Management of menstrual disorders 1 Flashcards Preview

AC- CLPT lectures > Management of menstrual disorders 1 > Flashcards

Flashcards in Management of menstrual disorders 1 Deck (54)
Loading flashcards...
1
Q

Describe the menstrual cycle?

A

Day 1: first day of menstruation- period starts

Menstrual phase: lasts ~4-7 days

  • shedding of endometrium
  • 80mL of blood loss

Follicular phase

  • endometrial proliferation
  • FSH–> develops follicle–> increased oestrogen levels
  • ends as oestrogen production peak–> surge in LH (which stimulates ovulation)

Ovulation: at ~day 14, mature egg released

Luteal phase

  • production of progesterone & less potent oestrogen by corpus luteum
  • endometrium maintained in case of pregnancy (implantation)
  • when no pregnancy or implantation of fertilised egg, progesterone declines–> period starts again
2
Q

What is dysmenorrhoea?

A
  • recurrent, significant pain associated with menstruation
    • primary dysmennorrhoea- no identifiable cause
    • secondary dysmennorrhoea- there is a cause
  • most common gynaecoloical symptom reported
    • >70% adolescent young women
    • 40% adult women
3
Q

What are some causes of secondary dysmenorrhoea?

A
  • endometroisis
  • endometrial polyps
  • fibroids
  • PID, pelvic inflammatory disease
  • IUD use
  • malformations of the genital tract
4
Q

What makes having secondary dysmenorrhoea more likely?

A
  • older women
  • irregular periods
  • heavy bleeding
  • patterns in pain changing
  • poor response to tx
5
Q

What is the pathophysiology of dysmenorrhoea?

A
  • at the start of menstruation, endometrial cells release PGs to due progesterone withdrawal
  • PG cause uterine contraction, vasoconstriction, nerve sensitisation which all lead to pain
  • severity of pain is proportional to PG concentration
6
Q

What are some risk factors to dysmenorrhoea?

A
  • early menarche- period starting
  • heavy/ long duration of menstrual flow
  • family hx
  • smoking
  • obesity
  • social environment (lack of support)
  • depression/ mood disorders
7
Q

What are the symptoms associated with dysmenorrhoea?

A
  • cramping, suprapubic pain
    • may extend to lower back, thighs
  • usually begins in the first year of period
  • starts several hours before menstruation
    • may persist up to 2-3 days
  • peak pain is with maximum blood flow
  • others- diarrhoea, nausea, vomitting, light headedness, fever
  • other causes of pelvic pain may worsen
8
Q

How is dysmenorrhoea diagnosed?

A
  • menstrual history
    • age at menarche, when did sxs start, length & regularity of cylce, dates of last few periods, duration of periods, amounts of bleeding
  • pain
    • type, location, radiation, timing, severity, duration
  • associated symptoms
    • diarrhoea
  • degree of disbaility
    • days off school/ work, effect on QOL
  • rule out secondary dysmenorrhoea
9
Q

What is pharmacological approach to treatment?

A
  • 1st line- NSAIDs
  • 1st line- COCs
  • 2nd line- progestins
10
Q

1st line- NSAIDs

A
  • start at onset of symptoms and contnue regularly for 2-3 days
    • use loading dose to start
    • can start prophylactically 24-48 hours prior to menstruation if symptoms severe
11
Q

1st line- COC

How does it work?

A
  • reduced endometrium= reduced PG= reduced pain
    • may take 3 months for full relief
  • less evidence compared with NSAIDs however used widely
  • COCP containing 30mcg ethinylestradiol
  • consider continuous use (extended cyles) if symptoms problematic
  • can use with NSAIDs especially in the initial stages
12
Q

2nd line-progestins

Which ones?

A
  • levonorgestrel IUD
    • local effect on endometrium
    • reduces menstrual flow, effective if heavy bleeding
    • periods may be irregular, spotting can be problematic
  • medroxyprogesterone depot
    • induces endometrial atrophy
    • reduces BMD+delayed return of menstruation
13
Q

What are some non pharmacological ways to manage dysmenorrhoea?

A
  • aerobic exercise can be rlly useful
    • helps to increase pelvic blood flow & induce good endorphins
  • high frequency transcutaneous electrical nerve stimulation (TENS)
  • acupuncture
  • heat packs (may be as effective as ibuprofen)
  • behavioural interventions- distraction techniques & sx awareness
14
Q

What is normal menstrual bleeding?

A
  • average cycle is between 21-35 days
    • average is 28 days
  • bleeding is from day 1-7
  • amount should be less than 1 pad or tampon per 3 hour period
15
Q

What classifies as heavy bleeding?

A
  • loss of >80mL of blood
  • > 7 days bleeding
  • mestruation loss considered unacceptable to women
16
Q

What is heavy menstrual bleeding?

A
  • menorrhagia
  • heavy cyclical bleeding
  • occurs over several consecutive cyles
  • thought to be caused by inadequate haemostasis due to excess fibrinolytic activity & excess PG production
  • haemostasis= process that prevents & stops bleeding
  • presumed to be caused by hormone dysfunction
17
Q

What are some causes of heavy menstrual bleeding?

A
  • endometrial polyps
  • fibroids
  • malignancy
  • trauma
  • hormonal contraceptives
  • anticoagulants
  • antipsychotics
  • SSRIs
  • tamoxifen
  • danazol
  • spirinolactone
  • ginseng
  • gingko
  • phytoestrogens
18
Q

What types of heavy menstrual bleeding are there?

A
  • ovulatory (more common)
    • heavy but regular periods
    • often accompanied by pelvic pain & PMS
  • anovulatory
    • irregular, unpredictable heavy bleeding
    • typically occurs in <20 & >40 year olds
    • also in PCOS, low body mass, excessive exercise
19
Q

How is heavy menstrual bleeding diagnosed?

A
  • patient menstruation history
    • age of menarche, frequency and amount of menstruation, impact
  • labs- rule out secondary causes
    • progesterone- FSH/ LH
    • FBC & ferritin- assess anaemia
    • TSH- rule out thyroid issues
  • pelvic ultrasound (polyps / fibroids present in 25-50% patients)
  • endometrial biopsy- rule out malignancy or pre- malignant conditions
    • esp in women over 40, or if at risk of endometrial cancer
20
Q

What do we need to consider before begin treatment?

A
  • need for contraception
  • fertility considerations
  • prescence of other symptoms/ medical conditions
  • patient preference
  • adverse effects
  • if anovulatory- treatment must include hormonal therapy
21
Q

What pharmacological approach do we take for heavy menstrual bleeding?

A
  • tranexamic acid- 1st line
    • preferred if no pain (dysmenorrhoea)
    • well tolerated
  • NSAIDs
    • start before or on 1st day of period & continuue regularly for 3-5 days or until cessation of period
  • COCP
    • commonly used but limited good quality evidence, may reduce blood loss by 43%
  • progestin
    • 21 day course if ovulatory
    • 12 day course if anovulatory
    • reduces blood loss by 80% however poorly tolerated and short term only
  • levonorgestrel releasing IUD
    • reduces blood loss by 70-90%
  • medroxyprogesterone depot
    • limited evidence
22
Q

What are some other pharmacological therapies that are rarely used?

A
  • steroid hormones- danazol​
    • must be used with non hormonal contraception
    • poorly tolerated- androgenic side effects- may be irreversible
    • acne, oily skin, oedema, weight gain, hirsutism, voice changes, hot flushes, vagina dryness, reduced breast size
  • GnRH agonists- goserelin
    • induces amenorrhoeic state
    • non hormonal contraception required
    • A/E- hot flushes, sweating, sexual dysfunction, vaginal dryness, myalgia, oedema, mood changes
      • not recommended for more than 6 months due to BMD loss
23
Q

How do we approach heavy menstrual bleeding non pharmacologically?

A
  • surgery
    • dilation & curettage
      • can also have diagnostic role if endometrial biopsy inconclusive
    • endometrial ablation- burning excessive endometrial growth
    • hysterectomy- removal of uterus
24
Q

Management of heavy menstrual bleeding, AMH

A
25
Q

How do you treat acute heavy menstural bleeding?

A
  • if bleeding severe& haemodynamic instability or Hb is very low
    • tranexamic acid IV 10mg q8h or PO 1-1.5g q6-8h until bleeding stops
  • if TXA not tolerated or unavailable
    • COCP q6h ethinylestradoil 30-35mcg
    • medroxyprogesterone acetate 10mg q4h
    • norethisterone 5-10mg q4h
    • use until bleeding stops
  • High dose estrogen may be required if bleeding continues
    • COCP containing 50mcg ethinylestradiol q6h until bleeding stops
  • need to taper progestin/COCP after bleeding stops
  • regular hormonal therapy required to prevent further acute events
26
Q

Monitong patiets with abnormal uterine bleeding

A
  • amount and frequency of flow
  • breakthrough bleeding
  • use of PRN analgesia
  • QoL – number of days of school/work missed
  • Side effects
  • Complications (anaemia!!!)
  • Trial therapy for 3 months, if inadequate adjust dose or change agent
27
Q

What is endometriosis?

A
  • endometrial tissue grown outside of the uterus
  • common in ovaries but can be in peritonium, cervix, vagina, bowel, colon, appendix
  • cyclical hormonal changes lead tissue to growth and breakdown–> scarring
  • cause unknown
  • main concerns= pain & subfertility
28
Q

What are the symptoms of endometriosis?

A
  • heavy bleeding
  • abnormal bleeding
  • bloating
  • dysmenorrhoea
  • dyspareunia
  • subfertility
  • pelvic pain
  • painful defacation
29
Q

What are the risks associated with endometriosis?

A
  • shorter cycle
  • longer flow length
  • family history
  • higher socioeconomic status
  • ?caffeine/ alcohol intake
30
Q

How is endometriosis diagnosed?

A
  • symptom history
  • pelvic exam, ultrasounds & MRI
  • definitve diagnosis an only be made with a laproscopy
    • visualise and remove lesions/ adhesions
    • biopsy
31
Q

How is endometriosis treated pharmacologically?

A
  • NSAIDs
  • COCP
  • Progestins
  • Danazol
  • GnRH agonists (goserilin)
32
Q

NSAIDs for endometriosis

A
  • relieves pain
  • best used regularly rather than prn
  • option if trying to conceive
  • inconclusive evidence on efficacy
33
Q

COCP for endometriosis

A
  • usually well tolerated
  • inhibits ovulation, less circulatory hormone, less endometrial growth
  • cyclical or continuous (if sxs severe in “pill free” period)
    • no evidence to support one over the other
34
Q

Progestins for endometriosis

  • not suitable if woman is trying to conceive- can cause amenorrhoea
A
  • levonorgestrel IUD, high dose medrocyprogesterone acetate 10mg BD oral or depot- short term only
  • a/e: weight gain, irregular bleeding, mood changes
35
Q

Danazol for endometriosis

  • not suitable if woman is trying to conceive- can cause amenorrhoea
A
  • use limited by androgenic A/E
  • limited duration: 6-9months
  • non-hormonal contraception also required
36
Q

GnRH agonists (goserelin)

  • not suitable if woman is trying to conceive- can cause amenorrhoea
A
  • use limited by A/E (hot flushes, vaginal dryness, reduced BMD)
  • “add back” therapy- giving low dose oestrogen/ progestin or tibolone- counteract BMD loss may extend treatment to 2 years
  • tibolone 2.5mg daily reduces osteoporosis and vasomotor symptoms
    • synthetic steroid that has estrogen effects in brain, bone, vaginal tissue- stops vaginal dryness
  • non hormonal contraception required
37
Q

What is non pharmacological therapy for endometriosis?

A
  • Symptoms often re-occur following cessation of medical treatment – surgery warranted
  • Surgery is often necessary for large lesions
    • laparoscopic ablation/removal of adhesions to total abdominal hysterectomy with bilateral salpingo-oophorectomy
    • most women have at least 3 laparoscopies prior to major surgery
    • medication may be used to delay surgery
  • Symptoms can also re-occur following surgery
    • no evidence to support any particular treatment before or after surgery to increase success
38
Q

What is PCOS- polycystic ovarian syndrome?

A
  • inappropriate gonadotrophin secretion
    • anovulation
    • increased androgen production
    • insulin resistance + hyperinsulinaemia
  • LH secreted too frequently
    • follicles don’t have time to develop properly so ovulation can’t occur
    • LH also increases andogren production
      • might be because of UP LH, no progesterone, no ovulation–> negative cycle
  • no luteal phase= reduced progesterone= unopposed oestrogen
    • risk of endometrial hyperplasia & cancer
39
Q

What are the clinical characteristics of PCOS?

A
  • hyperandrogenism
    • hirsutism- thick pigmented hair(upper lip/ lower abdomen)
    • acne
    • alopecia- hair loss, crown area of head
  • oligomenorrhoea (infrequent) or amenorrhoea
    • <9 menses per year
  • central/ abdominal obesity (30-60% of PCOS sufferers)
    • related to hyperandrogenism & hyperinsulinaemia
  • complications
    • impaired glucose tolerance & T2DM, metabolic syndrome & CV risk, OSA due to diabetes
40
Q

How is PCOS diagnosed?

A
  • hyperandrogenism
  • menstrual irregularity
  • polycystic ovaries
  • atleast 2 of these to have a PCOS diagnosis
41
Q

What are the treatment goals of PCOS?

A
  • reduce hirsutism, maintain cycle regularity, decrease insulin resistance
  • prevent long term complications
42
Q

How is PCOS treated?

A
  • COCP- low dose estrogen & consider anti androgen progestogen (cyproterone/ dropirenone)
    • regulates cycles & reduces androgenism
    • reduces risk of endometrial cancer
  • androgen hormones- contribute to growth & reproduction in menopausal women
  • cyclical progestin- if COCP contraindicated
    • 12 day cycle (e.g. MPA 10mg or norethisterone 5mg daily)
  • levonorgestrel IUD- minimise endometrial overgrowth only
43
Q

What else is used to treat PCOS?

A
  • metformin
    • helps to improve cycle regularity
    • improves insulin resistance
    • minimal benefit to hirsutism c/w COCP
  • spirinolactone
    • hyperandrogenism symptoms only
  • fertlity management
    • metformin, clomiphene
44
Q

How do you manage PCOS non pharmacologically?

A
  • 1st line treatment- reduce weight
    • 5% weight loss helps to restore regular menstrual cycle
    • possible reduces risk of endometrial cancer
  • diet & exercise
    • helps maintain weight
    • reducing risk of T2DM & CV disease
45
Q

What is PMS & PMDD?

A
  • premenstrual syndrome & premenstrual dysphoric disorder
  • a cyclic recurrence of symptoms during luteal phase of menstrual cycle
    • often symptoms dissipate(get worse) with onset of menses
    • mixture of mood, phsycial and cognitive symptoms
  • symptoms usually begin 25-35 years of age
  • can exacerbate other chronic conditions (epilepsy, migraine, asthma)
  • PMDD
    • severe PMS
46
Q

How is PMS/ PMDD diagnosed?

A

Symptoms must be:

  • characteristic of PMS/ PMDD
  • limited to luteal phase (often worse few days before menses)
  • impact daily life
  • present for 2 consecutive cyles
  • not explained by other diagnosis
  • DSM5- classified as a mental health disorder
  • can used GnRH therapy for 3 months diagnostically
47
Q

PMS diagnosis

A
  • PMS- at least 1 affective and 1 somatic symptom during 5 days before menses
  • Affective
    • depression
    • angry outbursts
    • irrritability
    • anxiety
    • confusion
    • social withdrawal
  • Somatic
    • breat tenderness
    • abdominal bloating
    • headache
    • swelling of extremeties
  • sx relieved within 4 days of menses and no not re-occur until day 13 of cycle
48
Q

PMDD diagnosis

A
  • marked depressed mood
  • Marked anxiety
  • Marked affective lability
  • Persistent anger/irritability
  • Decreased interests in usual activities
  • Difficulty concentration
  • Lethargy, fatigue
  • Changes in appetite (under/overeating)
  • Hypersomnia/insomnia
  • Sense of being overwhelmed
  • Other physical symptoms (listed for PMS)
  • sxs interfere with daily life and end a few dats after menses
49
Q

Assessing PMS & PMDD

A
  • Daily symptom diary for 2-3 months
  • If symptoms are not cyclical or not in luteal phase consider alternate diagnosis
  • If symptoms do not interfere with daily living -> mild PMS
  • If symptoms do interfere with daily living -> PMS
  • What have they tried in the past?
    • Anything worked? How long tried for? Including complementary therapies
  • Any other medical conditions?
    • Rule out potential causes – anaemia, hypothyroidism etc
  • Any changes in period?
    • Should not see any changes in PMS/PMDD
50
Q

How is PMS/PMDD treated?

A

1st line
COCP

  • Mixed result – 50% no change, 25% better, 25% worse
  • Use continuously – evidence for 168 day cycle n Consider anti-androgen progestogen if significant fluid retention
  • Only COCP to be studied in RCT was ethinylestradiol with drospirenone

SSRIs

  • Any SSRI can be tried
  • Intermittent (2 weeks before menses until day 1-3 of period) just as effective as continuous
  • If intermittent not effective switch to continuou
  • Drug of choice for PMDD
51
Q

How is PMS/PMDD treated?

  • 2nd line
A

2nd line

  • Transdermal oestrogen and cyclical progesterone
    • E.g. estradiol 100microg patch and micronised progesterone 100-200mg PV on day 17-28 of cycle
    • may supress ovulation (not guaranteed)
  • Higher dose SSRI
  • Note: Progestogens
    • Historically used but no evidence to support use
    • IUD – only to reduce endometrial proliferation
    • no effect on physical & mood symptoms
52
Q

What are some other ways PMS/PMDD is treated?

A
  • GnRH agonists
    • Effective but not routinely recommended
    • Use limited by adverse effects
    • Use “add-back” therapy (50-100microg estradiol patch and 100mg micronised progesterone, or tibolone)
  • Diuretics – spironolactone
    • 25-100mg/day during luteal phase
    • Most helpful for fluid retention, bloating, breast tenderness
  • NSAIDs
    • Naproxen, mefenamic acid most studied although likely class effect
    • May help with physical symptoms
  • Complementary therapies
    • Chasteberry, vitamin B6
    • Ensure adequate calcium intake (1200-1500mg/day)
53
Q

How is PMS/PMDD non pharmacologically managed?

A
  • Cognitive behavioural therapy – considered first line
  • Patient education and symptom diary
    • Knowledge can be empowering
  • Exercise
    • Regular aerobic exercise reduces severity of symptoms
  • Diet
    • Sodium restriction if bloating, caffeine reduction if irritable or insomnia
  • Hysterectomy and bilateral oophorectomy = last line for severe symptoms
    • Should trial GnRH agonist first
    • HRT required if patient <45 years old
54
Q

What to monitor in PMS/PMDD?

A
  • Symptoms – mood and physical
  • Comparison to start of therapy
  • Side effects
  • Additional therapies
    • Non-pharmacological
    • Support from friends/family
  • Try one agent for 2-4 cycles before switching to alternate therapy