Menstrual Disorder

Question 1

What is the average age of menarche?

Answer 1

Menarche = first period
average age = 12

Question 2

Early and late menarche

Answer 2

-early menarche: associated with breast cancer
-late menarche: associated with osteoporosis and increased fracture risk

Question 3

What influences the onset of menarche?

Answer 3

-race
-genetics
-nutritional status
-body mass (gymnast with delayed menarche due to muscles)

Question 4

What is the median cycle length of menses?

Answer 4

28 days
-more variability in adolescents bc their hormones are not balanced out yet (may have longer, irregular cycles)

Question 5

How long does the average menses last?

Answer 5

-3 to 7 days

Question 6

The average amount lost during the cycle

Answer 6

30 ml
-most blood is lost on days 1 and 2

Question 7

What does Menorrhagia mean?

Answer 7

-Loss of >80mL of blood per cycle or bleeding lasting longer than 7 days

-associated with severe anemia and impairments in
daily functioning

Question 8

What is Dysmenorrhea?

Answer 8

-Painful menstruation

Primary dysmenorrhea
Secondary dysmenorrhea

Question 9

Premenstrual Disorders

Answer 9

-Cyclic and composed of a combination of physical, mood,
and behavioral symptoms that occur during the luteal phase (after ovulation - the egg travels to the uterus)

Question 10

What are Menstrual Disorders eligible for OTC Treatment?

Answer 10

-Primary Dysmenorrhea
-Premenstrual Syndrome (PMS)

Complaints: Abdominal pain and cramping
Irritability, Fluid retention

Question 11

What differentiates primary from secondary Dysmenorrhea?

Answer 11

Both with Cramp-like lower abdominal pain during or before menstruation

-The symptoms: in primary: N/V, diarrhea, bloating, fatigue, headache

-Secondary Dysmenorrhea is caused by pelvic disease (infection of the uterus)

Question 12

Which patient population is mostly affected by Primary Dysmenorrhea?

Answer 12

-Teens and early 20s
-Increases in early and older adolescents and decreases after the age of 24 (hormones balanced, and they may use contraceptives which may help)
-up to 93% of adolescents affected

Question 13

When does Primary Dysmenorrhea happen?

Answer 13

Only during the ovulatory cycle

Question 14

What is the timing of Pain associated with Primary Dysmenorrhea?

Answer 14

-Starts with the onset of menstruation
-subsides in day 2-3

-N/V, fatigue, dizziness, bloating, diarrhea, headache

Question 15

Characteristics of Secondary Dysmenorrhea

Answer 15

-later after menarche (at least 2 years after menarche - mid to late 20’s)
-pelvic pathology
-may cause irregular menses
-pain outside of the ovulation cycle

Question 16

Nonpharmacologic Approach for Primary Dysmenorrhea

Answer 16

-Sleep
Hot bath/heating pad (vasodilation -> relaxes smooth muscles that cause abdominal cramping)
Light exercise (yoga, swimming)
Smoking cessation

Question 17

What are some OTC products that may help in pain reduction (no strong evidence)

Answer 17

-Omega-3-fatty acid (Fishoil): decreases the production of proinflammatory cytokines

-Vitamin D3: reduces production of prostaglandin

Question 18

Pharmacologic Approach for Primary Dysmenorrhea

Answer 18

Target is PAIN
-NSAIDs - Ibuprofen, Naproxen (BEST recommendation)
-Aspirin (high doses may increase bleeding)
-Tylenol (used when the woman is trying to get pregnant)

-Start 1-2 days before the menstrual cycle
-regular periods during the cycle

Question 19

Best pain medication if the woman tries to get pregnant

Answer 19

Tylenol

Question 20

Which of the Pain medications have DDI with Warfarin?

Answer 20

-NSAIDs
-Aspirin

Question 21

When to Refer

Answer 21

-Pain persists
-New symptoms occur
-> because there might be other things causing the pain
-Secondary dysmenorrhea and/or menorrhagia !!!!
-History of PID, infertility, irregular
menstrual cycles, endometriosis, or ovarian
cysts
-use of warfarin, heparin, or lithium
-Active GI disease (PUD, GERD, ulcerative
colitis)
-Diagnosis of bleeding disorder

Question 22

Premenstrual Syndrome (PMS)

Answer 22

-Symptoms usually begin in the teenage
years up to the early 20s
-only during the ovulary cycle
-disappears during pregnancy, breastfeeding and menopause

60-80%: mild symptoms
20-30%: clinically
significant symptoms
6-8%: severe symptoms

Question 23

Symptoms of PMS

Answer 23

-Fatigue, lack of energy
-mood changes
-breast tenderness (physical symptom)
-appetite and sleep change
-joint/muscle pain, headache

Positive: increased libido, sense of control, or energy

The presence and severity of symptoms differentiate PMS from regular premenstrual symptoms and PMDD

Question 24

Key differences in Menstrual Conditions
!!!

Answer 24

Typical premenstrual symptoms: mild, do not interfere with daily life

PMS: at least one mood or physical symptom during the 5 days before menses - negative effect on daily life

PMDD (PM dysphoric disorder): five or more symptoms (mood or physical) -should go away in the week after menses -> if NOT it might be Premenstrual exacerbation of other disorders

Premenstrual exacerbation of other disorders:
worsening of other disorders (often psychiatric, depression, anxiety) - there is no symptom-free interval

Question 25

When is a therapy considered effective?

Answer 25

When the symptoms are reduced by 50%
-may need multiple agents to address all symptoms (behavioral, physical symptoms)
-treat the most bothersome symptoms first

Question 26

Which supplements can be helpful for mood symptoms?

Answer 26

-Vitamin B6 (Pyridoxine) 100 mg (at high doses peripheral neuropathy)
-Vitamin D 600 IU daily
-Calcium 1200 mg in divided dose

Question 27

Which supplements can be helpful for bloating or fluid retention?

Answer 27

-Diuretics
-Ammonium chloride (Dont: use for more than 6 days and in renal/liver impairment)
-Caffeine
-Pamabrom (my cause gold urine)

Question 28

Why might diuretics not be helpful?

Answer 28

during menses the fluid is actually not retained but shifted to the abdomen, diuretics will just shift somewhere else

Question 29

What to look out for in caffeine

Answer 29

-Tolerance
-may worsen other PMS symptoms
-DDI with MAOI
-worsen insomnia and anxiety

Question 30

Why should combination products be not recommended?

Answer 30

-we want to treat the most severe symptoms first and go from there
-it contains Tylenol and NSAIDs -> pain is often not the chief complaint
-it contains antihistamines -> no evidence to be helpful in emotional symptoms of PMS

Question 31

Refer when:

Answer 31

-Severe PMS or PMDD
-uncertain, inconsistent patterns of symptoms
-symptoms started with taking oral contraceptives
-contraindications with specific agents