Week 2: Periods Suck (part 2)

Question 1

___ is the painful menstruation associated with ovulation

Answer 1

dysmenorrhea

**This can be a dx and or a symptom

Question 2

Facts on dysmenorrhea (painful menstruation from ovulation)

Answer 2

-affects 50%
-5-10% miss school or work
-Primary or secondary

Question 3

What is the patho for primary dysmenorrhea?

Answer 3

-Absence of pelvic pathology and must occur with ovulatory cycles.

-Result of excessive endometrial prostaglandin production

-Prostaglandin F2-alpha

Question 4

What would the secondary cause of dysmenorrhea be?

**Secondary from a pathological cause

Answer 4

1. PCOS
2. cancer
3. endometriosis

Question 5

Dysmenorrhea:

Subjective data?
Questions?
What common symptoms?

Answer 5

Add OLDCARTS for the characteristics of pain** look up

location?
does it radiate?
any associated symptoms?

Question 6

Dysmenorrhea

Objective data?
Exam
Differentials?

Answer 6

Exam will be the same

Differentials:
-endometrioisis
-fibroids
-GI pain

Question 7

Dysmenorrhea:

Plan?
Psychosocial interventions?
Medications?
Surgeries?
Follow up?

Answer 7

-psych- discuss the plan & interventions usually BC pills 6-12 months

-NSAIDS instead of BC is ok if does not want BC or trying to get pregnant
*** can be taken 3-4 days before the onset of their cycle & then stop 2 days after they start bleeding
(to manage the pain)

Follow up of all indications, risks, side effects, NSAIDS take them with food, signs of toxicity, include maximum dose to not go over in the daily amount

Question 8

Abnormal bleeding

Answer 8

Any uterine bleeding that does not result from normal menstruation.

Anovulatory bleeding 95% of all AUB between 16-17

-Decreases during childbearing years
-Increases during perimenopause

Question 9

how long can perimenopause last before stopping having periods?

In smokers its how long?

Answer 9

10 years

5 years shorter

Question 10

Ovulatory abnormal bleeding

Answer 10

-10% of women of all ages
-50% have midcycle bleeding/breakthrough bleeding

Underlying causes:
Prolonged progesterone production
Corpus luteum insufficiency (can make it hard to get pregnant)
Luteal phase defect (can make it hard to get pregnant)

Question 11

IUP (intrauterine pregnancy) bleeding

Highest incidence between 18-35 y/o

Bleeding occurs in 1 out of 5 pregnancies

Answer 11

Medication problems
Birth control pills
MAIOs
Opiates
Thyroid medication
Etc (see handout

** Can cause this

Question 12

PID

Answer 12

Suspect in any woman with abdominal pain, abnormal bleeding, leukocytosis, low-grade fever, and pelvic tenderness

Question 13

Neoplasms can cause abnormal bleeding

Answer 13

20% occurring in girls under 11
Benign and malignant growths

Question 14

Abnormal bleeding

Answer 14

Trauma
Rape
Abuse
Lacerations

Question 15

Blood dyscrasias (blood clotting disorder)

Answer 15

10% have abnormal uterine bleeding

Question 16

How can tell if ovulation or anovulation?
History
What do you need to know?

Answer 16

Are they having pain? They have to be ovulating to have pain with bleeding!!! **

Question 17

How can tell if ovulation or anovulation?

Menstrual Problems

Answer 17

Remember this is a disease of exclusion!!***

Subjective data?
Will depend on client age

If prepuberty consider foreign body trauma or abuse

If childbearing age – multiple causes including IUP, infections, abuse

If perimenopausal or menopausal – consider endometrial hyperplasia or neoplasm

Question 18

Puberty & Teens
Menstrual Irregularities

Subjective data?

Answer 18

Subjective data
Must have a detailed menstrual history!
Medication
FH
PMH
Experiences with bleeding
Associated S/S
Description of bleeding (OLDCARTS)
Ask questions to determine if ovulatory/anovulatory (is she having pain)
Social history

Question 19

Puberty & Teen
Menstrual Irregularities

Objective Data

Answer 19

Objective data

Complete PE (physical exam)
Pallor not associated with tachycardia
Signs of hypovolemia
Pelvic masses
Fever
Leukocytosis
Pelvic tenderness
Fine or thin hair
Hypoactive reflexes
bruising

Question 20

Assessment differentials (there can be a lot of them)

PLAN

for Puberty & Teen:

Menstrual Irregularities

Answer 20

Plan

Labs
CBC
UA
Pap
Pregnancy test
STDs
Thyroid function
Coagulation disorders
others

Question 21

Menstrual Irregularity Plan for Puberty & Teen

Answer 21

Plan

Treat underlying cause if present (if treat cause & it stops NO FURTHER treatment)

Psychosocial interventions - let pt. know plan & outcomes
Surgery
Medication- BC pills

Question 22

Primary childbearing years: period problems

Answer 22

Most common causes are contraceptive causes and pregnancy
Same history
Same physical
Labs
Endometrial biopsy
Plan
Treat underlying cause

Question 23

Age 40 and older

Answer 23

Anovulatory bleeding accounts for 90% of cases of abnormal bleeding in this age group but always consider cancer until you rule it out!

grade 5- can do an endometrial biopsy

Question 24

Age 40 and older: Subjective

Answer 24

Menopausal symptoms
Personal and family history of malignancy
History of ERT (estrogen replacement therapy)

Question 25

Age 40 and older: Objective

Answer 25

Objective Same Labs Endometrial biopsy Must do if endometrium is greater than 5-6 mm!!** on a postmenopausal woman Plan Refer to physician- for abnormal endometrial result OR if result is normal but pt. continues to have bleeding Must treat the woman with a mass aggressively

Question 26

Abnormal bleeding before age 11

Answer 26

Never overlook the possibility of malignant genital tract tumors in young girls

Question 27

Abnormal bleeding frequently manifests sexual abuse of children or young teenagers

Answer 27

One in four female children are sexually abused

Question 28

Pad counts are not accurate for blood loss but more than 25 pads or 30 tampons per period is too much

Answer 28

Pad must be completely soaked through How many pads do they change a day? How often or frequent do they change a tampon? **A pad must be completely soaked through

Question 29

Do not use a rectal bimanual exam True or False

Answer 29

True

Question 30

In a nonpregnant patient, a pelvic mass requires

Answer 30

aggressive evaluation

Question 31

Perform endometrial sampling in all women over 30 and in those over 20 with frequent or exceptionally heavy bleeding before

Answer 31

beginning HRT including BC pills

Question 32

Perform hysteroscopy before endometrial sampling to find any abnormalities the sampling may miss

Answer 32

Women treated with Tamoxifen (used in breast cancer) have the same endometrial cancer rate as women treated with unopposed estrogen; about 7x the rate for untreated women

Question 33

PMS

Answer 33

-A combination of physical and psychological symptoms that occur in the luteal phase of the menstrual cycle. -Includes any physical, psychological, or behavioral changes distressing enough to impair to ADL or relationships -There are about 150 symptoms associated with or attributed to PMS

Question 34

A woman comes into the office c/o saying that their husband wanted me to talk about? She is in the luteal cycle What is she most likely experiencing?

Answer 34

PMS

Question 35

PMS symptoms: LONG LIST

Answer 35

Abdominal bloating Anxiety Change in libido Depression Dizziness or fainting Fatigue Food cravings Hostility Inability to concentrate ^appetite Ins Insomnia Irritability Lethargy Mood swings Panic attacks Paranoia Withdrawal from others Acne ETOH intolerance Breast engorgement Clumsiness Constipation/D Decreased urination HA ^risk of minor infections Peripheral edema Weight gain

Question 36

How prevalent is PMS

Answer 36

Prevalence -5-10% have severe to disabling symptoms -50% moderately distressing -All women suffer from this at some point during the lifespan -May differ in symptoms from cycle to cycle

Question 37

Patho of PMS

Answer 37

The end result of abnormal tissue response of nervous, immunologic, vascular, and GI symptoms to the normal changes of the menstrual cycle

Question 38

PMS

Answer 38

Runs in families Research has discovered a relationship between severity or frequency of PMS with feelings of poor health, family conflicts, history of abuse, history of affective disorder, and lack of proper exercise or diet

Question 39

subjective for PMS

Answer 39

The same as previous BUT 1. need to know how often it is? 2. Is this every cycle? 3. which days before the cycle? 4. how long does it last?

Question 40

objective data for PMS

Answer 40

Do a complete physical exam Objectives

Question 41

Treatment for PMS

Answer 41

Treatment based on relief of symptoms SSRIs Birth control pills Anxiolytics Lifestyle changes

Question 42

A woman comes into the office c/o of PMS and wants hormone levels checked is this standard protocol?

Answer 42

No- treatment is more based on the symptoms usually zofoft or prozac is given - use 1-2 weeks prior to starting period, BC pills

Question 43

PMS varies for every woman so the provider must?

Answer 43

-listen to pt. -be open to what the pt. thinks is moderate to debilitating **finding the right treatment plan for them is essential