women's health Flashcards
Name the common menstrual cycle disorders and their definitions
- Amenorrhoea
- no menstrual bleeding in a 90 day period - Menorrhagia
- heavy menstrual bleeding (menstrual blood loss > 80mL per cycle OR bleeding for > 7 days per cycle) - Dysmenorrhoea
- pain on menstruation / menstrual cramps - Pre-menstrual syndrome (PMS) / Pre-menstrual dysphoric disorder (PMDD)
- cyclic pattern of somatic (physical) and/or affective (mood) symptoms occurring 5 days before menses, that resolves at onset of menses - Polycystic Ovarian Syndrome (PCOS)
- ovaries produce excess androgens, small cysts form in ovaries, and menstrual irregularities occur - Menopause (early onset / pre-mature menopause)
- permanent cessation of periods due to loss of ovarian follicular activity
Describe the management of amenorrhoea
non-pharmacological: treatment of underlying cause, e.g. weight gain / reduction of exercise intensity / stress management
pharmacological: COC, estrogen / progestin only (incl. topical formulations like creams), copper IUD etc.
Describe the management of menorrhagia
pharmacological:
if contraception desired: COC / POP / progestin injection / progestin IUD
if contraception not desired: NSAIDs during menses (inhibits production of prostaglandins; high levels of prostaglandins are associated with heavy menstrual bleeding), Tranexamic acid during menses (slows down the breakdown of clots), cyclic progestin (give during menses?)
non-pharmacological: endometrial ablation / hysterectomy
Describe the management of dysmenorrhoea?
pharmacological:
first line: NSAIDs (inhibit production of prostaglandins, which is the cause of vasoconstriction and thus cramps)
second line: COC (regulate the shedding)
third line: progestin injections / progestin IUD *secondary to the ability to render patients amenorrhoeic
non-pharmacological: topical heat therapy, exercise, acupuncture, low-fat vegetarian diet
Describe the management of PMS / PMDD?
pharmacological:
for somatic / physical symptoms: COC
for affective / mood symptoms: SSRIs (e.g. fluoxetine, paroxetine, sertraline)
non-pharmacological: exercise, decrease caffeine and sodium intake
Describe the management of PCOS?
pharmacological: COC (can consider anti-androgenic progestin if patient presents with acne/hirsutism), metformin (can be considered for those pre-DM, due to association with insulin resistance / metabolic disease by PCOS)
What are the ages for early-onset and pre-mature menopause?
early-onset: when patient presents with symptoms of menopause < 45 years old
pre-mature: when patients present with symptoms of menopause from 30-39 years old (in their 30s)
Describe the clinical presentation / symptoms of peri-menopause / menopause / early post-menopause and their associated etiology?
- Vasomotor symptoms
- hot flushes, night sweats, intense feeling of heat on the face, perspiration, cold sweats, rapid/irregular HR, anxiety, sleep disturbances
- due to thermoregulatory dysfunction at the hypothamus level due to estrogen withdrawal - Genitourinary syndrome of menopause (GSM)
- vaginal dryness, irritation, burning
or pain, lubrication difficulty during sex, painful intercourse, impaired sexual function / libido, urinary urgency, urinary frequency, dysuria, recurrent UTI
- due to vaginal and urethral lining atrophy (becomes thin and dry), decreased secretion of fluids during sexual activity, narrowing and shortening of the vagina, due to estrogen withdrawal - Psychological symptoms
- depression (most common), anxiety, poor concentration, poor memory, mood swings
- estrogen withdrawal plays a role, but likely multifactorial involving other psychological factors - Bone fragility
- increased joint pain, increase risk of osteoporosis and fractures
- loss of bone mineral density due to estrogen withdrawal - other symptoms
- hair loss, breast tenderness, loss of libido, brittle nails, digestive problems, fatigue, dizziness, headaches, weight gain
Describe the non-pharmacological management for menopause?
For MILD vasomotor symptoms: layered clothing that can be removed or added as necessary, lower room temperature, less spicy food/caffeine/hot drinks, more exercise, dietary supplements (isoflavones and black cohosh)
For MILD genitourinary symptoms: non-hormonal vaginal lubricants / moisturizers
Name the pharmacological management for menopause?
Menopausal Hormone Therapy (MHT) (estrogen replacement)
Under what circumstances can unopposed estrogen replacement be given, as part of MHT?
- patient does not have uterus (past hx of hysterectomy etc.)
- only giving topical local estrogen formulations (e.g. pessary, cream), meant to be applied to the vagina and not systemically absorbed
State the dose of estrogen (in terms of EE equivalent) to be used in MHT, common formulations used, and dosage forms available?
dose for MHT: 10-15 mcg
common formulations used: 17-beta estradiol, conjugated equine estrogens (CEE)
dosage forms available: systemic oral (tablets), systemic topical (patches, gels), local topical (creams, pessary)
- for patch: replace twice a week, placed on the lower back/abdomen/thing/buttocks, to rotate sites when replacing
- for gel (only avail for unopposed estrogen): apply daily, ruler provided to measure dose which is to be applied over arms/thigh and let dry, to rotate sites
- for tablet: take at the same time daily, one finished with a pack, start a new one right away
- for pessary: insert twice a week into vagina, just before bedtime to minimize movement
Why is progestin added on to estrogen in MHT?
To reduce the risk of endometrial cancer (stabilizes the endometrium and prevents estrogen induced endometrial hyperplasia)
Describe the dosing regimens for estrogen + progestin MHT (in terms of the continuous-cyclic option and continuous-combined option?
continuous-cyclic: take estrogen daily progestin is added on either on the 1sth or 15th day of the month, for 10-14 days
- withdrawal menstrual bleeding will occur when progestin component is withdrawn, hence can help to regulate menstrual cycle (confer predictable bleeding) in peri-menopausal women facing irregular periods
continuous-combined: take estrogen and progestin daily
- breakthrough bleeding will happen initially, however amenorrhoea will set in after a few months, hence can be given to women who are already post-menopausal
Describe the monitoring for MHT?
patient counselling points for monitoring:
- may take 2 to 3 months to see vast improvement of menopausal symptoms
- continue MHT provided there is a need, if taking long term need to be aware of the increased risk of cardiovascular disease in older patients >= 60 years old
- upon discontinuation, there is 50% chance of symptoms returning
- upon initiation, annual mammography required
- upon initiation, self-endometrial surveillance required;
unopposed estrogen: to check for any vaginal bleeding
continuous-cyclic: to check for any bleeding when progestin component is still on
continous-combined: to check for any prolonged / heavier-than-normal / frequent breakthrough bleeding, and breakthrough bleeding that persists for > 10 months after treatment started
