Problems commonly associated with menstruation Flashcards
Definition of puberty?
onset of maturity, tends to happen earlier in girls then boys 8-14 and 9-14 for boys
Definition of precocious puberty?
maturity that happens earlier than normal, if it happens before the age of 8 for girls and 9 for boys. Toddlers can go through puberty e.g. bodily hair and breast tissu
Definition of delayed puberty?
if a girl hasn’t developed breasy tissue by 13 or menstruation by 15 this is delayed and 14 for boys
What is amenorrhoea/dysmenorrhoea?
something isn’t right with period. E.g. period pain
What is menorrhagia?
bleeding is heavier than expected
What is premenstrual syndrome?
Physical and emotional symptoms which you can get in the 1 or 2 weeks before a period comes.
What is premature ovarian insufficiency?
Woman goes into menopause early before the age of 40. Can be linked to cancer and medication.
What is menopause?
average age is 51, time in which women stop having periods and you can no longer conceive. Chances of conceiving start to reduce over the age of 35 and by 40 you risk of miscarriage increases
What is postmenopausal bleeding?
Usually a reason behind this such as cancer, always would be investigated.
Incidence of dysmenorrhoea?
Research suggests 50-80% of women will have it at some point in their reproductive life
10% are severely debilitated
Difference between primary and secondary dysmenorrhoea?
PRIMARY
- Peak incidence teens to twenties
- Cramping with pelvic pain
- May radiate to thighs and back
- GI symptoms – nausea, vomiting and diarrhoea
- Headaches, fatigue or faintness
SECONDARY
- Peak incidence thirties, forties may be a link to fertility issues
- Consequence of other pelvic pathology – underlying reason why the pain is happening
- Pain may begin before menstruation, could be up to 3-5 days before
Aetiology of dysmenorrhoea ?
• Higher concentrations of prostaglandins in menstrual fluid [mainly PGF and PGE]
• Increased myometrial contractility – this is what causes the cramping pain
• Other potential mediators include
o Endothelin’s – vasoactive peptides
Role in [local] regulation of prostaglandin synthesis
o Vasopressin – post. Pituitary hormone
Stimulates uterine activity
Decreases uterine blood flow [vasoconstriction causes myometrial ischaemia contributing to the pain]
Mediators of prostaglanding production include endothelins and vasoactive peptides produced in the endothelium, as well as the posterior pituitary hormone, vasopressin.
Pathophysiology of dysmenorrhoea?
- Progestogen withdrawal triggers production of arachidonic acid and leukotrienes.
- Arachidonic acid is a precursor to prostaglandins [mainly PGF and PGE] , which cause vasoconstriction, myometrial ischaemia/hypoxia and myometrial contractility leading to pain.
- Leukotrienes are thought to contribute to myometrial contractility and vasoconstriction.
- Period pain comes about due to vasoconstriction and myometrial contraction; this is caused by the withdrawal of progesterone at the end of the menstrual cycle.
Pharmacological management of primary dysmenorrhoea?
Just treat the symptoms as there is no underlying issue
- NSAIDs
- OTC – Feminax Express, Feminax Ultra and measures to manage symptoms
- Oral contraceptive pill
o Inhibits ovulation
o Prevents increased PG synthesis in luteal phase
o Decreased uterine contractility
o Moderate the levels of hormones present to try and avoid having extreme levels
- Antispasmodics eg hyoscine butylbromide
o Limited by poor oral bioavailability – is commonly used anyway
o Unlicensed OTC – something that is used to manage symptoms of IBS but works to manage symptoms of cramps
Pharmacological management for secondary dysmenorrhoea
- Investigate and ascertain underlying cause
- Treat accordingly dependent upon underlying cause
- Options include
- -> Surgery – ablation (removal of thin uppermost layer of endometrium using heat methods), laser therapy etc
- -> Symptomatic relief (pain relief)
- -> Pharmacological interventions (non-analgesic treatments)
You are the pharmacist in a high street pharmacy. A young woman approaches the counter and requests a remedy for period pain. She is experiencing significant pain and leading to time off work. Questions to ask?
o Location, duration, before or after?
o Additional symptoms? Irregular bleeding, N&V, faintness, clammy?
o Other medication or medical conditions? – this could be a cause of the symptoms
o OTC options
Co-codamol, ibuprofen, naproxen, heat wraps, hyoscine (unlicensed)
o Other options
Hot water bottle, exercise – these both help to counteract the vasoconstriction that is happening and promote vasodilation
o Consider the need to refer for further investigation
Secondary dysmenorrhoea aetiology:
- Prostaglandin involvement
- Underlying pelvic pathology
- -> PID (would require antibiotic treatment) – pelvic inflammatory disease, need to treat it effectively as it is linked to infertility
- Endometriosis
- Menorrhagia
- Fibroids
- Uterine polyps etc…
Endometriosis- aetiology:
Benign, women on reproductive age – age 13 to late 40s
Endometrial tissue is found outside uterus
o Outside reproductive tract
o GI tract
o Urinary tract
o Lung
Even in embryos they can see some of the endometrial tissue is where is isn’t mean to be – showing they can be born with it
Aetiology - unclear – poorly understood
o Theory 1-embryological Theory 2 - Retrograde menstruation
reflux of menstrual loss
Increased prevalence with outflow obstruction
Epidemiology
o C. 10% of the female population, 75% recurrence 2 years post op
The two endometriosis theories?
Theory 1-embryological – cells de-differentiate back to their primitive form to endometrial cells, have found endometrial cells in peritoneum and post-mortem embryos
Theory 2 -
- Retrograde menstruation
- Reflux of menstrual loss
- Increased prevalence with outflow obstruction
Endometriosis- symptoms
Most common: pain, fatigue and subfertility
Common symptoms – caused by endometrial tissue travelling where is isn’t meant to be
Dyspareunia (painful intercourse)
Dyschezia (difficulty passing stool)
Dysuria – symptoms similar to a UTI, irritation on passing water and passing more water than usual, may be passing blood
Chronic pelvic pain & menstrual irregularities
Rarer symptoms
Cyclical haematuria (endometrial tissue in the bladder bleeds in response to hormonal variation)
Cyclical haemoptysis (endometrial tissue in the lungs bleeds in response to hormonal variation)
Cyclical tenesmus (constant need to open bowels)
Others: ureteric obstruction, rectal bleeding or rectal obstruction
Endometriosis - diagnosis
Diagnosis
o Pelvic exam (masses, reduced organ mobility – this happens because as the tissues travel they stick things together and loss mobility)
o Pelvic ultrasound (transabdominal or transvaginal) to identify/characterise masses
o Diagnostic laparoscopy
o NOT RECOMMENDED – bloods or MRI, they don’t give you the right level of results and they aren’t definitive
Staging of endometriosis:
Staging: Grades 1-4
o Milder symptoms.
o Limited correlation to pain, subfertility, prognosis
Stage 1-2
- Minimal to mild, poorly visualised on US
- Common implantation sites – uterine and ovarian
Stage 3-4
- Mod to severe, commonly associated with adhesions
- Rectovaginal endometriosis, bowel invasion (adenomyosis)
Management options for endometriosis?
Management
◦ Surgical treatment (laparoscopy or hysterectomy*) aims to
Hysterectomy an option for women who do not plan further/any pregnancy
◦ Restore normal pelvic anatomy
◦ Divide adhesions
◦ Ablate endometrial tissue
◦ Medical treatment aims to
◦ Aims to provide symptomatic relief and improve fertility if desired
Pharmacological management of endometriosis (NICE):
- 1st line (analgesia) – NSAIDs +/- paracetamol
- 2nd line (“shrinkers”) treatments utilise the fact that endometrial tissue is oestrogen dependent
o Drugs opposing oestrogen will inhibit growth of endometrial tissue
- Contraceptives: CHCs, POC, LNG – IUS – help to make sure there isn’t too much oestrogen being released within the body
- Progestogens
- GnRH analogues – gonadotropin releasing hormone. Used to manage the condition, they are also used in prostate cancer
- Antiprogestogens - Gestrinone/danazol (last resort) – very bad side effects so don’t tend to use if the patient hasn’t gone through all the other treatments.
New treatments:
- SARMS (selective androgen receptor modulator), immunomodulators, drugs targeting steroid biosynthetic pathways
What is Menorrhagia?
- Menstrual blood loss above 80ml per month (risk of Fe deficiency anaemia)
- Subjective – flooding, large clots (larger than 50p) , double sanitary protection, frequent sanitary changes
- 3 days menorrhagia =1 month /year of reduced QOL
- Tiredness as they have iron defiency
Epidemiology of menorrhagia?
30% of women complain of heavy bleeding
Aetiology of menorrhagia?
o unclear
o proteinoids have been implicated
o 60% of women have no underlying pelvic pathology or medical conditions which would account for this which is classed as DUB
Causes of menorrhagia ?
DUB (60%) dysfunctional uterine bleeding
- Absence of pelvic pathology, disease or pregnancy - idiopathic
Other gynaecological causes (35%)
- Menopause
- Fibroids, PID
- Miscarriage or ectopic pregnancy
- IUD – can make periods heavier
- Adenomyosis (inner lining of the uterus breaks through myometrium)
Endocrine & haematological causes (5%)
- Hepatic, renal or thyroid disease, PCOS. If you have some kind of liver or renal impairment it effects RBC production - Blood thinning medication or condition
Coagulopathy related (e.g. Von Willebrand disease)
Symptoms suggestive of underlying pelvic pathology ?
- Irregular bleeding – in-between periods
- Sudden change in blood loss – period lasted 4 days and now lasting 7-10 days
- Intermenstrual bleeding
- Post coital bleeding
- Dyspareunia (painful intercourse)
- Pelvic pain
- Premenstrual pain
Diagnosing menorrhagia:
Blood tests
–> FBC, Iron, Ferritin (thyroid??)
Physical exam (tummy, cervix, enlarged or tender ovaries and uterus)
Cervical smear
–>Pap smear/cervical smear
Endometrial biopsy
Ultrasound (pelvic or transvaginal)
–> uterus, ovaries and pelvis
Sonohysterography
Hysteroscopy
Management Options for menorrhagia:
Aims to provide symptomatic relief and improve fertility is desired
Surgical treatment option
- -> UAE (uterine artery embolization)
- -> Myomectomy (fibroidectomy – this is a cut off if they get to a certain size you have to remove them)
- -> Hysterectomcy
Pharmacological management of menorrhagia:
If contraception required:
o CHC, POC
o IUS/parenteral progesterone (IUS most effective) (Mirena)
If contraception is not required
o Tranexamic acid – antifibrinolytic reduced the blood loss from periods
o GnRH analogues/antagonists
o Mefenamic acid (NSAID) other NSAIDs can be used
o Oral progestogen (high dose [5mg] norethisterone – not used for contraception)
o Antiprogestogens - Gestrinone/danazol (last resort)
