Week 2: Periods Suck (part 2) Flashcards
part 2 (menstrual irregularities)
___ is the painful menstruation associated with ovulation
dysmenorrhea
**This can be a dx and or a symptom
Facts on dysmenorrhea (painful menstruation from ovulation)
-affects 50%
-5-10% miss school or work
-Primary or secondary
What is the patho for primary dysmenorrhea?
-Absence of pelvic pathology and must occur with ovulatory cycles.
-Result of excessive endometrial prostaglandin production
-Prostaglandin F2-alpha
What would the secondary cause of dysmenorrhea be?
**Secondary from a pathological cause
- PCOS
- cancer
- endometriosis
Dysmenorrhea:
Subjective data?
Questions?
What common symptoms?
Add OLDCARTS for the characteristics of pain** look up
location?
does it radiate?
any associated symptoms?
Dysmenorrhea
Objective data?
Exam
Differentials?
Exam will be the same
Differentials:
-endometrioisis
-fibroids
-GI pain
Dysmenorrhea:
Plan?
Psychosocial interventions?
Medications?
Surgeries?
Follow up?
-psych- discuss the plan & interventions usually BC pills 6-12 months
-NSAIDS instead of BC is ok if does not want BC or trying to get pregnant
*** can be taken 3-4 days before the onset of their cycle & then stop 2 days after they start bleeding
(to manage the pain)
Follow up of all indications, risks, side effects, NSAIDS take them with food, signs of toxicity, include maximum dose to not go over in the daily amount
Abnormal bleeding
Any uterine bleeding that does not result from normal menstruation.
Anovulatory bleeding 95% of all AUB between 16-17
-Decreases during childbearing years
-Increases during perimenopause
how long can perimenopause last before stopping having periods?
In smokers its how long?
10 years
5 years shorter
Ovulatory abnormal bleeding
-10% of women of all ages
-50% have midcycle bleeding/breakthrough bleeding
Underlying causes:
Prolonged progesterone production
Corpus luteum insufficiency (can make it hard to get pregnant)
Luteal phase defect (can make it hard to get pregnant)
IUP (intrauterine pregnancy) bleeding
Highest incidence between 18-35 y/o
Bleeding occurs in 1 out of 5 pregnancies
Medication problems
Birth control pills
MAIOs
Opiates
Thyroid medication
Etc (see handout
** Can cause this
PID
Suspect in any woman with abdominal pain, abnormal bleeding, leukocytosis, low-grade fever, and pelvic tenderness
Neoplasms can cause abnormal bleeding
20% occurring in girls under 11
Benign and malignant growths
Abnormal bleeding
Trauma
Rape
Abuse
Lacerations
Blood dyscrasias (blood clotting disorder)
10% have abnormal uterine bleeding
How can tell if ovulation or anovulation?
History
What do you need to know?
Are they having pain? They have to be ovulating to have pain with bleeding!!! **
How can tell if ovulation or anovulation?
Menstrual Problems
Remember this is a disease of exclusion!!***
Subjective data?
Will depend on client age
If prepuberty consider foreign body trauma or abuse
If childbearing age – multiple causes including IUP, infections, abuse
If perimenopausal or menopausal – consider endometrial hyperplasia or neoplasm
Puberty & Teens
Menstrual Irregularities
Subjective data?
Subjective data
Must have a detailed menstrual history!
Medication
FH
PMH
Experiences with bleeding
Associated S/S
Description of bleeding (OLDCARTS)
Ask questions to determine if ovulatory/anovulatory (is she having pain)
Social history
Puberty & Teen
Menstrual Irregularities
Objective Data
Objective data
Complete PE (physical exam)
Pallor not associated with tachycardia
Signs of hypovolemia
Pelvic masses
Fever
Leukocytosis
Pelvic tenderness
Fine or thin hair
Hypoactive reflexes
bruising
Assessment differentials (there can be a lot of them)
PLAN
for Puberty & Teen:
Menstrual Irregularities
Plan
Labs
CBC
UA
Pap
Pregnancy test
STDs
Thyroid function
Coagulation disorders
others
Menstrual Irregularity Plan for Puberty & Teen
Plan
Treat underlying cause if present (if treat cause & it stops NO FURTHER treatment)
Psychosocial interventions - let pt. know plan & outcomes
Surgery
Medication- BC pills
Primary childbearing years: period problems
Most common causes are contraceptive causes and pregnancy
Same history
Same physical
Labs
Endometrial biopsy
Plan
Treat underlying cause
Age 40 and older
Anovulatory bleeding accounts for 90% of cases of abnormal bleeding in this age group but always consider cancer until you rule it out!
grade 5- can do an endometrial biopsy
Age 40 and older: Subjective
Menopausal symptoms
Personal and family history of malignancy
History of ERT (estrogen replacement therapy)
Age 40 and older: Objective
Objective
Same
Labs
Endometrial biopsy
Must do if endometrium is greater than 5-6 mm!!**
on a postmenopausal woman
Plan
Refer to physician- for abnormal endometrial result OR if result is normal but pt. continues to have bleeding
Must treat the woman with a mass aggressively
Abnormal bleeding before age 11
Never overlook the possibility of malignant genital tract tumors in young girls
Abnormal bleeding frequently manifests sexual abuse of children or young teenagers
One in four female children are sexually abused
Pad counts are not accurate for blood loss but more than 25 pads or 30 tampons per period is too much
Pad must be completely soaked through
How many pads do they change a day?
How often or frequent do they change a tampon?
**A pad must be completely soaked through
Do not use a rectal bimanual exam
True or False
True
In a nonpregnant patient, a pelvic mass requires
aggressive evaluation
Perform endometrial sampling in all women over 30 and in those over 20 with frequent or exceptionally heavy bleeding before
beginning HRT including BC pills
Perform hysteroscopy before endometrial sampling to find any abnormalities the sampling may miss
Women treated with Tamoxifen (used in breast cancer) have the same endometrial cancer rate as women treated with unopposed estrogen;
about 7x the rate for untreated women
PMS
-A combination of physical and psychological symptoms that occur in the luteal phase of the menstrual cycle.
-Includes any physical, psychological, or behavioral changes distressing enough to impair to ADL or relationships
-There are about 150 symptoms associated with or attributed to PMS
A woman comes into the office c/o saying that their husband wanted me to talk about? She is in the luteal cycle
What is she most likely experiencing?
PMS
PMS symptoms: LONG LIST
Abdominal bloating Anxiety
Change in libido
Depression
Dizziness or fainting
Fatigue
Food cravings
Hostility
Inability to concentrate
^appetite
Ins
Insomnia
Irritability
Lethargy
Mood swings
Panic attacks
Paranoia
Withdrawal from others
Acne
ETOH intolerance
Breast engorgement
Clumsiness
Constipation/D
Decreased urination
HA
^risk of minor infections
Peripheral edema
Weight gain
How prevalent is PMS
Prevalence
-5-10% have severe to disabling symptoms
-50% moderately distressing
-All women suffer from this at some point during the lifespan
-May differ in symptoms from cycle to cycle
Patho of PMS
The end result of abnormal tissue response of nervous, immunologic, vascular, and GI symptoms to the normal changes of the menstrual cycle
PMS
Runs in families
Research has discovered a relationship between severity or frequency of PMS with feelings of poor health, family conflicts, history of abuse, history of affective disorder, and lack of proper exercise or diet
subjective for PMS
The same as previous BUT
- need to know how often it is?
- Is this every cycle?
- which days before the cycle?
- how long does it last?
objective data for PMS
Do a complete physical exam
Objectives
Treatment for PMS
Treatment based on relief of symptoms
SSRIs
Birth control pills
Anxiolytics
Lifestyle changes
A woman comes into the office c/o of PMS and wants hormone levels checked is this standard protocol?
No- treatment is more based on the symptoms
usually zofoft or prozac is given - use 1-2 weeks prior to starting period, BC pills
PMS varies for every woman so the provider must?
-listen to pt.
-be open to what the pt. thinks is moderate to debilitating
**finding the right treatment plan for them is essential
