Menstruation-related Diseases I

Question 1

What is menstruation?

Answer 1

Menstruation is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina.

Question 2

What is menarche?

Answer 2

The initial/first menstruation cycle

Question 3

What is the average age of menarche?

Answer 3

12 years
May occur 9 - 16 years.

Question 4

What are the factors that influence the onset of menstruation?

Answer 4

Race
Genetics
Nutritional status
Body mass

Question 5

How long does the menstrual cycle last?

Answer 5

Average of 28 days
May range from 21 - 35 days

Question 6

How long does menstrual flow last?

Answer 6

Average of 5 days
May range from 3 - 7 days, but most of the bleeding occurs on days 1 and 2.

Question 7

What are the components of menstrual fluid?

Answer 7

Endometrial cellular debris and blood.

Question 8

What is the average amount of blood that is lost per menstrual cycle?

Answer 8

30 - 50 ml

Question 9

A loss of more than ___ ml of blood is associated with anaemia.

Answer 9

80 ml

Question 10

The menstrual cycle is regulated by the hormonal activity of _______

Answer 10

the hypothalamus, pituitary gland and ovary.

Question 11

What are the phases involved in the ovarian and menstrual cycles?

Answer 11

Ovarian:
i. Follicular phase: Days 1-14. FSH stimulates the maturation of ovarian follicles, which secrete estrogen, which promotes the growth of the endometrium. One follicle matures to a Graafian follicle.

ii. Ovulatory phase: About 3 days in length. During this phase, there is an LH surge, which aids the maturation of an ovum, and the production of prostaglandins and proteolytic enzymes, which are necessary for releasing the ovum from the Graafian follicle. Levels of estradiol (estrogen) decrease during LH surge. This may cause mid-cycle endometrial bleeding.
Ovulation happens 35-44 hours after the surge begins, and releases 5 to 10ml of follicular fluid which contains the oocyte mass; this event may cause abdominal pain (mittelschmerz) for some women.

iii. Luteal phase: Lasts for about 14 days (+/- 2). After the follicle ruptures, it is referred to as the corpus luteum, which secretes progesterone, estradiol and androgens, which alter the endometrial lining; glands mature, proliferate and become secretory in nature (secretory phase) in preparation for a fertilised egg. Progesterone and estrogen levels reach their peaks in the middle of the luteal phase, whereas levels of LH and FSH decline in response to the increase in these two hormones.

Menstrual cycle
i. Proliferative phase
ii. Secretory phase
iii. Menstruation: Overlaps and occurs during days 1-5 of the follicular phase.

Question 12

If pregnancy occurs, _______ released by the developing embryo supports the function of the corpus luteum.

Answer 12

human chorionic gonadotropin

Question 13

What is dysmenorrhea?

Answer 13

Difficult or painful menstruation

Question 14

Dysmenorrhea is divided into:

Answer 14

• Primary dysmenorrhea: idiopathic and associated with cramp-like abdominal pain with no identifiable pelvic disease
• secondary dysmenorrhea: associated with pelvic pathology

Question 15

Dysmenorrhea usually develops within _____ months of menarche and generally affects women during their teenage years and early 20s

Answer 15

6-12 months

Question 16

Discuss the Etiology of dysmenorrhea.

Answer 16

During menstruation, the endometrium and myometrium produce prostaglandins, which causes the uterus to contract and promote shedding of the endometrium. The pain felt is due to this contraction of the uterus.
Serum and endometrial prostaglandin levels are 3-4 times greater in women with dysmenorrhea than in women without it, and are highest during the first 2 days of menses, when dysmenorrhea commonly occurs.

Leukotrienes, inflammatory mediators known to cause vasoconstriction and uterine contractions, have also been found to be elevated in women with dysmenorrhea.
It has been suggested that leukotrienes may contribute significantly to dysmenorrhea in women who do not respond to therapy with prostaglandin inhibitors i.e., NSAIDS.

Question 17

Discuss the pathophysiology of dysmenorrhea.

Answer 17

At the end of the luteal phase, progesterone levels drop, resulting in an increase in arachidonic acid, a precursor for prostaglandins (PGF2a) and leukotrienes.

Prostaglandins stimulate uterine contractions and cervical narrowing, and release vasopressin.
Leukotrienes increase the sensitivity of uterine pain fibres.

The increased levels of prostaglandins, leukotrienes and vasopressin lead to strong uterine contractions and vasoconstriction, resulting in uterine ischemia and pain.

During normal menses, contraction pressure is 50 to 80 mm Hg, each lasting about 15 to 30 seconds with a frequency of 1-4 contractions every 10 minutes
With dysmenorrhea, contraction pressure may exceed 400 mm Hg, may last longer than 90 seconds, with a frequency of 1 contraction every 15 seconds. These contribute to ischemia and tissue hypoxia and, thus, to pain.

Question 18

What are the signs and symptoms of primary dysmenorrhea?

Answer 18

i. Pain in the mid-abdominal or suprapubic area which may radiate to the lower back and upper thighs.
ii. Nausea
iii. Vomiting
iv. Diarrhoea
v. Weakness
vi. Fatigue
vii. Dizziness
viii. Headache
ix Nervousness
x. Onset is several hours before or at the start of menses
xi. Dysmenorrhea occurs with the first 3 years after menarche, but not within the first 6 months.

Question 19

What are the signs that indicate secondary dysmenorrhea?

Answer 19

• If dysmenorrhea appears during first several cycles (within 6 months of) or years after menarche (at 25 years or older).
• If pelvic pain occurs at times other than during menses and is not related to the first day of menses
• If the patient experiences irregular menstrual cycles, has menorrhagia (heavy flow) or a history of pelvic inflammatory disease (PID) or infertility.

Question 20

Mention 5 causes of secondary dysmenorrhea.

Answer 20

1. Endometriosis
2. Pelvic inflammatory disease
3. Ovarian cysts
4. Benign uterine tumours
5. Uterine fibroids
6. Cervical stenosis
7. Congenital disorders
8. Intrauterine devices (IUDs)

Question 21

Mention 3 conditions that cause alterations to menstrual cycling.

Answer 21

• amenorrhea
• menorrhagia
• dysfunctional uterine bleeding

Question 22

Mention 5 non-pharmacological therapies for dysmenorrhea

Answer 22

1. Rest
2. Heat
   3 Regular exercise
3. Massage
4. Lifestyle changes e.g., cessation of smoking

Question 23

What are the pharmacological therapies for dysmenorrhea?

Answer 23

1. Analgesics
2. Hormonal contraceptives

Question 24

Why is Aspirin not recommended in adolescents?

Answer 24

Because of its association with Reye’s syndrome.

*Reye’s syndrome is an acute condition that causes swelling in the liver and brain.

Question 25

Mention 5 analgesics used in dysmenorrhea, their recommended dosage and maximum daily dosage.

Answer 25

Drug | dosage| maximum daily dosage

1. Acetaminophen| 650-1000mg every 4-6 hrs| 4000mg
2. Aspirin| 650-1000mg every 4-6 hrs| 4000mg
3. Ibuprofen| 200-400mg every 4-6 hrs| 4000mg

4.Naproxen sodium| 220-440mg initially, then 220 mg every 8-12 hrs| 660mg

5. Ketoprofen| 12.5-25mg every 4-8hrs (not more than 25mg within 4-6 hrs) | 75mg

Question 26

Mention 4 drug-drug interactions of Aspirin.

Answer 26

i. Anticoagulants e.g. warfarin
ii. Oral hypoglycemics
iii. High doses of antacids
iv. Probenecid
v. Phenytoin
vi. Valproate
Vii. Methotrexate

Question 27

What are the patient counselling points for primary dysmenorrhea?

Answer 27

i. Education about the condition
ii.They should be reassured of the normalcy of the condition
iii. Patients should be made aware that while the non-prescription non-salicylate NSAIDs are appropriate for therapy, not all women respond to them.
iv. Patients should be educated on the proper use of the medications and their adverse effects
v. Pharmacist should carry out follow-up to discuss therapy efficacy and emphasise the importance of scheduled dosing
vi. The patient with persistent symptoms should be advised to try another non-prescription non-salicylic NSAID or see a primary care provider for evaluation.
 

Question 27

What are the contraindications of aspirin?

Answer 27

i. Aspirin allergy
ii. Peptic ulcer
iii. Gastritis
iv. Bleeding disorders
v. Asthma
vi. Renal insufficiency