11 - Dysmenorrhea & PMS Flashcards
(65 cards)
1
Q
Dysmenorrhea
A
Defined as pain during menstruation
2
Q
When does dysmenorrhea occur?
A
Only during the ovulatory cycles - follicular phase of the menstrual cycle
3
Q
When does dysmenorrhea usually begin?
A
With the onset of menses (within the first 6-12 months of menarche)
4
Q
How long do the symptoms occur?
A
With the onset of menses (several hours prior) and lasts 2-3 days
5
Q
Symptoms of dysmenorrhea?
A
Cramping in lower abdomen, pelvic pain may radiate to back and legs (thighs)
- Other symptoms associated:
- headache
- nausea
- vomiting
- fatigue
- IBS
6
Q
Dysmenorrhea can be primary or secondary:
Define primary
A
Uterine contractions often involving increased PGs
Primary is though to be due to prostaglandins:
- Concentration of PGE2 and PGF2 alpha are increased in the endometrium. This increase correlates with pain severity.
- PGs result in an increase in uterine activity, strength and frequency of contractions
- *So if we decrease PGs, we decrease dysmenorrhea.
7
Q
Dysmenorrhea can be primary or secondary:
Define secondary
A
Due to pelvic pathology such as endometriosis, uterine polyps or uterine fibroids.
*Fibroids can cause secondary dysmenorrhea: they are benign growths within the muscle tissue of the uterus
8
Q
What does estrogen cause in the menstrual cycle?
A
causes the lining to build up
*building the house LOL
9
Q
What does progesterone cause in the menstrual cycle?
A
causes glycogen, mucus and prostaglandins to build up in the endometrial tissue
*decorating the house LOL
10
Q
Knowing that PGs are the issue, how should we treat dysmenorrhea?
A
NSAIDs
11
Q
Primary dysmenorrhea:
Age of onset
A
Typically 6-12 months after menarche
12
Q
Secondary dysmenorrhea:
Age of onset
A
Mid to late 20’s through 30’s and 40’s
13
Q
Primary dysmenorrhea:
Menses
A
More likely to be regular with normal blood loss
14
Q
Secondary dysmenorrhea:
Menses
A
More likely to be irregular, menorrhagia (menstruation with prolonged or abnormally heavy bleeding) more common
15
Q
Primary dysmenorrhea:
Pattern & Duration
A
Onset just before or coincidental with menses, pain with each or most menses, lasting 2-3 days
16
Q
Secondary dysmenorrhea:
Pattern & Duration
A
Vary with cause, change in pain pattern or intensity may indicate secondary disease
17
Q
Primary dysmenorrhea:
Pain at other times of menstrual cycle?
A
No way jose
18
Q
Secondary dysmenorrhea:
Pain at other times of menstrual cycle?
A
Yes - May occur before, during or after menses
19
Q
Primary dysmenorrhea:
Response to NSAIDs and/or OC (oral contraception)?
A
Yes
20
Q
Secondary dysmenorrhea:
Response to NSAIDs and/or OC (oral contraception)?
A
No
21
Q
Primary dysmenorrhea:
Other symptoms?
A
N, V, fatigue, dizziness, irritability, diarrhea, and headache may occur at the same time as dysmenorrhea
22
Q
Secondary dysmenorrhea:
Other symptoms?
A
Vary with cause, may include dyspareunia and pelvic tenderness
23
Q
Dysmenorrhea will only occur during ______ cycles
A
ovulatory
*that’s why birth control can help because it prevents ovulation
24
Q
Risk factors for dysmenorrhea?
A
- < 30 years old
- BMI < 20
- smoking
- menarche before 12 years old
- longer menstrual cycles/duration of bleeding
- irregular or heavy menstrual flow
- history of sexual assault
- PMS or pelvic inflammatory disease
- sterilization
25
What is endometriosis?
the lining that normally is formed on the inside of the uterus occurs on the outside of the uterus
26
Red Flags for Dysmenorrhea
- Onset of pain > 2 years post-menarche (i.e. secondary dysmenorrhea)
- Symptoms occur outside the first 3 days of menses
- Change in severity or pattern of pain
- Change in characteristics of menstrual fluid
- If trial of OTC treatment fails
27
List some non-pharms for dysmenorrhea
- Heat therapy (warm baths, heating pads, etc.)
- Lifestyle modifications: Stop smoking or exposure to smoke, regular exercise, decrease fat intake
- Relaxation
28
Is acetaminophen effective for dysmenorrhea?
No - doesn't affect prostaglandins
You can still recommend it if they are unable to take NSAIDs if they really want it.
*Always recommend heat therapy tho - VERY EFFECTIVE
29
Describe the non-prescription treatment for dysmenorrhea
1st line: NSAIDs
- one agent at a time
- ibuprofen or naproxen
- start at onset of pain or menses and continue on a scheduled basis for 72 hours
-3 month trial may be done before referring or if symptoms not relieved or pain worsens
* very important to schedule it to prevent further prostaglandin release
- no PRN dosing
- routine scheduling
30
Would you ever recommend ASA/Acetaminophen?
They do not affect PG's so they are not affective
| -Can recommend if NSAIDs are not appropriate therapy to provide patient comfort.
31
Describe the prescription treatment for dysmenorrhea
- NSAIDs: propionic acids (ex. naproxen, ibuprofen) or fenamates (ex. mefenamic acid) or acetic acids (indomethacin)
- Mefenamic acid unique as it both inhibits prostaglandin synthase and blocks the action of prostaglandins that have already been formed.
- Clinical efficacy is similar for all NSAID options
- OC (oral contraceptives) are 90% effective because they block ovulation
- Low dose agents provide lighter, shorter and less painful periods, or no periods at all (i.e. progestin only)
32
Treatment for secondary dysmenorrhea?
Referral and treat the underlying causes such as:
- endometriosis
- IUD use
- cervical stenosis
- PID
- infection
33
Monitoring parameters for dysmenorrhea
For Improvement:
-May take up to 3 cycles for improvement of dysmenorrhea issues/symptoms overall
For SEs:
-Depends on the self-tx approach. Most self-tx products are unlikely to the clinically significant SE's
34
Max duration of Tx for dysmenorrhea?
3 days - treat cyclically
35
When do you refer dysmenorrhea?
If symptoms are severe, if endometriosis or other secondary causes are suspected
36
What is PMS (Premesntrual syndrome) ??
- Cyclic disorder affecting 40% of women of reproductive age
- "Recurrent physical, psychological and behaviour symptoms which occur during the luteal phase of the cycle (day 14-28) and which are relieved by menstruation with a symptom free week. The symptoms have a negative impact on the QOL of the woman"
37
PMS:
| Onset ?
anytime after puberty, typically in mid-twenties
38
PMS:
| When do symptoms start, improve, and disappear ?
Symptoms start anywhere from 7-14 days before menstruation; symptoms 'peak' just a few days before.
Symptoms improve significantly (or disappear) within the 1st several days of menstruation.
Symptoms disappear (or resolve) during events that interrupt ovulation (i.e. pregnancy or menopause)
39
PMS: See table 1 for PMS symptoms
bitchin
40
Describe the ethology of PMS
-Remains unknown & may be complex and multi-factorial
Possible etiologies:
1-Exaggerated response to normal hormonal changes
-Fluctuations in estradiol and progesterone cause an abnormal response
2-Serotonin deficiencies
-Women with PMS have been found to have decreased serotonin concentration and decreased platelet uptake of serotonin during the late luteal phase
-Decreased serotonin may lead to depressed mood, irritability, anger, aggression, poor impulse control and appetite disturbances
3-Abnormalities in catcholaminergic, GABA and opioid neurotransmitter systems
41
Risk factors for PMS
- Lower intake of vitamin D
- Genetic predisposition
- High body mass index
- Stress
- Traumatic life events
42
What is Premenstrual Dysphoric Disorder (PMDD) ?
- Severe form of PMS affecting 5% of women of reproductive age
- Formerly 'Late Luteal Phase (Dysphoric) Disorder'
- Considered a mental disorder ??
- Symptoms are usually severe enough to cause functional impairment/disruption
- Symptoms usually peak in 3rd or 4th decade
- During perimenopause (5-10 yrs prior to menopause) it may become severe
- If suspected; refer
43
Negative outcomes associated with PMDD?
- Marital issues
- Physical/verbal abuse of others
- Difficulties in parenting
- Criminal behavior
- Poor work or school performance
- Work absenteeism
- Social Isolation
- Accidents
- Hospitalization
- Suicidal ideation
44
Key information gathering assessment (in addition to SCHOLAR and MAPPL)
Type of symptoms and severity?
-Most distressing symptoms?
Timing of symptoms:
- Nature - cyclic or not
- When during the menstrual cycle does the patient experience symptoms?
Smoker?
```
Validated scales (ex. PRISM or COPE)
^^don't know what these are
```
Patients should prospectively report symptoms in luteal phase of cycle for at least 2 cycles
45
Red flags for PMS?
- Severe cases of PMS (PMDD)
- Uncertain or unusual patterns of symptoms or symptoms inconsistent with PMS
- Affective disorder (depression, anxiety)
- Onset of symptoms associated with OCP & HRT
- Symptoms related to other medical conditions
- Other conditions: Anemia/thyroid disorder/diabetes/endometriosis/chronic fatigue syndrome/psychiatric disorders
- Peri-menopause
- Signs of infection, ovarian cysts
- Individuals who do not respond to Tx or symptoms become worse
46
Treatment philosophy for PMS?
PMS is a multi-symptom disorder:
- Behavioral, psychological and physical symptoms
- Tx approach should be selected to address the Pt's most bothersome symptoms
- Generally combined Tx approach is necessary
47
Treatment goals for PMS?
- To have a good understanding of PMS
- Relieve symptoms
- Reduce impact on activities and interpersonal relationships
48
Non-pharm treatment for PMS?
- Education
- Supportive
- Behavioral
- Dietary
49
Pharmacological treatment for PMS?
- PG inhibitors and other analgesics (1st line are ibuprofen/naproxen)
- Diuretics (pamabrom)
- Antihistamine (pyrlimaine)
- Natural Health Products (NHPs): Herbal
- Calcium
- Vitamin B6
- Magnesium
- Evening Primrose
- Chasteberry
50
Describe non-pharm treatment for PMS:
| Cognitive
Behavioral therapy emphasizes relaxation techniques & stress reduction:
- Assist individual to cope or deal with the changes
- Smoking cessation (if applicable)
- Sleep hygiene
51
```
Describe non-pharm treatment for PMS:
Nutritional therapy (unproven)
```
- Balanced diet
- Decreased salt intake
- Decreased caffeine
- Small, frequent intake of carbs
- Dietary changes are recommended 7-14 days before the menses begins (minimum)
52
Describe non-pharm treatment for PMS:
| Exercise
Women who practiced aerobic exercise (3-4x/week) experience fewer symptoms compared to those with no exercise
Rationale:
- Exercise reduces symptoms of depressive illness
- Luteal-phase of endorphin secretion appears to be altered in women with PMS
- Exercise boosts "feel-good" endorphins
- Structured sleep schedule - consistent sleep/wake times, especially during luteal phases
53
Describe the pharmacological treatment for PMS:
| Evening Primrose Oil (EPO)
- EPO contains 72% linoleic acid (PGE1 precursor)
- Trials have found no effect of this product
- Do not recommend this
54
Describe the pharmacological treatment for PMS:
| Chasteberry
- Not proven
- Don't recommend
- Lots of bad side effects
55
Describe the pharmacological treatment for PMS:
| Pyridoxine (Vitamin B6)
- Cofactor in synthesis of dopamine and the metabolism of tryptophan (serotonin precursor)
- A meta-analysis found that pyridoxine may be beneficial for the treatment of PMS
- Dose should be recommended from 50-100 mg daily due to potential neuropathy
- Risk of neuropathy (toxicity) is associated with as low dose as 200 mg/day
56
Describe the pharmacological treatment for PMS:
| Magnesium
- Mg2+ in dosage 200-400mg/day - minimal benefit in alleviating fluid retention
- Mg deficiency is rare - diet enough usually
- American College of Obstetrics & Gynaecology (ACOG) does not recommend Mg
- Too much = diarrhea, dizziness, weakness, fatigue
**Evidence not definitive
57
Describe the pharmacological treatment for PMS:
| Calcium
- Historic data indicates that lower plasma Ca2+ levels premenstrually compared week following menses
- Symptoms of hypocalcemia similar to PMS
- Ca helps with mood, abdominal pain, water-retention (bloating), cramps and food cravings
- ACOG recommends Ca2+ supplementation
*Also good for bone health - hitting 2 birds with 1 stone man
* Has strongest evidence amongst herbs, vitamins, and minerals
- Take with food/watch for DI's (2-3 hours window minimum)
*Ca is considered a preventative or corrective option rather than a FAST treatment option
58
Should we recommend combined OTC products (such as Midol, Pamprin, Tylenol XS Menstrual) ?
No - they all contain acetaminophen which has no effect for dysmenorrhea or PMS
**Remember - NSAIDs are better !!
59
Pamabrom is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.
- Very uneffective
- Derivative of theophylline that promotes diuresis
- Use in the tx of physical symptoms (bloating, weight gain, water retention)
- 50 mg QID (max dose 200mg/day)
*not found to add benefit over treatment with an analgesic
60
Pyrilamine is an ingredient in combined OTC products for Dysmenorrhea & PMS:
Describe it.
*Dose in these products is below the recommended 100 mg adult dose
MOA: sedative effects for women experiencing emotional symptoms? Anxiety, nervous tension and irritability
* Will simply help you sleep
* not found to add benefit over treatment with an analgesic
61
Are NSAIDs helpful in PMS treatment?
- May be helpful due to theory that PMS is due to an abundance of prostaglandins
- Provides pain relief for symptoms of headache, breast pain, and muscle aches
- Ibuprofen or naproxen may be started when the pain begins and used short term at lowest effective dose
62
Rx treatment for PMS?
- PG inhibitors - NSAIDs (naproxen, megenamic acid)
- SSRIs (citalopram, fluoxetine, sertraline)
- Diuretics (spironolactone)
- Androgens (danazol)
- Oral contraceptives (OCP)
- Gonadatropin Releasing hormone(GnRH) ex. leuprolide
63
What is the bottom line for PMS treatment?
- Follow Figure 1 for Treatment of PMS in CTMA
- Begin with non-pharms
- Then consider options such as Calcium
- Add on a pain reliever, such as NSAIDs, which may help with symptom relief o headache, muscle and breast pain if required.
64
Monitoring parameters for PMS?
Improvement:
- Symptoms should be improved or alleviated within 1-3 cycles
- SEs: depends on the self-Tx approach. Most self-tx products are unlikely to have clinically significant SEs
65
When do you refer PMS?
If symptoms do not alleviate within 1-3 months or worsen at any point.
Also refer for symptoms that are disruptive to personal relationship, or inability to engage in usual activities or function productively at work - see physician.
Or any of the symptoms associated with negative outcomes of PMDD
