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
24
Q
Management of heavy menstrual bleeding, AMH
A
