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Therapeutics > Ex. 5 L5 -Abnormal Bleeding (47) > Flashcards

Ex. 5 L5 -Abnormal Bleeding (47) Flashcards

1
Q

Normal Bleeding

A

35mL of blood per day
Cycle length of 22-35 days
Menstruation lasting 3-7 days
Median age of mearche: 12.4 years (starting period)

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2
Q

Types of abnormal bleeding

A

Dysmenorrhea
Amenorrhea
Oligomenorrhea
Polymenorrhea
Heavy Menstrual Bleeding (HMB)
Metrorrhagia

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3
Q

Dysmenorrhea

A

Pain associated with menstruation

Primary:
-Normal ovulatory cycles and pelvic anatomy
Secondary:
-Underlying anatomic or physiologic cause

Occurring in 17-90% of women

About 6-12 months after cycle - more immediate

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4
Q

One of the key symptoms of endometriosis is

A

Dysmenorrhea

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5
Q

Pathophysiology of Dysmenorrhea

A

-Buildup of fatty acids in cell membranes, then released
-Prostaglandins and leukotrienes released in uterus
-Inflammatory response causes symptoms

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6
Q

Risk Factors - Dysmenorrhea

A

< 20 years old
Weight loss attempts
Depression/anxiety
Heavy Menses
Menarche before <12YO
Nulliparity
Smoking
Family History

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7
Q

Symptoms of Dysmenorrhea

A

Diarrhea
Vomiting
Nausea
Crampy Pelvic Pain
Dizziness
Muscle Cramps
Headache

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8
Q

Goals of therapy for patients with Dysmenorrhea

A

Provide symptomatic relief
Reduce lost school/work productivity
Improve QOL/ADLs

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9
Q

Dysmenorrhea - Treatment Overview

A

First-Line
-Non-steroidal anti-inflammatory (NSAID), +/-
Oral Contraceptives +/-
Non-pharmacologic

Second-Line
-Depot Medroxyprogesterone acetate (DMPA)
-Levnorgestrel-releasing IUD

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10
Q

Treatment for Dysmenorrhea - Non-Pharmacologic

A

-Heating Pad
-Exercise
-Nutritional Supplementation: Omega-3-fatty acids, vitamin B, Ginger
-Smoking Cessation
-Acupuncture

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11
Q

NSAID Therapy: Dysmenorrhea

A

MOA: Inhibits COX enzyme (1 and 2), leading to decrease in prostaglandin production
-Dosing can be taken around the clock 1-2 days before cycle start
-Intended for short-term use
No NSAID found to be more efficacious than another

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12
Q

Dysmenorrhea NSAID drugs and dosing

A

Celecoxib
(COX2 specific)
-Rx only
-400mg x 1, then 200mg PO Q12h

Diclofenac
-Rx only
-100mg x 1, then 50 mg PO q8h

Ibuprofen
-Rx and OTC
-800mg x 1, then 400-800mg PO Q8h

Naproxen
-Rx and OTC
-500mg x 1, then 220-550mg PO Q12h

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13
Q

Pros and Cons of NSAID therapy

A

Pros:
-Good option for those wanting to conceive
-Short term use
-Pain relief within hours
-Cheap, non-Rx

Cons:
-SE can be intolerable
-Not a great option for those with CV history

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14
Q

NSAIDs SE and precautions & counseling

A

SE and Precautions
-GI bleeding/ulcers and upset
-Renal injury
-Onset of CV events, exacerbate HTN

Counseling and Education:
-Take w/food or milk to minimize GI upset
-Monitor for abnormal bleeding
-Scheduled dosing vs. PRN

NOT RECOMMENDED FOR PATIENTS WITH CV HISTORY

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15
Q

Oral contraceptive therapy

A

MOA: Inhibition of endometrial tissue proliferation, leading to decreased endometrial production of prostaglandins and leukotrienes

Multiple options:
-Combined hormonal contraceptives (CHCs)
Can use ethinyl estradiol component up to 35 mcg (or 50 mcg)
Dosing: efficacy noted with cyclic and continuous regimens
-No regimen found to be more efficacious than another

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16
Q

Hormone therapy pros and cons

A

Pros:
-Appropriate for those seeking contraception
-Can be used in conjunction w/NSAIDs

Cons:
-Not appropriate for patient desiring pregnancy
-RX needed
-Delayed relief *1-2 months)

17
Q

Hormone therapy SE and Precautions & Counseling and Education

A

SE and Precautions
-Increased BP
-Weight gain
-Fluid retention
-Risk of blood clots/stroke (increased w smoking)

Patient ED and counseling
-Monitor for nausea, HA, breast discomfort and changes in mood

18
Q

Levonorgestrel IUD and Depot Medroxyprogesterone Acetate (DMPA)

A

MOA: related to amenorrhea SE
-Beneficial in those desiring contraception
-Delayed Relief, often with initial months of therapy
-Recommended to try levonorgestrel IUD before DMPA

Levonorgestrel recommended to try BEFORE depot

19
Q

Monitoring and Follow Up

A

Assess patient symptom improvement (pain rating scales, self reported symptoms, etc)
-If symptoms have not lessened in severity or resolved in ** 3-6 months of traditional therapy, REFER**

20
Q

Amenorrhea

A

The absence of a menstrual cycle
Primary:
-No menses by age 15
Secondary:
No menses x3 months in previously menstruating women

21
Q

Amenorrhea traits

A

Characteristics and Symptoms
-Often asymptomatic
-Can be accompanied by weight loss/gain

Often a symptom rather than a condition itself
-Lab tests: pregnancy test, FSH/LH levels, TSH, prolactin, estrogen
-PCOS, low BMI, eating disorders, excessive exercise
-MEDICATIONS
(IUD, Depotshot, etc)

Prevalence
Primary: <0.1%
Secondary: 3-4%

22
Q

Drug induced amenorrhea

A

First gen antipsychotics
-Prochlorperazine, chlorpromazine
-Haloperidol
-Chloprothixene

Second-gen antipsychotics
-Risperidone
-Molindone

Antidepressants
-Clomiphene

Monoamine oxidase inhibitors
-Pargyline
-Clorgyline

Antihypertensives
-Verapamil

GI promotility agents
-Metoclopramide
-Domperidone

23
Q

Goals of therapy amenorrhea

A

Ovulation restoration
(especially if fertility desired)
Bone density preservation
Bone loss prevention

24
Q

Amenorrhea treatment - first line

A

RULE OUT PREGNANCY
-Determine underlying cause

24
Q

Treatment for amenorrhea, non pharmacologic

A

If cause if Anorexia
-Weight gain
-Consider work-up for eating disorder
-Cognitive behavioral therapy (CBT)

If cause is Excessive Exercise
-Reduction in exercise quantity and intensity

If cause is Medications
-May consider alternative agents that do NOT inhibit dopamine receptor or increase prolactin levels
OR -> initiate dopamine agonist

24
Q

Monitoring and follow-up Dopamine agonists:

A

SE
Monitoring:
-BP
-HR
-Hepatic/renal function
-Pregnancy status
-Prolactin level

Average time to resolution of menses: ~6-8 weeks
-If no resolution seen with one agent, try other!!

24
Q

Pharmacologic Tx for Amenorrhea: cause is hypoestrogenic

A

-If cause is hypoestrogenic - provide supplemental estrogen
-Must include a progestin component

Agent:
-Conjugated Equine Estrogen
(Common brands: Premarin, Cenestin, Enjuva)
Regimen:
Take 0.625 - 1.25mg PO daily on days 1-25 of cycle

Agent:
Estradiol (patch)
(Common brands: Climara, Vivelle-Dot)
Regimen:
Apply 0.1 mg patch to the skin once or twice weekly

25
Q

Pharmacologic Tx for Amenorrhea: cause is Medications

A

If cause is medications that increase prolactin levels…provide Dopamine agonist

Bromocriptine
-Multiple daily dosing (short half life)

Cabergoline
-Weekly or twice weekly dosing (long half life)

Contraindications
-Breast feeding, uncontrolled HTN,
Mild SE: N/D, HA, orthostatic hypotension, fatigue

26
Q

Oligomenorrhea

A

Menstrual cycle interval >35 days (but less than 90 days)

Overlaps with amenorrhea
-Similar causes and tx approaches

27
Q

Polymenorrhea

A

Menstrual cycle interval <21 days

Common Causes
-Stress
-Infections (STDs)
-Endometriosis
-Menopause

MAY CAUSE CHALLENEGES IN CONCEIVING

28
Q

Heavy Menstrual Bleeding (HMB)

A

-Previously called “menorrhagia”
Bleeding >80mL OR lasting > 7 days
“Excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, or maternal quality of life”

Prevalence
-Accounts for 18-30% of gynecologic visits

29
Q

HMB - pathophysiology

A

-Multiple Etiologies
-MUST RULE OUT: pregnancy, ectopic pregnancy, miscarriage

Hematologic
-Bleeding/clotting disorders

Hepatic
-Cirrhosis

Endocrine
-Hypothyroidism

Uterine
-Structural abnormalities
-Uterine fibroids(up to 40%)

30
Q

HMB - symptoms

A

Heavy blood flow w/menstruation
-With or without pain (dysmenorrhea)
-Possibly: fatigue and lightheadedness

31
Q

HMB Goals of therapy

A

-Reduce menstrual blood flow
-Correct iron-deficiency anemia or underlying disorders (if applicable)
-Improve QOL/ADLs

32
Q

HMB - Chronic management (monthly)

A

Hormonal
-CHC
-Progestins
-Levonorgestrel IUD
-Danazol
-GnRH

Nonhormonal
-NSAIDs
-Tranexamic Acid
-Iron*

*not indicated to lessen bleeding, but to treat iron-deficient anemia if applicable

33
Q

Tranexamic Acid

A

MOA - antifibrinolytic - prevents the degradation of blood clots

Dosing:
1,300 mg PO TID x 5 days (at onset of menses)
-Intended for short-term use (duration of menses)
-Nonhormonal; usually reserved for those unable to take CHCs or wanting to conceive

Contraindications
-Active and/or h/o DVT or Pulmonary embolism
H/o seizure

SE
-Generally well tolerated
-Can cause HA, nasal symptoms

34
Q

Metrorrhagia

A

Hemorrhage of the uterus
-Irregular menstrual bleeding Between cycles

Causes:
-Hormone imbalance
-Fibroids, polyps, endometriosis
-Medications
-IUDs
-Infections

Treatment
-Target underlying cause
-Hormonal contraceptive

35
Q

Comparing AUB conditions

A

Which conditions are related to cycle length?
-Oligomenorrhea (>35 days)
-Amenorrhea (Cycle >90 days)
-Polymenorrhea (Cycle <21 days)
-Bleeding occurring between cycles: Metrorrhagia

Which conditions are descriptors of blood flow?

Therapeutics (49 decks)

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