Mensural Disorders

Question 1

What causes menstrual cycles?

Answer 1

Hormonal activity of the hypothalamus, pituitary gland, and ovaries (HPO)

Question 2

What is a single menstrual cycle?

Answer 2

the onset time between two menstrual flow periods

Question 3

What is the average age for menarche (initial cycle) in the US?

Answer 3

12 years old (11-14.5 years old)

Question 4

What is the median cycle length and what is the range for adults?

Answer 4

28 days (range from 25 - 34 days for adults)

Question 5

How long is the median cycle length? When does the most blood loss occur?

Answer 5

Menstrual period lasts 3-7 days; most blood loss during days 1 and 2

Question 6

Which menstrual disorders are appropriate for self-care?

Answer 6

Primary dysmenorrhea and premenstrual syndrome

Question 7

Which major events occur during the menstruation period?

Answer 7

1. Maturation/ Release of ovum

2. Preparation of uterine endometrial lining for implantation by fertilized ovum

Question 8

What is the timing and onset age of symptoms for primary and secondary dysmenorrhea?

Answer 8

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

Question 9

What are the causes for primary and secondary dysmenorrhea?

Answer 9

1. Idiopathic (no identifiable causes)
   No pelvic pathology
   associated with cramps at time of menstruation
2. Associated with pelvic pathology

Question 10

Describe the menses for primary and secondary dysmenorrhea?

Answer 10

1. Regular with normal blood loss
2. Irregular
   Menorrhagia (heavy/prolonged bleeding) and intermenstrual bleeding is common

Question 11

What is the pattern and pain for primary and secondary dysmenorrhea?

Answer 11

1. Onset before/during menses
   Pain with most periods
   Lasts 2-3 days
2. Yes, occurs any time

Question 12

Is there a response to NSAIDS and OTCs for primary and secondary dysmenorrhea?

Answer 12

1. Yes

2. Depends on cause of pain

Question 13

What are some other symptoms of primary and secondary dysmenorrhea?

Answer 13

1. Fatigue, headache, nausea, change in appetite, backache, dizziness, irritability, depression
2. Vary according to cause of pain. May include dyspareunia (painful intercourse) and pelvic tenderness

Question 14

What are counseling points for patients taking NSAIDS for primary dysmenorrhea?

Answer 14

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

Question 15

What is the dosing regimen for NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?

Answer 15

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

Question 16

What is the timing for NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?

Answer 16

-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

Question 17

What are the adverse effects associated with NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?

Answer 17

• Analgesic effect plateaus (further dose increases may only increase ADRs)
• ADRs: GI (dyspepsia, vomiting, heartburn, abdominal pain, diarrhea, constipation)

Question 18

What are some concerns associated with pregnant/lactating people when taking NSAIDS (Ibuprofen, Naproxen) used to treat primary dysmenorrhea?

Answer 18

o Ibuprofen ok in lactating patients; naproxen half life is concerning
o Avoid if trying to get pregnant

Question 19

What are some counseling points for patients taking Aspirin used to treat primary dysmenorrhea?

Answer 19

o Adequate for mild pain but limited effect on prostaglandins
(moderately effective)
o May increase menstrual flow
o Avoid in children and adolescents

Question 20

What are some counseling points for patients taking hormonal contraceptives used to treat primary dysmenorrhea?

Answer 20

o Combination oral contraceptive, vaginal ring, transdermal patch, etc

Question 21

What are some counseling points for patients taking dietary supplements used to treat primary dysmenorrhea?

Answer 21

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

Question 22

Differentiate premenstrual syndrome from typical premenstrual symptoms and premenstrual dysphoric disorder

Answer 22

• 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

Question 23

What are the common negative and positive symptoms associated with premenstrual syndrome (PMS)?

Answer 23

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-assurance

Question 24

What is premenstrual dysphoric disorder?

Answer 24

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

Question 25

What are the common symptoms of premenstrual dysphoric disorder (PMDD)? Also what symptoms are required for diagnosis of this disorder?

Answer 25

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

Question 26

What is the relationship between Calcium and Vitamin D treatments to premenstrual syndrome?

Answer 26

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

Question 27

What are the adverse effects associated with taking Calcium and Vitamin D for premenstrual syndrome?

Answer 27

Constipation. nausea

Question 28

What is the dosing regimen for taking Calcium and Vitamin D for premenstrual syndrome?

Answer 28

- 1000 - 1300mg (Meet daily recommendations in diet first; supplement PRM) - Good initial treatment: 500 - 600mg calcium BID + 600 IU vit D daily

Question 29

What are counseling points for Pyridoxine treating premenstrual syndrome? Include the dosing regimen and potential risks associated with this treatment.

Answer 29

Dosing: 100mg daily Max: 100mg/day -risk of peripheral neuropathy above the daily max) Mixed results; one study found that daily use improved mood

Question 30

What are counseling points for Magnesium treating premenstrual syndrome? Include the dosing regimen and potential risks associated with this treatment.

Answer 30

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

Question 31

What are counseling points for Vitamin E treating premenstrual syndrome? Include the dosing regimen associated with this treatment.

Answer 31

Dosing: 100mg daily -->Use for 3 cycles to reduce physical/mental symptoms Deficiency not established with PMS Limited evidence that supplements help

Question 32

What are counseling points for NSAIDs treating premenstrual syndrome?

Answer 32

-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

Question 33

What are the diuretics used to treat premenstrual symptoms? What causes/symptoms would cause PMS patients to use diuretics?

Answer 33

- 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)

Question 34

What are counseling points for Caffeine, a diuretic treating premenstrual syndrome?

Answer 34

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

Question 35

What are counseling points for Pamabrom, a diuretic treating premenstrual syndrome?

Answer 35

Theophylline derivative in combo products or standalone agent Dose: up to 50mg QID AEs: GI irritation CI: MAOIS or Theophylline

Question 36

What are counseling points for Ammonium Chloride, a diuretic treating premenstrual syndrome?

Answer 36

• 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)

Question 37

What are counseling points for Combination Products treating premenstrual syndrome?

Answer 37

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

Question 38

What are complementary therapies and what are their associated counseling points

Answer 38

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

Question 39

What are the risk factors associated with toxic shock syndrome?

Answer 39

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

Question 40

What are the signs and symptoms associated with toxic shock syndrome?

Answer 40

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

Question 41

What are prevention strategies associated with toxic shock syndrome?

Answer 41

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

Question 42

Counsel patients on the treatment for primary dysmenorrhea

Answer 42

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

Question 43

Counsel patients on the treatment for premenstrual syndrome

Answer 43

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

Question 44

Counsel patients on the treatment for premenstrual syndrome

Answer 44

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