Problems commonly associated with menstruation

Question 1

Definition of puberty?

Answer 1

onset of maturity, tends to happen earlier in girls then boys 8-14 and 9-14 for boys

Question 2

Definition of precocious puberty?

Answer 2

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

Question 3

Definition of delayed puberty?

Answer 3

if a girl hasn’t developed breasy tissue by 13 or menstruation by 15 this is delayed and 14 for boys

Question 4

What is amenorrhoea/dysmenorrhoea?

Answer 4

something isn’t right with period. E.g. period pain

Question 5

What is menorrhagia?

Answer 5

bleeding is heavier than expected

Question 6

What is premenstrual syndrome?

Answer 6

Physical and emotional symptoms which you can get in the 1 or 2 weeks before a period comes.

Question 7

What is premature ovarian insufficiency?

Answer 7

Woman goes into menopause early before the age of 40. Can be linked to cancer and medication.

Question 8

What is menopause?

Answer 8

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

Question 9

What is postmenopausal bleeding?

Answer 9

Usually a reason behind this such as cancer, always would be investigated.

Question 10

Incidence of dysmenorrhoea?

Answer 10

 Research suggests 50-80% of women will have it at some point in their reproductive life
 10% are severely debilitated

Question 11

Difference between primary and secondary dysmenorrhoea?

Answer 11

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

Question 12

Aetiology of dysmenorrhoea ?

Answer 12

• 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.

Question 13

Pathophysiology of dysmenorrhoea?

Answer 13

• 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.

Question 14

Pharmacological management of primary dysmenorrhoea?

Answer 14

 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

Question 15

Pharmacological management for secondary dysmenorrhoea

Answer 15

• 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)

Question 16

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?

Answer 16

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

Question 17

Secondary dysmenorrhoea aetiology:

Answer 17

• 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…

Question 18

Endometriosis- aetiology:

Answer 18

 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

Question 19

The two endometriosis theories?

Answer 19

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

Question 20

Endometriosis- symptoms

Answer 20

 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

Question 21

Endometriosis - diagnosis

Answer 21

 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

Question 22

Staging of endometriosis:

Answer 22

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)

Question 23

Management options for endometriosis?

Answer 23

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

Question 24

Pharmacological management of endometriosis (NICE):

Answer 24

• 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

Question 25

What is Menorrhagia?

Answer 25

• 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

Question 26

Epidemiology of menorrhagia?

Answer 26

30% of women complain of heavy bleeding

Question 27

Aetiology of menorrhagia?

Answer 27

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

Question 28

Causes of menorrhagia ?

Answer 28

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)

Question 29

Symptoms suggestive of underlying pelvic pathology ?

Answer 29

• 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

Question 30

Diagnosing menorrhagia:

Answer 30

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

Question 31

Management Options for menorrhagia:

Answer 31

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

Question 32

Pharmacological management of menorrhagia:

Answer 32

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)