Menstruation-Related Disorders (Pharm) Flashcards
(86 cards)
1
Q
What constitutes a menstruation disorder?
A
- Primary Dysmenorrhea.
- Menorrhagia.
- Endometriosis.
- PMS/PMDD.
- Amenorrhea.
2
Q
Treatments (4) for Primary Dysmenorrhea?
A
1st: NSAIDs.
2nd: OCPs.
3rd: Progesterone – Medroxyprogesterone Acetate (MPA), (DepoProvera) or Levonorgestrel IUD (Mirena).
4. Non-pharm therapy – topical heat, exercise.
3
Q
Goal and Treatments (5) for Menorrhagia?
A
**GOAL: decrease blood loss.
- OCPs – decrease menstrual blood loss (50% of pt’s).
- Levonorgestrel IUD (Mirena or Skyla):
- -Decreases menstrual blood flow loss by >90%, over 1/2 of treated pt’s are able to avoid a hysterectomy. - Progesterone Therapy:
- -PO Medroxyprogesterone (Provera) during luteal phase of menstrual cycle or for 21 days starting on day 5 of the cycle; about 40% reduction of blood loss. - NSAIDs – taken during menses to decrease menstrual blood loss; average 30% reduction.
- Surgical measures – ablation, hysterectomy.
4
Q
Treatments (6) for Endometriosis?
A
NSAIDs, OCPs, Progesterone, GnRH Analogs, Androgens, Surgery.
5
Q
Treatments (5) for PMS/PMDD?
A
NSAIDs, Monophasic OCPs, GnRH Analogs, Spironolactone, SSRIs.
6
Q
Painful menstruation (cramping) that is cyclic without intermenstrual pain or known pelvic disease? Affects how many women?
A
Primary Dysmenorrhea – affects 50-75% of all women during menstruating years.
- Pathophysiology:
- -Release of prostaglandins.
- -Possible vasopressin-mediated vasoconstriction.
7
Q
The medical term for menstrual periods with abnormally heavy and prolonged bleeding?
A
Menorrhagia.
8
Q
What is the treatment focus of menorrhagia?
A
To decrease blood flow and improvement of associated symptoms.
9
Q
Effects of NSAIDs for menstruation-related disorders?
A
Beneficial effects due to prostaglandin inhibition.
- All NSAIDs are equally efficacious (Ibuprofen, Naproxen, Mefenamic Acid).
- Celecoxib (Celebrex) for less GI AEs.
**The prostaglandins are a group of lipids made at sites of tissue damage or infection that are involved in dealing with injury and illness. They control processes such as inflammation, formation of blood clots, dilation/constriction of blood vessels, control of BP, contraction/relaxation of smooth muscle, and the induction of labor.
10
Q
Ways to utilize NSAIDs for increased effectiveness?
A
- Loading dose (double dose), then resume recommended dose until Sx resolve.
- Begin NSAID therapy at start of period or the ‘day prior to menses’ and continue Tx with scheduled doses.
- DON’T wait till the onset of symptoms or PRN dosing.
11
Q
Effectiveness of OCPs for menstrual-related disorders?
A
- Decreases symptoms of dysmenorrhea by inhibiting the proliferation of endometrial tissue.
- Leads to decrease in endometrial prostaglandins.
- Trial of 2-3 months is required to determine effectiveness.
- Monophasic OCPs may be more efficacious.
12
Q
Progesterone only compounds (drugs)?
A
Medroxyprogesterone (Depo-Provera), Levonorgestrel IUD (Mirena, Skyla).
13
Q
MOA of Progesterone only compounds for menstruation related disorders?
A
- Inhibits secretion of gonadotropins to prevent follicular maturation and ovulation.
- Results in endometrial thinning.
- Amenorrhea is possible after several months of Tx.
14
Q
Black box warning for Androgens?
A
Thromboembolism, intracranial HTN, hepatitis and hepatic adenoma.
**Rule out pregnancy before treatment.
15
Q
MOA of Androgens? Drugs?
A
Danazol (Danocrine).
–Suppresses output of LH and FSH leading to regression/atrophy of normal and ectopic endometrial tissue.
16
Q
Adverse effects of Androgens?
A
- CV – edema, HTN.
- CNS – emotional lability.
- Derm – acne, hair loss or hirsutism, rash, SJS.
- Metabolic – amenorrhea, glucose intolerance, libido changes.
- Hematologic changes.
- Hepatic – adenoma, incr. LFTs.
- Neuromuscular – joint pain.
17
Q
Endometrial tissue growing outside of the uterine cavity?
A
Endometriosis – found at pelvic sites and distant sites.
*Patho is not well understood.
18
Q
Most common symptom of Endometriosis?
A
Dysmenorrhea.
**Pt’s less likely to obtain relief with NSAIDs and OCPs.
19
Q
Clinical presentation of Endometriosis?
A
Signs/Sx depends on location/extent of disease.
- Dysmenorrhea.
- Pelvic pain; related to menstrual cycle.
- Dyspareunia.
- Abnormal vaginal bleeding.
- Infertility.
20
Q
Describe the pelvic pain associated with Endometriosis?
A
Aching-type pain, beginning 2-7 days prior to menses and becomes worse until flow lessens.
21
Q
Surgical measures used for Endometriosis?
A
- Laparoscopic ablation of endometrial implants.
- Uterine nerve ablation.
- Total abdominal hysterectomy and bilateral oophorectomy (TAH-BSO).
22
Q
MOA of OCPs in the use of Endometriosis?
A
Prolonged suppression of ovulation, inhibiting further stimulation of residual endometriosis.
23
Q
Approved OCPs used for Endometriosis?
A
Seasonale/Seasonique.
- -OCPs for Endometriosis are especially useful if taken after other therapies (GnRH agonists or surgery).
- -Unapproved: cont’d use of monophasic OCPs.
24
Q
MOA of GnRH Analogs/Agonists?
A
- Continuous admin leads to decreased levels of LH and FSH – 2dry decreased estrogen and testosterone (estrogen decreased to postmenopausal levels).
- Results in pain relief and reduction of endometrial lesions.
- Menses usually ceases.
25
GnRH analog drugs?
1. Leuprolide (Lupron Depot).
2. Goserelin (Zalodex).
3. Nafarelin (Synarel).
*Most are only used for up to 6 months.
26
Adverse effects of GnRH analogs?
- Hot flashes, decreased libido, breast changes, amenorrhea, vaginitis, acne.
- HA, depression, emotional lability, bone loss.
- Anaphylaxis is rare.
27
Monitoring with use of GnRH analogs?
- Bone density changes due to hypoestrogen state.
- Exclude pregnancy before initiation.
- Suppresses pituitary-gonadal-system so Dx tests for pituitary gonadotropic/gonadal Fxn may be misleading.
28
Combination of mood disturbances (psychological and behavioral) and physical symptoms occurring prior to menses and resolving with the initiation of menses?
PMS -- Premenstrual Syndrome.
29
What does PMDD stand for?
Premenstrual Dysphoric Disorder.
30
Premenstrual distress with deterioration in functioning occuring during the 2 weeks preceding menses?
PMDD -- affects 2-5%.
31
Clinical presentation of PMDD?
Same Sx as PMS, but increased severity with functioning (social and occupational).
**Depressed or labile mood, anxiety, irritability, anger, and other Sx occurring exclusively during the 2 weeks preceding menses.
32
What are the 4 FDA approved treatments for PMDD?
1. Fluoxetine (Prozac).
2. Paroxetine controlled-release (Paxil CR).
3. Sertraline (Zoloft).
4. Together w/Drospirenone/EE (YAZ) OCP.
33
Dosing of SSRIs for PMS and PMDD?
Given continuously OR during the luteal phase of the menstrual cycle -- initiate at the time of ovulation and D/C at the onset of menses.
34
Misc. Treatment for PMS or PMDD?
1. Midol (APAP/Caffeine/Pyrilamine maleate) -- analgesic, stimulant, diuretic.
2. Anxiolytics.
3. Diuretics -- Spironolactone (Aldosterone antagonist).
35
MOA and AE of Spironolactone?
MOA -- Relieves breast tenderness and fluid retention; given during luteal phase.
AE -- hyperkalemia, antiestrogenic effects.
36
Non-pharm treatment of PMS/PMDD?
Rest, Exercise, Diet, and Sx diary.
37
Failure of menses to occur by age 16 in a pt with otherwise normal growth and secondary sexual characteristics? Incidence of?
Primary Amenorrhea; 2.5%.
**Menses has not yet began.
38
Cessation of menses sometimes after menarche has occurred, most often consisting of the absence of menses x6 months or more?
Secondary Amenorrhea.
39
Disorder that results in deterioration of interpersonal relationships and normal activity?
PMS.
40
Define PRIMARY Dysmenorrhea?
- Painful menstruation w/o associated pelvic pathology.
| - Function of menstrual cycle.
41
Define SECONDARY Dysmenorrhea?
- Painful menstruation 2dry to identifiable pelvic pathology.
- Pelvic pain w/ and w/o menses.
- Pain UNRELATED to onset of MENSES -- Endometriosis.
42
Clinical presentation of Primary Dysmenorrhea?
- Crampy, colicky pelvic, groin or back pain.
- Pelvic pain w/focused intensity in the midline.
- N/V/D.
- Headache.
43
Result of the pelvic exam in Primary Dysmenorrhea?
NORMAL pelvic exam.
44
What is the goal of treatment of Primary Dysmenorrhea?
Conservative Tx, reassurance and pt. education.
45
An absence of menstrual bleeding, which can be a normal finding in prepubertal, pregnant and postmenopausal females?
Amenorrhea.
46
What should ALWAYS be done in all pt's of reproductive age that presents with Amenorrhea?
Pregnancy test!
47
What is the most common cause of 2dry Amenorrhea?
Pregnancy!
48
What is the importance of a physical exam in the work-up of Amenorrhea?
May lead to identification of underlying disorders responsible.
*The exam should include overall assessment of sexual development, nutritional status, general health and measurement of Ht/Wt.
49
What is affected by menorrhagia due to the significant amount of blood loss and cramping?
Daily activities.
50
What age does PMS appear?
It can appear anywhere from puberty to menopause, but most commonly begins in late 20s to 30s.
51
What percentage of women experience PMS symptoms at some point in their life?
90%.
*20% experience PMS, 10% with severe PMS.
52
Risk factors for PMS?
1. Obesity; BMI >30 are 3x more likely.
2. Smoking; 2x more likely.
3. Age -- MC as women age through 30s.
4. FH.
5. Hx of depression or anxiety.
6. Lack of exercise.
7. High stress.
8. High caffeine intake.
53
When does PMS occur during the menstrual cycle?
PMS occurs 7-14 days prior to menses.
54
What is are the physical manifestations of PMS?
1. Joint/muscle pain.
2. Headache.
3. Fatigue.
4. Weight gain due to fluid retention.
5. Abd. bloating.
6. Breast tenderness.
7. Constipation or diarrhea.
55
What are the behavioral manifestations of PMS?
1. Tension or anxiety.
2. Depressed mood.
3. Crying spells.
4. Mood swings/irritability/anger.
5. Appetite changes/food cravings.
6. Insomnia.
7. Social withdrawal.
8. Poor concentration.
9. Change in libido.
56
Describe the pathogenesis of PMS?
1. Serotonin deficiency.
2. Mag, Calcium or Vitamin B6 deficiency.
3. EXAGGERATED RESPONSE TO HORMONAL CHANGES.
4. Women with Hx of abuse in early life are at higher risk for PMS in mid-late reproductive yrs.
57
What are the 5 categories that PMS Symptoms are divided into?
"A-C-D-H-O"
1. PMS-Anxiety.
2. PMS-Craving.
3. PMS-Depression.
4. PMS-Hydration.
5. PMS-Other.
*See slides 10-11 for further clarification.
58
What is the emphasis of treatment for PMS?
Symptom relief.
59
What is the 1st line therapy for PMS?
SSRIs.
60
Name the lifestyle changes for improvement of PMS symptoms?
1. Higher protein during menses.
2. Low carbs.
3. Low sodium.
4. Limit caffeine intake.
5. Limit alcohol intake.
6. Eat 4-6 small meals per day.
7. Exercise.
8. Stress reduction techniques.
61
What surgical intervention can be done as treatment for PMS in severely affected women who no longer desire to have children?
Bilateral Oophorectomy; rarely done.
62
What distinguishes PMS from PMDD and MDD?
- MDD is not typically associated with the menstrual cycle.
- PMS symptoms are only associated with menstrual cycles, +/- mood Sx, and NO social impairment.
- PMDD has mood Sx, PMS physical Sx, MARKED IMPAIRMENT, and associated with menstrual cycles.
63
When does Primary Dysmenorrhea occur in the menstrual cycle?
During the OVULATORY Cycle.
64
When do symptoms manifest in Primary Dysmenorrhea?
Just hours before or just after the onset of menstruation and lasts 48-72 hrs.
65
What is painful menstruation caused by an organic pelvic disease?
Secondary Dysmenorrhea.
66
Pelvic pain present at NON-Menstruating times and unrelated to menstrual cycle or menses onset?
Secondary Dysmenorrhea.
67
What is the onset of age for Secondary Dysmenorrhea?
Onset after 20 yrs, but more prevalent in women 30-40 yrs of age.
68
What are some other associated symptoms of Secondary Dysmenorrhea?
Dyspareunia, Infertility, Abnormal bleeding.
69
What are some common causes of Secondary Dysmenorrhea?
Endometriosis, PID, Adenomyosis, Leiomyomas, Ovarian cysts, Pelvic congestion or adhesion, Duct abnormalities, IUD, tumor.
70
What is the treatment for Secondary Dysmenorrha?
Resolve the underlying condition.
71
What are some of the other causes of Amenorrhea?
1. Hypothalamic-Pituitary Dysfunction.
2. Endocrine Dysfunction -- PCOS.
3. Ovarian Dysfunction.
4. Alteration of Genital Outflow tract.
5. Asherman Syndrome.
72
What is Asherman Syndrome?
Scarring of the uterine cavity.
73
What are the 1st line labs to evaluate Amenorrhea?
UPT or BhCG, Thyroid function tests, Prolactin, FSH/LH, Estradiol, Serum testosterone, DHEAs (dehydroepiandrosterone).
74
Imaging studies for evaluation of Amenorrhea?
1. Pelvic U/S -- eval congenital abnormalities.
2. MRI -- hypothalamic/pituitary lesions.
3. Hysterosalpingography + Hysteroscopy -- eval for Asherman Syndrome.
75
What is the Progestin Challenge Test?
Can be used to evaluate and diagnose Amenorrhea; but is rarely used.
* The progesterone challenge test is done by giving oral medroxyprogesterone acetate (Provera) 10 mg daily for 5-10 days or one IM injection of 100-200 mg of progesterone in oil.
* A positive response is any bleeding more than light spotting that occurs within 2 weeks after the progestin is given. This bleeding will usually occur 2-7 days after the progestin is finished.
If the patient experiences bleeding after the progestin she has estrogen present but is not ovulating (anovulation). If no withdrawal bleeding occurs, either the patient has very low estrogen levels or there is a problem with the outflow tract such as uterine synechiae (adhesions) or cervical stenosis (scarring).
76
What is the treatment of Amenorrhea directed towards?
At correcting the underlying pathology.
77
What is the goal of treating Amenorrhea due to loss of hormone production?
Prevention of Osteoporosis.
78
What is a major complication of persistent Amenorrhea and why?
Endometrial Cancer -- due to no cycles and the body not shedding the endometrial lining on a regular basis allowing the endometrium to thicken and possibly allowing the differentiation of cells.
79
What is the treatment for Secondary Amenorrhea?
1. OCPs.
2. Meds to relieve Sx of PCOS -- Clomiphene Citrate (Clomid) can help trigger ovulation and get cycles back on track.
3. Estrogen Replacement Therapy -- help balance hormones and restart cycles.
4. Surgery to remove uterine scarring or resection of pituitary tumors.
80
What is a big concern for pt's who present with Menorrhagia?
The disruption of ADLs because of the amount of blood loss and cramping.
81
What are the signs and symptoms of Menorrhagia?
1. Soaking through 1 or more sanitary pads or tampons every hour for several consecutive hours.
2. Needing to use double sanitary protection.
3. Needing to wake up to change sanitary protection.
4. Bleeding for longer than a week.
5. Passing blood clots larger than a quarter.
6. Restricting ADLs due to heavy menstrual flow.
7. Symptoms of Anemia -- tiredness, fatigue, SOB.
82
What is the cause of Menorrhagia?
Hormone Imbalance -- the endometrium develops in excess (thickness) and will eventually shed causing the heavy menstrual bleeding.
*Certain conditions -- PCOS, obesity, Insulin resistance and thyroid problems.
83
Other causes of Menorrhagia?
Dysfunction of the ovaires, Uterine fibroids, Polyps, Adenomyosis, IUD, Pregnancy complications, Cancer, Inherited bleeding disorders, medications.
84
Diagnostic tools for evaluation of Menorrhagia?
1. Medical Hx and description of menstrual cycles.
2. Diary of bleeding and non-bleeding days including heaviness of flow, how many tampons/pads used, how often they are changed, and #/size of blood clots.
3. Labs -- eval anemia, TFTs, CMP, etc.
4. Pap test -- test for infection, inflammation or changes of the cervix.
5. Endometrial biopsy.
6. U/S.
7. Sonohysterography.
8. Hysteroscopy.
85
Medical treatment for Menorrhagia?
1. NSAIDs -- reduce blood loss and cramping.
2. Tranexamic Acid (Lysteda) -- reduces blood loss and only taken at time of bleeding.
3. OCPs -- regulate menstrual cycle and reduce excessive/prolonged bleeding.
4. Oral Progesterone -- correct hormone imbalance.
5. IUD -- releases progestin (levonorgestrel), which makes the uterine lining thin and decreases menstrual blood flow and cramping.
86
Surgical treatment for Menorrhagia?
*Only if medical treatment is unsuccessful.
1. DandC -- Dilation and Curettage.
- -dilation of cervix, then lining of the uterus is scraped to reduce menstrual bleeding.
2. Uterine Artery Embolization.
3. Focused U/S Surgery -- US waves to destroy fibroid tissue.
4. Myomectomy -- removal of uterine fibroids.
5. Hysterectomy -- ends menstrual cycles.
6. Endometrial Ablation -- destroys lining of uterus.
