Ex. 5 L5 -Abnormal Bleeding (47)

Question 1

Normal Bleeding

Answer 1

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)

Question 2

Types of abnormal bleeding

Answer 2

Dysmenorrhea
Amenorrhea
Oligomenorrhea
Polymenorrhea
Heavy Menstrual Bleeding (HMB)
Metrorrhagia

Question 3

Dysmenorrhea

Answer 3

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

Question 4

One of the key symptoms of endometriosis is

Answer 4

Dysmenorrhea

Question 5

Pathophysiology of Dysmenorrhea

Answer 5

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

Question 6

Risk Factors - Dysmenorrhea

Answer 6

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

Question 7

Symptoms of Dysmenorrhea

Answer 7

Diarrhea
Vomiting
Nausea
Crampy Pelvic Pain
Dizziness
Muscle Cramps
Headache

Question 8

Goals of therapy for patients with Dysmenorrhea

Answer 8

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

Question 9

Dysmenorrhea - Treatment Overview

Answer 9

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

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

Question 10

Treatment for Dysmenorrhea - Non-Pharmacologic

Answer 10

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

Question 11

NSAID Therapy: Dysmenorrhea

Answer 11

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

Question 12

Dysmenorrhea NSAID drugs and dosing

Answer 12

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

Question 13

Pros and Cons of NSAID therapy

Answer 13

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

Question 14

NSAIDs SE and precautions & counseling

Answer 14

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

Question 15

Oral contraceptive therapy

Answer 15

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

Question 16

Hormone therapy pros and cons

Answer 16

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)

Question 17

Hormone therapy SE and Precautions & Counseling and Education

Answer 17

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

Question 18

Levonorgestrel IUD and Depot Medroxyprogesterone Acetate (DMPA)

Answer 18

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

Question 19

Monitoring and Follow Up

Answer 19

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**

Question 20

Amenorrhea

Answer 20

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

Question 21

Amenorrhea traits

Answer 21

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%

Question 22

Drug induced amenorrhea

Answer 22

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

Question 23

Goals of therapy amenorrhea

Answer 23

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

Question 24

Amenorrhea treatment - first line

Answer 24

RULE OUT PREGNANCY
-Determine underlying cause

Question 24

Treatment for amenorrhea, non pharmacologic

Answer 24

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

Question 24

Monitoring and follow-up Dopamine agonists:

Answer 24

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!!

Question 24

Pharmacologic Tx for Amenorrhea: cause is **hypoestrogenic**

Answer 24

-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

Question 25

Pharmacologic Tx for Amenorrhea: cause is **Medications**

Answer 25

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

Question 26

Oligomenorrhea

Answer 26

Menstrual cycle interval >35 days (but less than 90 days) Overlaps with **amenorrhea** -Similar causes and tx approaches

Question 27

Polymenorrhea

Answer 27

Menstrual cycle interval <21 days **Common Causes** -Stress -Infections (STDs) -Endometriosis -Menopause **MAY CAUSE CHALLENEGES IN CONCEIVING**

Question 28

Heavy Menstrual Bleeding (HMB)

Answer 28

-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

Question 29

HMB - pathophysiology

Answer 29

-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%)

Question 30

HMB - symptoms

Answer 30

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

Question 31

HMB Goals of therapy

Answer 31

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

Question 32

HMB - Chronic management (monthly)

Answer 32

**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

Question 33

Tranexamic Acid

Answer 33

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

Question 34

Metrorrhagia

Answer 34

Hemorrhage of the uterus -Irregular menstrual bleeding **Between** cycles **Causes**: -Hormone imbalance -Fibroids, polyps, endometriosis -Medications -IUDs -Infections **Treatment** -Target underlying cause -Hormonal contraceptive

Question 35

Comparing AUB conditions

Answer 35

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?