Women's Health Issues During Reproductive Years Flashcards
Amenorrhea Definition
No Menstrual Bleeding in a 90 day period
Primary Amenorrhea
Absence of menses by age 15 years in females who have never menstruated
Secondary Amenorrhea
Absence of menses for 3 cycles or for 6 months in a previously menstruating individual
What are 3 categories of etiology for amenorrhea?
Anatomical Causes
Endocrine Disturbances
Ovarian Insufficiency/Failure
What is the normal sequence of hormones that does not occur without ovulation?
- Estrogen production
- Progesterone production
- Estrogen/Progesterone Withdrawal
What are the signs of Amenorrhea?
- Cessation of menses >6 months for those with established menstruation
- Absence of menses by age 16 in normal secondary sexual develop
- Absence of menses by age 14 in the absence of normal secondary sexual development
- Recent significant weight loss or gain
- Presence of acne, hirsutism, hair loss, or acanthuses nigricans
What are the symptoms of Amenorrhea?
- Cessation of menses
- Infertility, vaginal dryness, or decreased libido
What are the treatment goals for Amenorrhea?
- Bone density preservation
- Bone loss prevention
- Restoration of ovulation to improve fertility
- Correct of premature ovarian failure
What is the definition of heavy menstrual bleeding (menorrhagia)?
Heavy menstrual blood loss (>80 mL per cycle) or prolonged menstrual bleeding >7 days
What are the treatment options for menorrhagia?
NSAIDs, Hormal Contraception, Medroxyprogesterone, and Tranexamic Acid
What is the place of therapy for NSAIDs in menorrhagia?
20-50% reduction in blood loss, 1st LINE
What is the place of therapy for Hormonal Contraception in menorrhagia?
30-60% for oral
79-97% fr IUD
1st LINE
What is the place of therapy for Medroxyprogesterone in menorrhagia?
32-50% reduction
AVOID
What is the place of therapy for Tranexamic Acid in menorrhagia?
34-56% reduction
Antifibrinolytic effect, Not as effective
What is Premenstrual Syndrome PMS?
Results from the interaction of cyclic changes in ovarian steroids and central neurotransmitters
What is diagnostic criteria for Premenstrual Dysphoric Disorder PMDD?
At least 5 symptoms are present for most of the time during the late luteal phase, with at least 1 system that is severe
What are the severe symptoms?
Affective lability, irritability, tension/anxiety, and depressed mood
What is diagnostic criteria for PMS?
Must have at least 1 physical and 1 behavioral symptom that is self-reported to have occurred in each of 3 prior menstrual cycles
What are the nonpharmacologic therapies for mild/moderate PMS?
Dietary modifications and regular exercise
Antidepressants for PMS/PMDD
Fluoxetine
Paroxetine
Sertaline
What is the efficacy of antidepressants?
60-90%
When do antidepressants become effective and what is its place in therapy for PMS/PMDD?
Within first treatment cycle
FIRST LINE
What antidepressants are considered Second Line (when SSRIs are not tolerated or CI)?
SNRIs: Clompiramine, Duloxetine, Nefazodone, and Venlafaxine
Benzodiazepines for PMS/PMDD
Alprazolam
When is alprazolam utilized for PMS/PMDD?
Most useful for treatment of acute anxiety and intermittent insomnia, short term use only
5HT1A Agonist for PMS/PMDD
Buspirone
What is the place of therapy for 5HT1A?
May be tried in patients with anxiety if drug dependence is a concern, to avoid benzos
What are nonprescription therapies for PMS/PMDD?
Calcium
NSAIDs
Pamprin
When should calcium be recommended for PMS/PMDD?
Should be recommended for all women with symptoms of PMS because of potential benefits if it is well-tolerated, benefits for osteoporosis prevention
What Ovulation Suppression is commonly prescribed for PMS and PMDD symptoms?
CHC: combination hormone
Those containing drospirenone Yah or Tasmin more beneficial
What are 2 different therapies for PMDD that should not be used in PMS?
GnRH Agonist and Surgery
What is the GnRH Agonist utilized in PMDD?
Leuprolide (Lupron Depot) IM
What is the action of Leuprolide?
A medical oophorectomy, reserved for those with severe PMDD who do not respond to more conservative measured due to adverse effects
What entails a surgical therapy for PMD??
Surgical ablation of the ovaries
What is the dosing of Ibuprofen for Dysmenorrhea?
400 mg Q4-6 hrs for 3 days each month, max dose 3200 mg/day
What is the dosing of Naproxen Sodium (anaprox) for Dysmenorrhea?
275 mg PO Q6-8hrs or 550mg Q12 hrs for 3 days each month
What is the dosing of Fluoxetine/Sarafem for PMS/PMDD?
10-20mg QD or days 14-28 of the cycle
What is the dosing of Paroxetine/Paxil CR for PMS/PMDD?
12.5-25 mg QD or 14-28 of the cycle
What is the dosing for Sertraline/Zoloft for PMS/PMDD?
50-150mg QD or 14-28 of the cycle
What is the dosing for Calcium for PMS/PMDD?
600 mg BID (plus adequate vitamin D intake)
What is Dysmenorrhea?
Crampy pelvic pain occurring with just prior to menses
What is primary dysmenorrhea?
Cause by factors INTRINSIC to the uterus
What is secondary dysmenorrhea?
Caused by UNDERLYING PELVIC PATHOLOGY such as pelvic inflammatory disease, endometriosis, complications associated with IUDs, and ovarian cysts
What are the steps of the ovulation?
Ovulation –> Increased Serum Progesterone –> Increased arachidonic acid -converted to-> prostaglandins and leukotrienes –> pain, inflammation, and uterine contractions
What are the risk factors of Dysmenorrhea?
Young age, nulliparity, period before age 12, heavy menstrual flow, tobacco use, BMI <20 or >30, stress, anxiety, and depression
What are the nonpharmacologic treatment for Dysmenorrhea?
Regular exercise, low-fat, vegetarian diet, smoking cessation, and local application of heat
What are the pharmacologic treatment for Dysmenorrhea?
- Analgesics: NSAIDs and COX-2 Inhibitors
- Contraceptives: CHC
- Dietary Supplements: omega-3 fatty acid and vitamin D
What is the MOA of NSAIDs?
Inhibits prostaglandin synthesis and provides analgesia
What is the dosing of Diclofenac Potassium (Cataflam) for Dysmenorrhea?
50 mg Q8hrs RX
When should NSAIDs be used in Dysmenorrhea?
Initiate 1-2 days prior to onset of menses and duration usually up to 3 days, FIRST LINE
What should the frequency be for NSAIDs for Dysmenorrhea?
Scheduled
What are the contraindications for Dysmenorrhea?
- Hypersensitivity to NSAID or ASA
- Renal Disease
- History of GI bleeding or ulceration
What is the MOA of COX-2 Selective Inhibitors?
Inhibits prostaglandin synthesis and provides analgesia
What is the dosing for Celecoxib (Celebrex) for Dysmenorrhea?
200 mg PO Q12 hrs
What is the place of therapy for Celecoxib?
Similar to NSAIDs, but should be limited in patients with significant risk for GI ulceration
Is Acetaminophen recommended for Dysmenorrhea?
NO
What is the MOA of Contraceptives CHC?
Suppresses ovulation, decreases menstrual fluid volume, and thereby decreases prostaglandin production and uterine cramping
What is the place of therapy for CHC for Dysmenorrhea?
FIRST LINE if Contraception is also desired
How long should a drug therapy be given before switching therapy?
At least a 3 month trial
If pain does not respond to drug therapy, it may be necessary to what?
Perform laparoscopy to determine cause
What are the exclusions for Self Treatment of Dysmenorrhea?
- Severe dysmenorrhea and/or menorrhagia
- Symptoms inconsistent with primary dysmenorrhea
- History of pelvic inflammatory disease PID, infertility, irregular menstrual cycles, endometriosis, ovarian cysts
- IUD
- Allergy to aspirin or NSAIDs
- Warfarin, Heparin, or Lithium
- Active GI disease (PUD, GERD, Ulcerative Colitis)
- Bleeding disorders
