Module 1.1 (Management of Menstrual Disorders) Flashcards
Describe the menstrual cycle, include the 4 stages and the days at which they occur
- Day 1: first day of menstruation
- Menstrual phase: lasts ~4-7 days
> shedding of endometrium
> 80mL blood loss
- Follicular phase
> endometrial proliferation (normally 6-12 mm)
> FSH -> develops follicle -> increased oestrogen
> Ends as oestrogen production peaks -> surge in LH
- Ovulation: around day 14 –> mature egg released
- Luteal phase
> Production of progesterone & less potent oestrogen by corpus luteum
> Endometrium maintained
> Upon no implantation of fertilised product, progesterone declines and menstruation occurs
Intermenstrual length: 24-35 days
What is dysmenorrhoea?
Recurrent, significant pain associated with menstruation
> Primary dysmenorrhoea (no pathology)
> Secondary dysmenorrhoea
Most common gynaecological symptom reported by women
> >70% of adolescent/young women
> 40% adult women
What are the potential causes of seconday dysmenorrhoea? How to treat?
- Endometriosis
- Endometrial polyps
- Fibroids
- Pelvic inflammatory disease (PID)
- IUD use
- Malformations of the genital tract
> The treatment of secondary dysmenorrhoea involves treating the underlying cause
When/who is secondary dymenorrhoea more likely to occur?
- Occurs in older women
- Periods are irregular
- Dyspareunia, heavy bleeding, post-coital bleeding
- Patterns in pain changes
- Poor response to treatment
What has prostaglandins have to do with dysmenorrhoea? What do they cause?
At the start of menstruation endometrial cells release prostaglandins
> prostaglandin release = progesterone withdrawal
PG causes
- Uterine contraction
- Vasoconstriction -> ischaemia
- Nerve sensitisation
> Severity of pain is proportional to PG concentration
What are the risk factors for dysmenorrhea?
- Early menarche (when period starts)
- Heavy/long duration of menstrual flow
- Family history
- Smoking
- Obesity
- Social environment (lack of support)
- Depression/mood disorders
- Nulliparity –> women who hasn’t given birth to a child
What are the symptoms of dysmenorrhea? What can worsen it?
- Cramping, suprapubic pain
May extend to lower back, thighs
- Usually begins in the first year of menstruation
- Starts several hours before start of menstruation
- May persist up to 2-3 days
- Peak pain is with maximum blood flow
- Others – diarrhoea, nausea, vomiting, light headedness, fever
- Other causes of pelvic pain (IBS, chronic PID etc) may worsen
How to assess dysmenorrhea through the following:
A) Menstrual history
B) Pain
C) Associated symptoms
D) Degree of disability
E) What to rule out
A)
- Age at menarche, when did symptoms begin, length and regularity of cycles, dates of last few periods, duration of periods, amounts of bleeding
B)
- Type, location, radiation, timing, severity, duration
C)
- diarrhoea, nausea, vomiting, light headedness, fever
D)
- Days off school/work, effect on QoL
E)
- Rule out secondary dysmenorrhoea
What is 1st line treatmet for dysmenorrhea? When to start?
(NSAID)
1st line – NSAIDs
- Reduce PG synthesis
- Effective in dysmenorrhoea in 50-70% of patients
> decrease pain, nause and diarrhoea
> all equally effective (except aspirin)
- Start at onset of symptoms and continue regularly for 2-3 days
> use loading dose to start
> can start prophylactically 24-48 hours prior to menstruation if symptoms severe
What is 1st line treatmet for dysmenorrhea? How does it work? What drug and dose to use?
(COCP)
1st line – Combined oral contraceptive pill (COCP)
- Reduced endometrium = reduced PG = reduced pain
- May take 3 months for full relief
- Less evidence compared with NSAIDs however used widely
- Use COCP containing 30microg ethinylestradiol or less
- Consider continuous use (extended cycles) if symptoms problematic
> Can combine with NSAID
What are some 2nd line treatments for dysmenorrhoea? How do they work?
2nd line – progestins – limited evidence
- Levonorgestrel IUD –> avoids systemic AE of progestins
- Local effect on endometrium
- Reduces menstrual flow, effective if heavy bleeding (relatively invasive)
- Periods may be irregular, spotting can be problematic
- Medroxyprogesterone depot –> 3 monthly injections
- Induces endometrial atrophy = less endometrium = less PGs
- Reduces BMD (not recommended in younger patients) + delayed return of menstruation
> not good option for someone looking to conceive (inhibit cycles for upto 1 year)
- Other agents (limited evidence –> CCB, vitamins, fish oil, paracetamol, montelukast)
What are non-pharmacological treatments for dysmenorrhea?
- Aerobic exercise
- High frequency transcutaneous electrical nerve stimulation (TENS)
- Acupuncture
- Heat packs (may be as effective as ibuprofen!)
- Behavioural interventions
What is summary for dysmenorrhoea?
Painful menstrual bleeding
Potentiated by PG release
First line –> NSAIDs, COC
Start therapy early and continue regularly if needed
Can use NSAID and COC together
Consider non-pharmacological treatments
How long does an average cycle last for? When does bleeding occur? What is the amount of bleeding?
Average cycle between 21-35 days
> average is 28 days
Bleeding from day 1-7
Amount should be less than 1 pad or tampon per 3 hour period
What constitutes heavy bleeding?
- Loss > 80ml
- > 7 days bleeding
- Menstruation loss considered unacceptable to woman
What are some of the characteristics of heavy menstrual bleeding? Why does it occur?
Menorrhagia = menstrual bleeding that lasts more than 7 days
- Heavy cyclical bleeding
- Occurs over several consecutive cycles
- Thought to be caused by inadequate haemostasis due to excess fibrinolytic activity (excessive breakdown of clots) and excess prostaglandin production
> most of the time caused by hormone dysfunction
Causes of heavy menstrual bleeding
A) structural
B) systemic condition
C) medication
D) complementary medicines
A)
- Endometrial polyps
- Fibroids
- Malignancy
- Trauma
B)
- Hyper- or hypothyroidism
- Coagulopathies –> inherited or acquired
- Renal/liver disease
- PCOS
- Cushing’s
C)
- Hormonal contraceptives (incl. IUD)
- Anticoagulants
- Antipsychotics
- SSRIs
- Tamoxifen
- Danazol
- Spironolactone
D)
- Ginseng
- Gingko
- Phytoestrogens
Outline the details of heavy menstrual bleeding in:
A) ovulatory (more common)
B) anovulatory
A)
- Heavy but regular periods
- Often accompanied by pelvic pain and PMS
B)
- Excessive estrogen = buildup of endometrium
- No ovulation: no progesterone to cause a withdrawal bleed
- Irregular, unpredictable heavy bleeding
- Typically occurs in <20 and >40 year olds
- Also in PCOS, low body mass, excessive exercise
How to diagnose heavy menstrual bleeding?
Through exclusion of the following
Patient menstruation history
Age of menarche, frequency and amount of menstruation, impact
Labs (rule out secondary causes)
> progesterone (day 21-23 to see if ovulation is happening), FSH/LH
> FBC and ferritin –> assess anaemia because of excessive blood loss
Pelvic ultrasound (polyps/fibroids present in 25-50% patients)
Endometrial biopsy – rule out malignancy or pre- malignant conditions
> esp in women over 40 or if at risk of endometrial cancer
> nulliparity (infertility), new onset heavy bleeding, obesity, PCOS, family hx
What are the treatment coniderations for heavy menstrual bleeding?
- Need for contraception
- Fertility considerations
- Presence of other symptoms/medical conditions
- Patient preference
- Adverse effects
> If anovulatory –> treatment must include hormonal therapy because of risk of endometrial overgrowth and cancer e.g. use COCP
Provide some information about the below drugs for heavy menstrual bleeding:
A) Tranexamic acid
B) NSAIDs
C) COCP
D) Progestin
E) Levorgestrel releasing IUD
F) Medroxyprogesterone depot
A)
- Inhibits clot breakdown
- Preferred if no dysmenorrhoea
- 1-1.5g q6-8h for 3-5 days starting at menstruation
- Can reduce blood loss by almost 50%
- Caution if risk of VTE – unlikely to be a problem
- Well tolerated besides stomach upset and nausea
B)
- NSAIDs can reduce blood loss by 20-50%
- Start before or on first day of menses and continue regularly for 3-5 days of until cessation of menses
- Required doses may be higher than OTC doses (e.g. ibuprofen up to 1600mg/day)
- Use PPI with to help with stomach adverse effect
C)
- Commonly used but limited good quality evidence (may reduce loss by 43%)
- Good option if contraception is a concern
D)
- 21 day course if ovulatory to induce withdrawal bleed
- 12 day course if anovulatory
- Reduce blood loss by 80% however poorly tolerated and short term only –> risk of hyperestrogenism
E)
- Good option if no desire to get pregnant in next few years
- Reduce blood loss by 70-90%
Levonorgestrel IUD is a first-line option. It is an effective long-term treatment but may take 6 months before its full benefit (eg light bleeding, amenorrhoea) is seen. Adverse effects such as spotting and breast tenderness may take 3–6 months to settle but systemic adverse effects are usually minimal.
F)
- Limited evidence
- Takes few months to work –> use NSAIDs in the meantime
> NSADs and progestin IUDs have best satisfaction
> Tranexamic acid and COCs well tolerated
> Oral progestogen lowest satisfaction
Trial therapy for 3 months, if indequate adjust dose or change agent
What are the TWO treatment options that are rarely used for heavy menstrual bleeding? Why are they not used?
Steroid hormones (danazol)
- Poorly tolerated (androgenic side effects- may be irreversible)
> Acne, oily skin, oedema, weight gain, hirsutism, voice changes, hot flushes, vaginal dryness, reduced breast size
- Must be used with non-hormonal contraception
GnRH agonists (goserelin)
- Induces amenorrhoeic state
- Non-hormonal contraception required
- A/E – hot flushes, sweating, sexual dysfunction, vaginal dryness, myalgia, oedema, mood changes
> not recommended for more than 6 months due to BMD loss
What surgery option is there for heavy menstrual bleeding?
Dilation and curettage (D&C) –> procedure to remove tissue from inside the uterus
> can also have diagnostic role if endometrial biopsy inconclusive
> endometrial ablation
> hysterectomy = last line
What is the pharmacological treatment of acute heavy menstrual bleeding?
If bleeding severe + haemodynamic instability or Hb very low
> Tranexamic acid IV 10mg q8h (or PO 1-1.5g q6-8h) until bleeding stops
If TXA not tolerated or unavailable –> use until bleeding stops for the below drugs
- COCP q6h (ethinylestradiol 30-35microg)
- Medroxyprogesterone acetate 10mg q4h
- Norethisterone 5-10mg q4h
- use antiemetic prophylactically
> High dose estrogen may be required if bleeding continues
–> COCP containing 50microg ethinylestradiol q6h until bleeding stops
> Need to taper progestin/COCP after bleeding stops
> Regular hormonal therapy required to prevent further acute events
Diagnosis of PMS by affective and somatic symptoms
see attahed image
PMS: Sx relieved within 4 days of menses and do not re-occur until day 13 of cycle
PMDD: Sx interfere with daily life and end a few days after menses
