Menstrual Disorders: Dysmenorrhea Flashcards
About the Menstrual Cycle
- Due to monthly cycling of female sex reproductive hormones (of hypothalamus, pituitary gland, ovaries)
- Single menstrual cycle = time between onset of one period of menstrual flow and the onset of the next
- Average age of menarche in US is 12 years old
- Median cycle length = 28 days (range 25-34)
- Menstrual period lasts 3-7 days; most blood loss during days 1 and 2
- Self-care appropriate for primary dysmenorrhea and premenstrual syndrome
Menstrual Cycle (Triggered? Major Events? If preg. does not occur?)
- Triggered by low estrogen and progesterone at end of last cycle
Major events occurring:
- Maturation/ release of ovum
- Preparation of uterine endometrial lining for implantation by fertilized ovum
If pregnancy does not occur,
- Corpus luteum breaks down and hormone levels decrease
- Leading to increase in prostaglandins -> ultimately leads to menstruation
Dysmenorrhea (Painful Menstruation): Primary vs Secondary
- Very common gynecologic problem
- Prevalence highest in adolescence (93% of those who menstruate affected)
- Leading cause of school absenteeism, lost working hours, and daily life
• Must differentiate between primary and secondary
- Primary is associated with cramp-like lower abdominal pain at time of menstruation in absence of pelvic disease
- Secondary is associated with pelvic disease (i.e., endometriosis, adenomyosis, ectopic pregnancy, etc)
Primary Dysmenorrhea Risk Factors
- Age under 30
- Nulliparity
- Early menarche (before 12)
- Heavy menstrual flow
- Tobacco smoking
- BMI <20
- PMS symptoms
- History of sexual assault
- Stress, anxiety, and depression
Dysmenorrhea Pathophysiology
- Prostaglandins and leukotrienes contribute substantially
- Increased levels -> excessive vasoconstriction -> uterine ischemia and pain
- Abnormal levels of nitric oxide and vasopressin may also be involved
Dysmenorrhea Presentation
- Cyclic pain directly related menses onset, usually subsides within 2-3 days
- Continuous dull ache with spasmodic cramping in lower midabdominal or suprapubic region
- Pain may radiate to the lower back and upper thighs
Additional symptoms
• Nausea, vomiting, fatigue, dizziness, bloating, diarrhea, headache
Dysmenorrhea Treatment
Self care appropriate for:
• Healthy young patients with history consistent with primary dysmenorrhea AND are not sexually active
• Previously diagnosed with primary dysmenorrhea
- NSAIDs and hormonal contraceptives are first line options
Exclusions for Self-Treatment
- Severe dysmenorrhea and/or menorrhagia
- Symptoms inconsistent with primary dysmenorrhea
- History of PID, infertility, irregular menstrual cycles, endometriosis, ovarian cysts
- Use of intrauterine contraceptives
- Allergy to aspirin or NSAIDs, intolerance for NSAIDs
- Use of warfarin, heparin, or lithium
- Active GI disease (PUD, GERD, ulcerative colitis)
- Bleeding disorders
Nonpharmacologic Therapy
- Sleep
- Hot baths or heating pad
- Exercise
- Discontinuing tobacco smoking or avoiding exposure
NSAIDs (dosing, AEs, how to take)
• Ibuprofen or naproxen are first line options (use for first 48-72h of menses)
- Ibuprofen 200-400 mg every 4-6h (max 1200 mg/day)
- Naproxen 220-440 mg initially, then 220 mg q8-12h (max 660 mg/day)
- Use at onset of menses/pain; if inadequate, begin 1-2 days before expected menses
- Optimal relief when taken on a schedule
- Treat 3-6 menstrual cycles w/ changes in agent, dosage, or both before determining efficacy
- If one does not work, try the other
- Analgesic effect plateaus (further dose increases may only increase ADRs)
- ADRs: GI (dyspepsia, vomiting, heartburn, abdominal pain, diarrhea, constipation)
- Ibuprofen ok in breastfeeding patients; naproxen half life is concerning
- Avoid if trying to get pregnant
Pharmacologic Therapy – Additional Options
• Aspirin
- Adequate for mild pain but limited effect on prostaglandins
- May increase menstrual flow
- Avoid in children and adolescents
• Acetaminophen
- Adequate for mild dysmenorrhea
- Ok during lactation
• Hormonal contraceptives
- Combination oral contraceptive, vaginal ring, transdermal patch, etc
Pharmacologic Therapy – Dietary Supplements
- Very limited evidence for many supplements!
- May consider
- Omega-3 fatty acids (180 mg eicosapentaenoic acid + 120 mg docosahexaenoic acid)
- Cholecalciferol (vitamin D3) 600 units daily
