms
- Diet
- Sodium restriction if bloating, caffeine reduction if irritable or insomnia
- Hysterectomy and bilateral oophorectomy = last line for severe symptoms
- Should trial GnRH agonist first
- HRT required if patient <45 years old
54
Q
What to monitor in PMS/PMDD?
A
- Symptoms – mood and physical
- Comparison to start of therapy
- Side effects
- Additional therapies
- Non-pharmacological
- Support from friends/family
- Try one agent for 2-4 cycles before switching to alternate therapy
