Mensural Disorders Flashcards
What causes menstrual cycles?
Hormonal activity of the hypothalamus, pituitary gland, and ovaries (HPO)
What is a single menstrual cycle?
the onset time between two menstrual flow periods
What is the average age for menarche (initial cycle) in the US?
12 years old (11-14.5 years old)
What is the median cycle length and what is the range for adults?
28 days (range from 25 - 34 days for adults)
How long is the median cycle length? When does the most blood loss occur?
Menstrual period lasts 3-7 days; most blood loss during days 1 and 2
Which menstrual disorders are appropriate for self-care?
Primary dysmenorrhea and premenstrual syndrome
Which major events occur during the menstruation period?
- Maturation/ Release of ovum
2. Preparation of uterine endometrial lining for implantation by fertilized ovum
What is the timing and onset age of symptoms for primary and secondary dysmenorrhea?
1: 6-12 months after menarche but typically several years later,
age: 13-17
2: ≥2 yrs after menarche OR begins after years of normal cycles
Age: typically midlate 20s or older
What are the causes for primary and secondary dysmenorrhea?
- Idiopathic (no identifiable causes)
No pelvic pathology
associated with cramps at time of menstruation - Associated with pelvic pathology
Describe the menses for primary and secondary dysmenorrhea?
- Regular with normal blood loss
- Irregular
Menorrhagia (heavy/prolonged bleeding) and intermenstrual bleeding is common
What is the pattern and pain for primary and secondary dysmenorrhea?
- Onset before/during menses
Pain with most periods
Lasts 2-3 days - Yes, occurs any time
Is there a response to NSAIDS and OTCs for primary and secondary dysmenorrhea?
- Yes
2. Depends on cause of pain
What are some other symptoms of primary and secondary dysmenorrhea?
- Fatigue, headache, nausea, change in appetite, backache, dizziness, irritability, depression
- Vary according to cause of pain. May include dyspareunia (painful intercourse) and pelvic tenderness
What are counseling points for patients taking NSAIDS for primary dysmenorrhea?
Regimen: Ibuprofen or naproxen are first line options
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)
Timing: use for first 48-72h of menses
Optimal relief when taken on a schedule (vs PRN)
Treat 3-6 menstrual cycles w/ changes in agent, dosage, or
both before determining efficacy
If one does not work, try the other
Adverse Effects: Analgesic effect plateaus (further dose increases may
only increase ADRs)
ADRs: GI (dyspepsia, vomiting, heartburn, abdominal pain,
diarrhea, constipation)
Pregnancy/Lactating: Ibuprofen ok in lactating patients; naproxen half
life is concerning
Avoid if trying to get pregnant
What is the dosing regimen for NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?
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
What is the timing for NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?
-use for first 48-72h of menses
-Use at onset of menses or pain; if inadequate relief, begin 1-2 days before expected menses
-Optimal relief when taken on a schedule (vs PRN)
-Treat 3-6 menstrual cycles w/ changes in agent, dosage, or both before determining efficacy
o If one does not work, try the other
What are the adverse effects associated with NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?
- Analgesic effect plateaus (further dose increases may only increase ADRs)
- ADRs: GI (dyspepsia, vomiting, heartburn, abdominal pain, diarrhea, constipation)
What are some concerns associated with pregnant/lactating people when taking NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?
o Ibuprofen ok in lactating patients; naproxen half life is concerning
o Avoid if trying to get pregnant
What are some counseling points for patients taking Aspirin used to treat primary dysmenorrhea?
o Adequate for mild pain but limited effect on prostaglandins
(moderately effective)
o May increase menstrual flow
o Avoid in children and adolescents
What are some counseling points for patients taking hormonal contraceptives used to treat primary dysmenorrhea?
o Combination oral contraceptive, vaginal ring, transdermal patch, etc
What are some counseling points for patients taking dietary supplements used to treat primary dysmenorrhea?
o Very limited evidence for many supplements!
o May consider
Omega-3 fatty acids (180 mg eicosapentaenoic acid + 120 mg
docosahexaenoic acid)
Cholecalciferol (vitamin D3) 600 units daily
Differentiate premenstrual syndrome from typical premenstrual symptoms and premenstrual dysphoric disorder
• Typical premenstrual symptoms: Symptoms do not interfere with
normal life functions
• Premenstrual syndrome (PMS): ≥1 symptom during 5 days before
menses + negative effect on daily functioning and distress
• Premenstrual dysphoric disorder (PMDD): Severe form of PMS with ≥5
symptoms that interferes w/ relationships and/or work
What are the common negative and positive symptoms associated with premenstrual syndrome (PMS)?
o Common negative symptoms
Fatigue, lack of energy
Irritability, anger
Labile mood (alternating sadness/anger)
Depression, decreased interest in usual activities
Anxiety, feeling stressed
Crying spells, oversensitivity
Difficulty concentrating
Abdominal bloating, pedal edema
Breast tenderness
Appetite changes (overeating/cravings)
Headache
Hypersomnia/insomnia
Joint/muscle pain
Feeling out of control/overwhelmed
o Common positive symptoms
Increased energy, more efficient at work
Increased libido, more affectionate Increased sense of control
Greater self-assuranceWhat is premenstrual dysphoric disorder?
Severe form of PMS with ≥5 symptoms that interferes w/ relationships and/or work
o Similar to PMS but greater severity
o Impairs relationships or ability to function well at work/school greater than PMS
What are the common symptoms of premenstrual dysphoric disorder (PMDD)? Also what symptoms are required for diagnosis of this disorder?
o Most common symptoms are mood-based; diagnosis requires:
Marked anger or irritability or depressed mood, anxiety or emotional lability
Difficulty concentrating, lethargy, hypersomnia/insomnia, breast tenderness, bloating
Significant impairment in functioning socially or at work week before
menses
Occur during most cycles in previous year and symptoms during last 7 days of cycle should be ≥30% worse than during days 3-9
o Refer to PCP to ensure proper diagnosis and management
What is the relationship between Calcium and Vitamin D treatments to premenstrual syndrome?
o Inverse relationship between both milk and vitamin D intake and PMS
o High dietary intake of both Ca and vitamin D may prevent PMS sx
o Improvement/efficacy of emotional and physical symptoms with
600mg BID
—-> >50-75% symptom improvement
What are the adverse effects associated with taking Calcium and Vitamin D for premenstrual syndrome?
Constipation. nausea
What is the dosing regimen for taking Calcium and Vitamin D for premenstrual syndrome?
- 1000 - 1300mg (Meet daily recommendations in diet first; supplement PRM)
- Good initial treatment: 500 - 600mg calcium BID + 600 IU vit D daily
What are counseling points for Pyridoxine treating premenstrual syndrome? Include the dosing regimen and potential risks associated with this treatment.
Dosing: 100mg daily
Max: 100mg/day
-risk of peripheral neuropathy above the daily max)
Mixed results; one study found that daily use improved mood
What are counseling points for Magnesium treating premenstrual syndrome? Include the dosing regimen and potential risks associated with this treatment.
Dosing: 360mg daily during luteal phase
AEs: Diarrhea
-Deficiency leads to PMS symptoms (e.g. irritability)
-Affective symptoms reduced with magnesium pyrrolidine carboxylic acid
-Magnesium oxide not helpful
What are counseling points for Vitamin E treating premenstrual syndrome? Include the dosing regimen associated with this treatment.
Dosing: 100mg daily
–>Use for 3 cycles to reduce physical/mental symptoms
Deficiency not established with PMS
Limited evidence that supplements help
What are counseling points for NSAIDs treating premenstrual syndrome?
-Reduce physical sx only (headache, MSK pains)
-Take several days before/during menses
-Benefit may reflect coexistence of dysmenorrhea and PMS or PMS as
primarily physical symptoms
What are the diuretics used to treat premenstrual symptoms? What causes/symptoms would cause PMS patients to use diuretics?
- 3 products: caffeine, pamabrom, ammonium chloride
- Abdominal bloating due to fluid shift/redistribution (not sodium or water
retention) - Distention may be due to relaxation of gut muscle by progesterone
- Diuretics unlikely to be helpful for most patients (may benefit few
patients with true water retention/weight gain)
What are counseling points for Caffeine, a diuretic treating premenstrual syndrome?
Dosing: 100 - 200mg q3-4h
MOA: promotes diuresis by inhibiting renal tubular reabsorption of Na+ and water
Safe/effective though may develop tolerance to diuresis
AEs: Anxiety, restlessness, insomnia, worsened irritability
- additive AEs with other caffeine products
- may cause GI irritation
CI: Pts taking MAOIs or theophelline
What are counseling points for Pamabrom, a diuretic treating premenstrual syndrome?
Theophylline derivative in combo products or standalone agent
Dose: up to 50mg QID
AEs: GI irritation
CI: MAOIS or Theophylline
What are counseling points for Ammonium Chloride, a diuretic treating premenstrual syndrome?
• Acid-forming salt with short duration in oral dosages up to 3 g daily
divided into 3 doses (max 6 consecutive days)
• Larger amounts can produce significant GI and CNS AEs
• CI: renal or liver impairment (concern of metabolic acidosis)
What are counseling points for Combination Products treating premenstrual syndrome?
Common examples: Midol, Pamprin
Some contain APAP, caffeine/pamabrom, and pyrilamine (antihistamine)
Some contains NSAIDs or combo of analgesic + diuretic or antihistamine
Pain not common symptom
No evidence that antihistamine treats emotional symptoms
Not recommended routinely for PMS; reserved for headaches, MSK pain, concomitant dysmenorrhea
What are complementary therapies and what are their associated counseling points
o Chasteberry
- Efficacy in decreasing mild-moderate sx though effect possibly
overestimated
- Avoid in pregnant and lactating patients (affects estrogen receptors
and prolactin)
- Caution in patients taking hormones or who have hormone-sensitive
cancers
o St. John’s wort
- contraceptive effectiveness reduction
o Ginkgo
- One trial showed improved breast pain, anxiety, irritability, and
depression
- Antiplatelet effects (may increase risk of bleeding) and drug-drug
interactions
o Saffron
- One trial found 30 mg reduced PMS and depression sx
What are the risk factors associated with toxic shock syndrome?
o Strongest predictor is tampon use, especially high-absorbency
tampons
o Continuous uninterrupted use of tampons for ≥1 day during menses
o Using tampons to manage discharge or non-menstrual bleeding
What are the signs and symptoms associated with toxic shock syndrome?
o Primarily affects young patients 13-19 years old
o Characterized by high fever, profound hypotension, severe
diarrhea, mental confusion, renal failure, erythroderma, and skin
desquamation
o Prodromal symptoms 2-3 days before onset of full-blown syndrome
Malaise, myalgias, chills, vomiting, diarrhea, and abdominal pain
o Evolves quickly
High fever, myalgias, severe vomiting and diarrhea, erythroderma,
decreased urine output, severe hypotension, and shock
Neurologic manifestations (headache, confusion, agitation, lethargy,
seizures)
Acute renal failure, cardiac involvement, adult respiratory distress
syndrome
o Dermatologic manifestations are characteristic
Early rash (described as sunburn, diffuse, macular erythroderma,
non-itchy)
Skin sloughs off after 5-12 days on face, trunk, extremities
What are prevention strategies associated with toxic shock syndrome?
o Use sanitary pads instead of tampons during menstruation
o If must use tampons:
Use lowest-absorbency tampons compatible with needs
Alternate with pads (e.g., use pads at night) so tampons not
continuously used
Change 4-6x a day at least q6h, overnight use <8hours
o Wash hands before inserting anything into vagina (tampon,
diaphragm, sponge, medication, etc) – staph on skin
o Don’t leave contraceptive sponge, diaphragm, or cap in vagina
longer than recommended nor during menstruation
o Do not use tampons, sponges, or cervical caps during 12 weeks
after childbirth; may also be best to avoid diaphragm
o Patients with symptoms of TSS should remove tampon or device
immediately and seek emergency care
o Patients with history of TSS are at risk for recurrence (28-64%);
avoid tampons, IUCs, diaphragms, caps, sponges
Counsel patients on the treatment for primary dysmenorrhea
o Inadequate management can lead to increased pain sensitivity during times other than menses and increased sensitivity to nonuterine pain
o Goals: resolve or provide significant improvement in pain and minimize disruption of usual activities
o Self care appropriate for:
Healthy young patients with history consistent with primary dysmenorrhea AND are not sexually active
Previously diagnosed with primary dysmenorrhea
o NSAIDs and hormonal contraceptives are first line options (80-90% success)
o Treatment choice influenced by desire for contraception, previous medication experiences, and other preferences
Counsel patients on the treatment for premenstrual syndrome
o Single agent unlikely to address all symptoms
o Treat most bothersome symptoms (≥50% reduction ideal)
o Symptom log or calendars may be helpful and allow tracking
o Cost, future pregnancy, and adverse effects should be considered
o Mild-moderate generally appropriate for self-treatment
o Goals
Better understand premenstrual disorders
Improve or resolve symptoms to reduce impact on activities and relationships
Counsel patients on the treatment for premenstrual syndrome
o Use sanitary pads instead of tampons during menstruation
o If must use tampons:
Use lowest-absorbency tampons compatible with needs
Alternate with pads (e.g., use pads at night) so tampons not continuously used
Change 4-6x a day at least q6h, overnight use <8hours
o Wash hands before inserting anything into vagina (tampon, diaphragm, sponge, medication, etc) – staph on skin
o Don’t leave contraceptive sponge, diaphragm, or cap in vagina longer than recommended nor during menstruation
o Do not use tampons, sponges, or cervical caps during 12 weeks after childbirth; may also be best to avoid diaphragm
o Patients with symptoms of TSS should remove tampon or device immediately and seek emergency care
o Patients with history of TSS are at risk for recurrence (28-64%); avoid tampons, IUCs, diaphragms, caps, sponges
