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Clinical Pharmacy > Dysmenorrhea and PMS > Flashcards

Dysmenorrhea and PMS Flashcards

1
Q

Dysmenorrhea only occurs during ______ cycles

A

ovulatory (during the follicular phase of the menstrual cycle)

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2
Q

When does dysmenorrhea usually begin?

A

usually begins with the onset of menses (within the first 6-12 months of menarche)

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3
Q

The onset and severity of dysmenorrhea often mimics what?

A

menstrual flow

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4
Q

What are the other associated symptoms with dysmenorrhea?

A
  • headache, nausea, vomiting, fatigue and IBS
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5
Q

What is the difference between primary and secondary dysmenorrhea?

A

Primary: uterine contractions involving increased PGs
Secondary: PID, endometriosis

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6
Q

Primary dysmenorrhea is often thought to be due to what?

A

to to prostaglandins

  • concentration of PGE2 and PGE2-alpha are increased in the endometrium. This increase correlates with pain severity
  • results in an increase in uterine activity, strength and frequency of contractions (dysrhythmic)
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7
Q

What is the difference of age of onset between primary and secondary dysmenorrhea

A

1: typically 6-12 months
2: mid to late 20s through 30s and 40s

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8
Q

What is the difference in menses between primary and secondary dysmenorrhea?

A

1: more likely to be regular with normal blood loss
2: more likely to be irregular, menorrhagia more common (increased amount of blood loss)

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9
Q

What is the patten and duration of primary and secondary dysmenorrhea?

A

1: onset just before or coincidental with menses, pain with each or most menses, lasting 2-3 days
2: vary with cause, change in pain pattern or intensity may indicate secondary disease

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10
Q

Will both primary and secondary menorrhea respond to NSAIDs?

A

1: yes it will
2: no it will not

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11
Q

What are the other symptoms associated with both primary and secondary dysmenorrhea?

A

1: N/V, fatigue, dizziness, irritability, diarrhea, and headache may occur at same time of dysmenorrhea
2: vary with cause, may include dyspareunia and pelvic tenderness

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12
Q

What are that main risk factors of dysmenorrhea?

A
  • under 30 y/o
  • BMI under 20 kg/meter squared
  • smoking
  • menarche before 12 y/o
  • longer menstrual cycles/duration of bleeding
  • irregular or heavy menstrual flow
  • history of sexual assault
  • PMS or pelvic inflammatory disease
  • sterilization
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13
Q

What are the red flags for dysmenorrhea?

A
  • onset of pain > 2 years post-menarche
  • symptoms occur outside the first 3 days of menses
  • change in severity of pattern of pain
  • change in characteristics of menstrual fluid
  • if trial of OTC treatment fails (because we know that dysmenorrhea is caused by the production of PGs, and NSAIDs block the production of these)
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14
Q

What are the non-pharm options for dysmenorrhea

A
  • heat therapy
  • lifestyle modifications
    (stop smoking, regular exercise, decreased fat intake)
  • other non-pharm measures: TENS, CBT, relaxation, etc
  • regular aerobic exercise throughout the cycle should decrease how painful periods are
  • decrease saturated fat - fish oil supplements can also be beneficial-high in omega 3 polyunsaturated fatty acids. Thought to decrease the severity of pain
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15
Q

What is the first line therapy for treating dysmenorrhea?

A
  • ibuprofen or naproxen (ASA and acetaminophen do not reduce PGs in menstrual fluid)
  • first choice to decrease prostaglandin concentrations in endometrial and menstrual fluid
  • start at onset of pain or menses and continue on a schedules basis for 72 hours
  • – there will be a 3 month trial before referring or if symptoms are not relieved or pain worsens
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16
Q

What are the rx options available for treating primary dysmenorrhea?

A
  • NSAIDs: propionic acids (naproxen, ibuprofen) or fenamates (e.g. mefenamic acid) or acetic acids (indomethacin)
  • mefenamic acid is unique because it inhibits PG synthase and blocks the action of PG that have already been formed
  • clinical efficacy is similar for all NSAID options
  • oral contraceptives are 90% effective, levonorgestrel IUS- modification of the menstrual cycle (blocks ovulation); low dose agents provide lighter, shorter and less painful periods, or no periods at all
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17
Q

When should a patient se improvement in symptoms?

A
  • may take up to 3 cycles for improvement of dysmenorrhea issues/symptoms overall
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18
Q

What is the maximum duration of treatment for self-treatment approaches?

A
  • 3 days each cycle
19
Q

What is the definition of PMS?

A
  • recurrent physical, psychological and behavioural symptoms which occur during the luteal phase of the cycle (day 14-28) and which are relieved by menstruation with a symptom free week. The symptoms have a negative impact on the quality of life of the woman
20
Q

When is the typical onset of PMS in a woman?

A

anytime after puberty, typically in the mid-twenties

21
Q

When are the symptoms of PMS usually experienced?

A
  • anywhere from 7-14 days before menstruation, symptoms peak just a few days before
  • usually improve significantly or disappear just a few days of menstruation
22
Q

Will a woman get symptoms of PMS during pregnancy or menopause?

A

no they will not

23
Q

What ar the three most supported aetiologies of PMS?

A
  1. Exaggerated response to normal hormonal changes
    - fluctuations in estradiol and progesterone cause an abnormal response
  2. 5HT deficiencies
    - women with PMS have been found to have decreased 5HT concentrations and decreased platelet uptake of 5HT during the late luteal phase
    - decreased 5HT may lead to depressed mood, irritability, anger, aggression, poor impulse control and appetite disturbances
  3. Abnormalities in catcholaminergic, GABA and opioid NT systems
24
Q

What are some of the risk factors associated with PMS?

A
  • lower intake of vitamin D
  • genetic predisposition
  • high BMI
  • stress
  • traumatic life events
25
Q

What is premenstrual dysphoric disorder? (PMDD)

A
  • severe form of PMS
  • symptoms are usually severe enough to cause functional impairment/disruption
  • sx usually peak around 3rd and 4th decade
  • may become severe in perimenopause (5-10 yr prior to menopause)
26
Q

What are the negative outcomes associated with PMDD?

A
  • marital issues
  • physical/verbal abuse of others
  • difficulties in parenting
  • criminal behaviour
  • poor work or school performance
  • work absenteeism
  • social isolation
  • accidents
  • hospitalization
  • suicidal ideation
27
Q

What are the red flags for PMS?

A
  • severe cases of PMS- unrelenting of progressive symptoms
  • uncertain or unusual patterns of symptoms or symptoms inconsistent with PMS
  • affective disorder
  • onset on symptoms associated with OCP and HRT
  • symptoms related to other medical conditions
  • other conditions such as anemia, thyroid disorder, diabetes, endometriosis, chronic fatigue syndrome, psychiatric disorder
  • peri-menopause
  • signs of infection or ovarian cysts
  • individuals who do not respond to treatment
28
Q

What are some of the cognitive non-pharmacological tx options for PMS?

A
  • behavioural therapy emphasizes relaxation techniques and stress reduction
  • assist individual to cope or deal with the changes
  • smoking cessation, if applicable
  • sleep hygiene
29
Q

What are some of the nutritional non-pharm tx options for PMS?

A
  • balances diet
  • decrease salt intake
  • decrease caffeine intake
  • small, frequent intake of carbs
  • dietary changes are recommended 7-14 days before the menses begins (minimum)
30
Q

What are some of the exercise non-pharm tx options for PMS?

A
  • women who practice aerobic exercise (3-4x/week) experience fewer symptoms compared to those with no exercise
31
Q

Why do women that exercise have less PMS sx?

A
  • exercise reduces the symptoms of depressive illness
  • luteal phase of endorphin secretion appears to be altered in women with PMS
  • exercise boosts “feel good” endorphins
  • structured sleep schedule- consistent wake/sleep times, esp during the luteal phase
32
Q

What is the efficacy of evening primrose oil in treating PMS?

A

efficacy similar to placebo

33
Q

What is the efficacy of chasteberry in treating PMS?

A
  • can help reduce breast discomfort and other symptoms of PMS
  • preparations are different in each formulation however - WATCH for this
34
Q

What are the main SE of chasteberry?

A
  • can cause GI problems, acne like rashes, headache, fatigue, dry mouth and dizziness
35
Q

Who should not take chasteberry?

A

women who are pregnant or taking birth control pills or who have hormone sensitive condition (such as breast cancer) should not use chasteberry
- people taking dopamine-related medications, such as selegiline, amantadine, and levodopa, should avoid using chasteberry

36
Q

What is the efficacy of pyridoxine (vitamin B6) in

A

cofactor in synthesis of dopamine and the metabolism of tryptophan (5HT precursor)

  • a meta analysis found that peroxide may be beneficial for the treatment of PMS
  • dose should be recommended from 50-100 mg daily due to potential neuropathy
37
Q

What is the efficacy of magnesium in treating PMS?

A

not beneficial

  • there is minimal benefit in alleviating fluid retention
  • too much Mg - can lead to diarrhea, dizziness, weakness and fatigue
38
Q

Is calcium recommended as a supplement to treat PMS?

A
  • helps with mood, abdominal pain, water retention (bloating), cramps and food craving
  • recommended for supplementation
  • premenstrually there are lower plasma calcium levels
  • ** if you start calcium supplementation and continue it on, the next period should have some improvement
39
Q

Is midol generally recommended?

A

NO

- it has acetaminophen, pamabrom, pyrilamine, methocarbamol, caffeine, etc in it

40
Q

What is pamabrom?

A
  • derivative of theophylline that promotes diuresis (use in the physical symptom treatment for things such as bloating, weight gain and water retention)
41
Q

What is pyrilamine used for in PMS products?

A
  • MOA: sedative effects for women experiencing emotional symptoms - anxiety, nervous tension and irritatbility
42
Q

What are the common rx treatments for PMS?

A
  • PG inhibitors- NSAIDS
  • SSRIs
  • Diuretics (spironolactone)
  • androgens
  • oral contraceptives
  • GnRH - leuprolide
43
Q

What are the treatment options available for PMS?

A
  • begin with non-pharm changes
  • then consider an option such as calcium
  • add on a pain reliever, such as NSAIDs, which may help with symptom relief of headache, muscle and breast pain if required
44
Q

What are the time lines that patients should notice improvement for treatment of PMS?

A
  • symptoms should be improved or alleviated within 1 to 3 cycles

Clinical Pharmacy (24 decks)

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