Menstrual Related Disorders Flashcards
Types of Menstrual Related Disorders
Pain with menstrual cycle:
Dysmenorrhea
Disorders of flow:
Abnormal uterine bleeding AUB
AUB w menstural periods (old term)
- Menorrhagia AUB w menstural periods (old term)
Hypomenorrhea - not much flow
Disorders of cycle length:
Amenorrhea No periods
Polymenorrhea Very freq peirods (<21 days)
Oligomenorrhea Not very freq (>35 days)
Dysmenorrhea
§ Recurrent, crampy pain associated with menses.
• Primary dysmenorrhea - no known cause
• Secondary dysmenorrhea - has a cause
§ Most common gynecological symptoms reported by women:
• >70% of adolescent or young women, 40% of adult women
Secondary dysmenorrhea: Potential causes
Endometriosis: Endrometrial linging grows outside uterus
§ Adenomyosis: Endrometrial tissue grow in myometrial layer (muscle layer of uterus)
§ Endometrial polyps: Benigh grown in endometrium
§ Uterine myomas (also known as fibroid)
§ Cervical stenosis: Narrowing of cervix
§ Obstructive malformations of the genital tract
Pathophysiology
decrease inprogesterone levels (Shedding of lining
Release prostaglandin)
↑PGF2α
↑PGE2
Sensitization of afferent nerves
Vasopressin
Myometrial contraction
Constriction of arterioles
Uterine
Ischemia
Pain
Note: Lysing endometrial cells release prostaglandins
Risk Factors
Early menarche (Eaarly period <12y)
Heavy and increased duration of menstrual flow
Family history
Smoking
Social environment: fewer social support, stressful close relationships
(Things affecting pain perception)
Lower socioeconomic status
Depression
Nulliparity: not having children
Diagnosis: Assessment
Symptoms:
§ Crampy, suprapubic pain
§ Starts several hours before start of menstruation
• may persist up to 2 – 3 days.
§ Peak pain is with maximum blood flow
§ Other symptoms: diarrhea, nausea and vomiting, lightheadedness and fever
Many E +P receptors in C+GI
§ Other causes of pelvic pain (i.e. IBS, IBD, chronic PID) may worsen.
Diagnosis: Assessment
oteher questions
§Menstrual history
§Age at menarche: How old were you when your period started
§Length and regularity of cycles, duration of periods, amount of bleeding
§Pain:
• Type, location, radiation, timing
• Severity, duration, progression
§Degree of disability (affect on QOL)
§Rule out secondary dysmenorrhea
Therapeutic Approach: Pharmacological
§ NSAID’s
• All equally effective - Because of prostaglandins
• Start at onset of dysmenorrhea and continue regular dosing x 2 – 3 days.
or around time they know they’re going to have issues with each regular peirod
§ Combined Hormonal contraceptives
§ Progestin only contraceptive
• Progestin only pill
• Depot medroxyprogesterone (DMPA)
§ Levonorgestrel IUS
Preferred over Cu IUD - some w Cu IUD make their coping worse
Maintains ling and atrophic lining ->
Shedding not as much
Atrophic lining - there is less menstraul bleeding nad dysmen is worse with higher menstrual bleeding
Ppl w heavy bleeds have worse dysmen
Therapeutic Approach: Non-pharmacological
Exercise Help with pain managmenet, decrease stress
§ High frequency transcutaneous electrical nerve stimulation (TENS)
§ Acupuncture
§ Topical heat therapy
§ Behavioral interventions – biofeedback, relaxation, hypnotherapy, mindfulness
Mixed evidence of acupunture, probably not harmful for someoen really suffering
Heating pad around pelivs to help in times of more pain
Cognitive behavioural tx, any kind of relaxation
Therapeutic Approach: CAM
§ Most evidence to support…
• Vitamin B1 100 mg daily
• Ginger 750 – 2000 mg during first 3
– 4 days of menses
§ Magnesium – small RCT’s (range of
doses in studies ie 360 – 500 mg per day)
Cochrane review: lack of evidence but at
least 1 RCT…
● Fish oils (omega-3 fatty acids)
● Fenugreek
● Valerian
● Zinc sulfate
Vit B1 prob has most evidence to support it
Can take it all the time to prevent dysmen
NO DOSING NEEDED FOR CAM
Abnormal Uterine Bleeding (AUB)
Defined as any change in menstrual period frequency, duration or amount of flow
(usually heavy), also includes breakthrough bleeding.
§ Anovulatory – irregular, unpredictable bleeding
§ Ovulatory – heavy, but regular menstrual cycles/periods
• called menorrhagia
Bleeding wihtout ovulation, PCOS is most common cause
If they don’t ovulate normally, there is no normal progesterone release
Endometrial lining is built unopposed, balance is affected and lining becomes heavy and can lead to bleed
Can also bleed when lining is too thin form too much prog
Abnormal Uterine Bleeding (AUB): Ovulatory
In Menorrhagia, imbalance between thromboxane and prostacyclin
Thromboxane comes from platelets, allows for platelet activation and vasoconstriction
Prostacyclin released from endothelial cells even in arteries and veins, causes platelet agg and vasodilation
Imbalance leads to heavier bleeding
Anovulatory Menstrual Cycles
Anovulatory Menstrual Cycles
§Inadequate progesterone secretion from lack of ovulation
§Endometrium experiences continued estrogen stimulation that is unopposed by
progesterone
§Endometrium lining breaks down but irregularly and can be heavier.
Etiology of AUB
§ Pregnancy or ectopic pregnancy
§ Structural:
● Polyps of the endometrium
● Submucous fibroids
● Malignancy
● Trauma
§ Medical conditions:
● Thyroid (hyper and hypo)
● Inherited coagulopathies
● Renal, liver disease
● PCOS
● Cushing’s
§ Medications:
● Hormonal contraceptives
● IUD’s
● Hormone therapy
● Anticoagulants
● Tamoxifen
● Danazol
● Spironolactone
§ Herbals:
● Ginseng, gingko,
phytoestrogens
NHP - plant like estrogen effects on estrogen recepotrs
- Regular use of ginseng or ginko
What is normal menstrual bleeding?
Menstrual cycle:
§Interval between 21 – 35 days (average is 28 days)
§Bleeding is 1 – 7 days.
§Amount should be less than 1 maxi pad or tampon per 3 hour period.
Important to ask during assessmnet
Diagnosis
Diagnosis of AUB is often one of exclusion and only after other causes have been
ruled out
§Patient history
§Menstrual history: age of menarche frequency and amount of menstruation
§Labs:
• progesterone – days 21 – 23
• TSH – r/o thyroid
Pelvic ultrasound
§Polyps or submucous fibroids in the uterus may commonly cause AUB
Fibroids in myometrial layer (smooth muscle layer), can determine size of endometrial lining to see if that is an issue
Endometrial biopsy
§To assess endometrium to r/o pre-malignant conditions or malignancy.
Hyperplasia is a pre-malignant sign
Progesterone level to determine if it is anovulatory and if progesterone is low within the range
Harder to determine for irrgular periods
Hyper and hypo throid could lead to it too
Treatment of AUB: Pharmacological
NSAIDs:
• Endometrial prostaglandins elevated in heavy
menstrual bleeding.
• NSAIDs can decrease blood loss by 20 –
50% if taken with menses.
• Start NSAID at first day of menses and
continue regular dosing for 2 - 3 days or until
cessation of menses.
As endometrial cells lyse, more prostaglandins released
Recommend 1st day regularly
Treatment of AUB: Pharmacological
§Combined hormonal contraceptives:
• Often first line if no contraindications
§Progestogens oral:
• Medroxyprogesterone acetate (MPA) oral, micronized progesterone or
norethindrone acetate*
• Recommended for 21 days for the last part of the cycle (ie days 5 to 26). Note:
may see different regimens.
§DMPA every three months
§Levonorgestrel IUS
*doses: MPA 10 mg daily, micronized progesterone 200 – 300 mg daily, norethindrone acetate 5 mg daily
Can consider prog only pills
Lean towards drospirenone, not notethindrone (can cause more breakthru bleeding)
*Progestogens = both synth and natural progesterone
Can consider prog only pills
Lean towards drospirenone, not notethindrone (can cause more breakthru bleeding)
Progestogens = both synth and natural progesterone
May see use for last 14 days of cycle
Management of Ovulatory AUB (Menorrhagia)
1st choice:
NSAIDs
or
CHC
If contraindications or inadequate response:
Progestogen oral or DMPA
or
LNG-IUS
Assess response in 3 months. If inadequate response
switch to another agent or increase dose (ie higher dose of progestin ie from MPA 10 to 20 mg)
Management of Anovulatory AUB
1st choice:
CHC
If contraindications or inadequate response:
Progestogen oral or DMPA
or
LNG-IUS
Assess response in 3 months. If inadequate response
switch to another agent or increase dose (ie higher dose of progestin ie from MPA 10 to 20 mg
Harder to predict with NSAIDs
Harder to prevent but can still use
Ulipristal (Fibristal)
§Selective progesterone receptor modulator (SPRM)
§Progesterone antagonist effects on fibroids (have selective antagonist or agonist
activity on progesterone receptors depending on target cells)
§Indicated for uterine fibroids
§Has been removed off the market because of safety risks (liver disease)
Ella
Worked very wlel for fibroids
Manily prog antagonist
5mg dose, with Ella it was 30mg so the liver risk doesn’t apply
Treatment of AUB: Antifibrinolytic Agents
Tranexamic acid (Cyclokapron™)
§1 gm TID po for 3 -4 days (starting on first
day of the period)
Role: women who do not want hormones
or heavy bleeding
Side effects: GI effects (nausea, diarrhea),
skin rash, color vision change
Reversible blockade on plasminogen
(inhibits conversion of plasminogen
to plasmin)
Note: VTE is theoretical risk, but not clinically relevant!
Can use for both types
Colour vision change not common
No cases reported with VTE
Pleasmin degrades a lot of proteis and plasma protein fibrin
Leading to a heavier bleed
By stopping thhe conversion to plasmin, you reduce that bleeding
Prevents fibrinolysis
Treatment of AUB
Surgical management:
§Dilatation and Curettage (D & C)
• Definition:
• Can also have a diagnostic role if endometrial biopsy inconclusive
Dilate cervix and scrape off endometrial layer
§Endometrial ablation
§Hysterectomy – if severe and if past childbearing
Treatment of Severe Acute Uterine Bleed
Nonemergency heavy bleed:
§CHC given bid to qid until bleeding stops. not given often
High dose of estrogen causes vasoconstriction in uterus and prevent heavy bleeding
If patient bleed is severe and there is hemodynamic instability or if Hgb very low…
§Inpatient - Premarin® 25 mg IV q4h x 24 hours
§D & C if no response in 2 – 4 doses of Premarin®
