Women's Health Issues Exam 3 Flashcards
What population is affected for dysmenorrhea?
women 17-24 y/o
Pathogenesis of dysmenorrhea
shedding of the uterine lining releases arachidonic acid and stimulates prostaglandin synthesis that causes uterine and GI smooth muscle contraction and ischemia
Non-Pharmacologic Treatment for Dysmenorrhea
- Regular exercise
- Smoking cessation
- Low-fat, vegetarian diet
- Local application of heat
Pharmacologic Treatment for Dysmenorrhea
- NSAIDS
- COX-2 inhibitors
- Combinational hormonal contraceptives (CHC)
- Other contraceptives
- try each therapy for 3 months; can switch or combine methods
Dysmenorrhea: NSAIDs
- pain relief in 72%
- NSAIDs are equally effective
- Ibuprofen
- Naproxen sodium
- Diclofenac potassium (Cataflam®)
- Mefenamic acid (Ponstel ®)
- Ketoprofen
- use up to 3 days; scheduled, NOT prn
Dysmenorrhea: NSAID contraindications
- Hypersensitivity to aspirin or NSAIDs
- Renal disease
- History of GI bleeding or ulceration
Dysmenorrhea: NSAID place in therapy
first line
Dysmenorrhea: COX-2 Selective Inhibitors
- Celecoxib (Celebrex®)
- similar efficacy to NSAIDs
Dysmenorrhea: COX-2 Selective Inhibitors place in therapy
limited to patients who have significant risk for GI ulceration or who have failed traditional NSAIDs
Dysmenorrhea: Combinational hormonal contraceptives (CHC) MOA
Suppresses ovulation, decreases menstrual fluid volume, and thereby decreases prostaglandin production and uterine cramping
Dysmenorrhea: Combinational hormonal contraceptives (CHC) place in therapy
- Generally second line.
- May be first-line if contraception is also desired.
- relieve dysmenorrhea in 50-80% of women
Dysmenorrhea: Other Contraceptives
- can be considered if other therapies ineffective
- Extended or continuous cycle CHC
- Levonorgestrel IUD
- Depo-medroxyprogesterone
Pharmacologic Treatment for Menorrhagia
- NSAIDS
- Hormonal contraception
- Medroxyprogesterone
- Tranexamic acid
Menorrhagia: NSAIDs
- 20-50% reduction in blood loss in 75% of women
Menorrhagia: NSAIDs place in therapy
first line
Menorrhagia: Hormonal contraception
- 40-50% reduction in blood loss with cyclic combined oral contraceptives
- 79-97% reduction in blood loss with levonorgestrel IUD
Menorrhagia: Hormonal contraception place in therapy
First line option in those desiring contraception
Menorrhagia: Medroxyprogesterone (MPA, Provera®) MOA
Suppresses FSH and LH and ultimately estrogen and progesterone
Menorrhagia: Medroxyprogesterone (MPA, Provera®)
32-50% reduction in menstrual blood loss
Menorrhagia: Tranexamic acid MOA
Antifibrinolytic
Menorrhagia: Tranexamic acid
26-60% reduction in menstrual blood loss
Pathogenesis of PMS
results from the interaction of cyclic changes in ovarian steroids and central neurotransmitters
Population affected by PMS
occurs in late 20s through early 40s
Diagnostic Criteria for PMS
Physical
- abdominal bloating
- acne
- backache
- breast tenderness
- fatigue
- headache
- weight gain
Psycholoigcal
- irritability
- depressed mood
- forgetfulness and difficulty concentrating
- increased appetite
- labile mood
- tension
Must have one of each for 3 cycles
Treatments for PMS and PMDD
- First line: Nonpharmacologic therapies for mild to moderate PMS
- First line: Pharmacologic therapies for severe PMS (i.e. PMDD)
Nonpharmacologic Therapies for PMS
- Decrease salt, caffeine, and refined sugars
- eat smaller
- more frequent meals
- aerobic exercise > 3x/week with an increase in exercise during the premenstrual week
Pharmacologic Therapies for PMS
- Antidepressants
- Anxiolytics
- Non-prescriptions therapies (calcium, NSAIDS, combination products)
- Ovulation suppression
Pharmacologic Therapies for PMS: Antidepressants: SSRIs
- Fluoxetine (Sarafem®)
- Paroxetine (Paxil CR®)
- Sertraline (Zoloft®)
- Improves both psychological and physical symptoms.
Pharmacologic Therapies for PMS: Antidepressants: SSRIs timing and duration
- Onset of efficacy: within first treatment cycle
- Initially, use only during the luteal phase (14 days premenstrual)
- If response is inadequate, increase to continuous daily regimen
- If response remains inadequate, may try switching to another SSRI
Pharmacologic Therapies for PMS: Antidepressants: SSRIs place in therapy
considered first-line
Pharmacologic Therapies for PMS: Alternative Antidepressants
- clomipramine
- duloxetine
- nefazodone
- venlafaxine
Pharmacologic Therapies for PMS: Alternative Antidepressants place in therapy
secondline in patients who fail, cannot tolerate, or have contraindications to SSRI therapy
Pharmacologic Therapies for PMS: Anxiolytics: Benzodiazepines
- Alprazolam
- also useful for acute anxiety and intermittent insomnia
Pharmacologic Therapies for PMS: Anxiolytics: Benzodiazepines timing and duration
TID days 1428 of cycle
Pharmacologic Therapies for PMS: Anxiolytics: Benzodiazepines place in therapy
agent of choice if intent is for short-term use
Pharmacologic Therapies for PMS: Anxiolytics: 5HT1A-Agonist
- Buspirone (BuSpar ®)
- does not improve physical symptoms
- also useful for anxiety and insomnia
Pharmacologic Therapies for PMS: Anxiolytics: 5HT1A-Agonist place in therapy
can be used in pts with anxiety esp if drug dependence is a concern
Pharmacologic Therapies for PMS: Anxiolytics: 5HT1A-Agonist timing and duration
take days 14-28 of cycle
Pharmacologic Therapies for PMS: Calcium
- Improves mood, bloating, food cravings, and pain.
- May take a few months to see improvement
Pharmacologic Therapies for PMS: Calcium place in therapy
all women with symptoms of PMS
Pharmacologic Therapies for PMS: NSAIDS
improves physical symptoms but not psychosocial
Pharmacologic Therapies for PMS: Ovulation Suppression: Hormonal Contraception (CHC)
- does not work for everyone
- CHC containing drospirenonemay be more beneficial because they reduce fluid retention (i.e. Yaz®, Yasmin®)
Pharmacologic Therapies for PMS: Ovulation Suppression: GnRH Agonists
- downregulates pituitary gonadotropin secretion and suppresses gonadal function
- Leuprolide (Lupron Depot®) (IM)
- works for both physical and psychological symptoms
- can give adjunct estrogen and progestin to counter hypo-hormone
Pharmacologic Therapies for PMS: Ovulation Suppression: GnRH Agonists place in therapy
reserve for those with severe PMDD who do not respond to more conservative measures due to adverse effects
Pharmacologic Therapies for PMS: Surgery
- oophorectomy
