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Special Populations - Menstration-Related Disorders (Exam 1)

Terms in this set (105)

A 39 yo female presents to the women's clinic today looking to initiate a contraceptive as she does not want more children and she is currently breastfeeding. Prior to this, she has not utilized hormonal contraceptives since she was an adolescent. She has a history of painful menstrual cycles and migraines with aura. Based on this information,w hat would be the most appropriate recommendation for contraceptive therapy?
A. Initiate copper IUD - no hormonal option should be recommended
B. Initiate oral COC - Ovral (0.5mg norgestrel/50 mcg EE)
C. Initiate oral COC. - Ortho-Cyclen (0.25mg norgestimate/35 mg EE)
D. Initiate transdermal patch Xulane (6mg norelgestromin/75 mcg EE)
E. Initiate oral POP - norethindrone 350 mcg
E. Initiate oral POP - norethindrone 350 mcg
A 16 yo female presents to the women's clinic today looking to initiate a contraceptive. She is a competitive swimmer with no significant medical history other than cramping with menses. She desires no menses due to swimming, but wants something discreet due to wearing a swimsuit.
A. Initiate copper IUD - no hormonal option should be recommended
B. Initiate oral POP - norethindrone 350 mcg
C. Initiate oral COC - Ovral - 21 active, 7 placebo
D. Lybrel - Extended Cycle
E. Initiate subdermal progestin implant (68mg etonogestrel)
D. Lybrel - Extended Cycle

This pill is all active pills
A 21 yo college student uses Annovera (segesterone/EE) vaginal ring for contraception. She has been using her ring for 4 cycles, with the ring inserted for 3 weeks and 1 week removed for menses. She has misplaced her ring and it is now 9 days since she removed her ring. Which of the following is the most appropriate next step?
A. If she has engaged in unprotected intercourse in the last 9 days, she should use emergency contraception - specifically the copper IUD due to better efficacy
B. If she has NOT engaged in unprotected intercourse in the last 5 days, she should insert a new ring and use back up contraceptive for the next 7 days
C. If she has engaged in unprotected intercourse in the last 5 days, she should take plan B one step and use back up contraceptive for the next 5 days.
D. No back up contraceptive is needed. She can insert a new ring and she is protected from pregnancy immediately
E. Emergency contraception is only indicated if unprotected intercourse has occurred in the last 72 hours. Insert new ring today, and use backup contraception for the next 7 days.
B. If she has NOT engaged in unprotected intercourse in the last 5 days, she should insert a new ring and use back up contraceptive for the next 7 days
Emergency contraception and obesity recommendation?
Lower efficacy of plan B and ulipristal (ella) may be possible in patients with BMI 25-29.9 and >30
-however, DO NOT recommend doubling the dose and DO NOT recommend delaying the oral EC
-studies saying this were not well powered

Copper IUD is not impacted by BMI
How common is abnormal bleeding in Nexplanon?
-59% abnormal bleeding
-15% amenorrhea
-37% regular periods

-concentration of etonogestrel increased risk of abnormal bleeding
-some women overcame this bleeding with use of oral contraceptive
How common is amenorrhea in IUDs?
-amenorrhea higher in lower BMI patients (24.4 versus 27.6)
-amenorrhea more frequent early in women that were normal weight
-ameonrrhea occurred later in women who were overweight or obese
What is primary amenorrhea?
1. Absence of menstruation by age 15 or 16 years with normal secondary sexual development
OR
2. Absence of menses by age 14 without normal secondary sexual development
How common is primary amenorrhea? Secondary?
Primary: occurs in <0.1% of the general population

Secondary: occurs in 3-4% of the general population
What is secondary amenorrhea?
1. Absence of menses x 3 cycles
OR
2. Absence of menstruation for 6 months in previously menstruating women
Secondary ameonrrhea is more frequent in what women?
<25 years old with history of menstrual irregularities or who are competitive athletes

Hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal cause in >50% of secondary amenorrhea
What organs can contribute to amenorrhea?
1. Uterus
2. Ovaries
3. Anterior pituitary
4. Hypothalamus
5. Pregnancy
Uterine disorders that may cause amenorrhea?
-anatomical anomalies
-imperforated hymen
-uterine agenesis
-cervical stenosis
Ovarian disorders that may cause amenorrhea?
-ovarian failure
-Gonadal dygenesis
-Turner's syndrome
-chemotherapy/radiation
Anterior pituitary abnormalities that may cause amenorrhea?
-hyperprolactinemia
-hypothyroidism
-medications
Hypothalamus abnormalities that may cause amenorrhea?
-hypothalamic suppression
-anovulation/PCOS
-eating disorders
-intense exercise
First step when evaluating for amenorrhea?
Pregnancy test
Assessment to evaluate for amenorrhea?
Age, height, weight, physical activity, menstrual history, medications

Diagnostic testing:
-pregnancy test
-TSH
-prolactin
-consider PCOS testing (next Q)
-consider premature ovarian failure testing or menopause
PCOS testing?
-free or total testosterone
-17 hydroxyprogesterone
-fasting glucose
-fasting lipid panel
Premature ovarian failure testing or menopause testing?
High FSH and LH
Low progesterone
Goals of ameonrrhea treatment?
1. Occurrence of normal puberty
2. Restore menstrual cycle
3. Ovulation restoration
4. Improve fertility
5. Bone density preservation and bone loss prevention
6. Improving QOL
What are the medications that can cause hyperprolactinemia?
Antipsychotics:
-phenothiazone (prochlorperazine, chlorpromazine)
-haloperidol
-chlorprothixene
-risperidone
-molindone

Antidepressants:
-clomipramine
-MAOIs

Antihypertensives:
-verapamil

Prokinetic/motility agents:
-metoclopramide
-domperidone
Nonpharm treatment of amenorrhea?
-weight gain (if due to eating disorder)
-exercise reduction in quantity and/or intensity
First question to ask woman before suggesting a pharm treatment of amenorrhea?
Is pregnancy desired?
-if so, don't use contraceptive
Pharm treatment options for amenorrhea?
Treat underlying cause!!
Or
-combination oral contraceptive
-conjugated equine estrogen
-ethinyl estradiol patch
-progestin
If treating amenorrhea with conjugated equine estrogen, what must be prescribed with it?
Progesterone
Treatment of amenorrhea if underlying cause is hyperprolactinemia?
Bromocriptine (dopamine agonist)
Treatment of amenorrhea if underlying cause is PCOS?
If pregnancy immediate goal: weight loss and letrozole

Or else weight loss with help of Metformin/thiazolidinedione; use combination OC containing a progesterone with reduced or antiandrogenic effects
Treatment of amenorrhea if underlying cause is hypothyroidism?
Thyroid replacement
Treatment of amenorrhea if underlying cause is aneorexia or excessive exercise?
Increase weight
Decrease level of exercise
Consider psychotherapy

If not effective, consider estrogen (if not contraindicated)
Always ensure adequate _______________ when treating amenorrhea?
Calcium and vitamin D
What are the progestin options for amenorrhea treatment?
1. Oral medroxyprogesterone acetate (Provera)
-5-10mg by mouth on days 14-25 of cycle

2. Norethindrone (Aygestin)
-5mg by mouth for 7-10 days

3. Micronized progesterone (Prometrium)
-400mg by mouth daily for 7-10 days
Why would you use progestin for treating amenorrhea?
Induces withdrawal bleeding by creating a large drop in circulating progestin, mimicking the end of a cycle
RC is a 31 yo female. She and her husband are hoping to become pregnant in the near future, but RC hasn't had her menses in over a year. Upon further investigation, this hadn't bothered her so she never really worried about it. She has a healthy BMI, no history of PCOS, and hasn't been on oral contraceptives for about 5 years.
What are the next steps to assess her amenorrhea?
Pregnancy test?
Weight ✅
Physical activity?
Medications?
TSH?
Prolactin?
PCOS ✅
Premature ovarian failure/menopause?
RC is a 31 yo female. She and her husband are hoping to become pregnant in the near future, but RC hasn't had her menses in over a year. Upon further investigation, this hadn't bothered her so she never really worried about it. She has a healthy BMI, no history of PCOS, and hasn't been on oral contraceptives for about 5 years.
Her prolactin level is 140 (normal 2-29 ng/mL), what would be the appropriate treatment?
Bromocriptine
What is menorrhagia?
Heavy menstrual bleeding (>80 mL/cycle) or menstrual bleeding > 7 days
Prevalence of menorrhagia?
-occurs in 18-30% of healthy women
-occurs in 100% of patients with von Willebrand's disease
--> 20% of women with menorrhagia will have von Willebrand's
-occurs in 98% of patients with platelet dysfunction
-
What organs contribute to menorrhagia?
1. Hematologic
2. Hepatic
3. Endocrine
4. Uterine
Hematologic disorders that can cause menorrhagia?
-von willebrand's disease
-platelet disorders
-idiopathic thrombocytopenic purpura
Hepatic disorders that can cause menorrhagia?
Cirrhosis

(Estrogen is metabolized by the liver. If liver not clearing estrogen = higher estrogen = thicker endometrial tissue)
Endocrine disorders that can cause menorrhagia?
Hypothyroidism
Uterine disorders that can cause menorrhagia?
-fibroids
-endometrial polyps
-gynecologic malignancies
Assessment to evaluate for menorrhagia?
1. Signs/symptoms: anemia symptoms

2. Lab testing: CBC, ferritin, coagulation disorders (if fam history)

3. Diagnostic testing
Signs/symptoms of menorrhagia>?
-orthostasis
-tachycardia
-pallor
-fatigue
-lightheadedness
-perceived heavy/prolonged menstrual flow
Lab testing for menorrhagia?
-CBC
-ferritin
-coagulation disorders (if suspected/if fam history)
Diagnostic testing for menorrhagia?
-pelvic ultrasound
-pelvic MRI
-PAP smear
-endometrial biopsy
-hysteroscopy
-sonohysterogram
Goals of therapy for menorrhagia?
1. Decrease menstrual blood flow
2. Improve patients quality of life
3. Defer need for surgical intervention
What are the most efficacious medications for treating menorrhagia?
Combination oral contraceptives (⬇️ 40-50%)

Minera IUD (⬇️ 79-97%)
Other hormonal treatments for menorrhagia?
-SubQ depo-medroxyprogesterone acetate
-oral medroxyprogesterone (Provera) 5-10mg on days 5-26 or during luteal phase
Non hormonal treatments for menorrhagia?
NSAID with onset of menses (⬇️ 20-50%)

Tranexamic acid (⬇️26-60%)

Surgery
NSAIDs for menorrhagia?
-diclofenac 50mg po TID
-ibuprofen 800mg po TID
-naproxen 275mg po up to 4x a day
Tranexamic acid dosing for menorrhagia?
1300mg po every 8 hours once heavy bleeding begins
-do NOT take with combination OCs!!! (Large risk of VTE)
Algorithm for treating menorrhagia?
TN is a 16 yo female who recently fainted at school. At the hospital, she is noted to have a low hematocrit and is currently menstruating. Upon further history, it is identified this is not the first time TN has experienced heavy menstrual bleeding or dizziness during menstruation. Additionally, her menses lasts about 9 days. What other information should we collect from this patient?
Do bleeding disorders run in the family?
TN is a 16 yo female who recently fainted at school. At the hospital, she is noted to have a low hematocrit and is currently menstruating. Upon further history, it is identified this is not the first time TN has experienced heavy menstrual bleeding or dizziness during menstruation. Additionally, her menses lasts about 9 days.
Bleeding disorders do not run in the family. What are her treatment options?
First: Combination oral contraceptive

Others: Mirena IUD (16, so don't jump to this), depo-provera, oral progesterone starting on day 5 of cycle, NSAIDs
What is anovulatory bleeding?
Dysfunctional or irregular uterine bleeding (i.e. spotting)
Prevalence of anovulatory bleeding?
~5% of women

PCOS accounts for 8-14% of cases
Physiologic etiologies of anovulatory bleeding?
-adolescence (takes ~3-5 years for cycles to regulate from menarche onset)
-perimenopause
-pregnancy
Pathologic etiologies of anovulatory bleeding?
-PCOS
-hypothalamic dysfunction (physical/emotional stress, exercise, weight loss)
-hyperprolactinemia (medications!!!!)
-ovarian failure
Pathophysiology of anovulatory bleeding?
What is PCOS?
Disorder of androgen excess that often includes polycystic ovarian morphology or ovulatory dysfunction
Pathophysiology of PCOS?
Diagnosis of PCOS?
Labs for diagnosing PCOS?
Symptoms of PCOS?
-menstrual irregularities
-amenorrhea
-menorrhagia
-anovulatory bleeding

Clinical hyperandrogenism:
-acne
-hirsuitism
-alopecia

Obesity
Menstrual irregularities in PCOS?
1-3 years menses onset: <21 days or >45 days

>3 years: < 21 days, >35 days, <8 cycles/year

>1 year: >90 days for any one cycle
PCOS is a significant risk factor for what negative health implications?
1. Metabolic syndrome
2. Type 2 diabetes (hyperinsulinemia or insulin resistance)
3. Dyslipidemia
4. Hypertension
5. Cardiovascular disease
6. Endometrial hyperplasia and cancer
7. Depression/anxiety
Goals for treatment of PCOS?
1. Improve quality of life
2. Improve menstrual regularity
3. Decrease long term concerns
4. Assist in fertility management (if pregnancy desired)
Nonpharm treatment options for PCOS?
1. Weight loss of 5-10%

Consider if not responsive to pharm treatment AND complete with childbearing
2. Endometrial ablation
3. Endometrial resection
4. Hysterectomy
Benefits of weight loss in PCOS?
-increase menstrual regularity
-ovulatory function
-decrease hirsutism
-improve insulin sensitivity
-improve fertility/response to fertility treatments
First line pharm treatment of PCOS?
Combination oral contraceptives
-use lowest effective estrogen dose (20-30 mcg EE)
-use low androgenic activity progestin
How to treat hirsutism from PCOS?
Combination oral contraceptive x 6+ months plus cosmetic therapy
4 alternative pharm treatments for PCOS?
1. COC + lifestyle + metformin
2. COC + antiandrogens
3. Progestin only (depot, intermittent oral MPA, IUD)
4. Metformin + lifestyle (sometimes TZDs may be used instead)
When to consider COC + lifestyle + metformin for PCOS?
If lifestyle and COC alone do not manage metabolic concerns
When to consider COC + antiandrogens for PCOS?
-If after 6-12 cosmetic treatments + COC does resolve hirsutism goals
-If androgenic alopecia present

Example antiandrogens: spironolactone, flutamide, finasteride
Why can't you just use an antiandrogen for PCOS treatment?
Need COC with it due to concern for male fetal virilization
How is metformin beneficial for PCOS?
-improved insulin sensitivity --> increases SHBG
-reduced circulating androgen concentration
-improved glucose tolerance
A 19 yo female presents to your community pharmacy complaining of severe headache, photophobia, and some numbness in her fingers. This is the worst headache she has ever experienced in her life. She requests your help in selecting an appropriate OTC product for her new onset headache. Past medical history includes asthma and wisdom teeth removal last year.
Current meds: vitamin D 1000 IU daily, Sprintec (0.25mg norgestimate/35 mcg EE) po daily, fluticasone 110 mcg 2 puffs BID, albuterol MDI 2 puffs every 4-6 hrs as needed.
A. Recommend she call her PCP for a stronger pain med
B. Recommend ibuprofen 600mg q6h and increase fluid intake
C. Recommend she stop her fluticasone and take APAP 650mg every 6 hours
D. Recommend she take her rescue inhaler as this might be due to an asthma attack
E. Recommend the patient go to the ER
E. Recommend the patient go to the ER
What is dysmenorrhea?
(Most common gynecologic complaint)
Cramping pelvic pain prior to or with menses
What is primary dysmenorrhea?
(90%)
-pain with normal pelvic anatomy and physiology
-a result of inflammatory response
A 32 yo female presents to the women's health clinic to discuss contraceptive options. Seven months ago, she had her 3rd child and no longer desires pregnancy. When she was younger, she was on Depo-Provera for 3 years. Her PMH includes gestational diabetes x2 pregnancies, seizures, depression, menorrhagia, and hypothyroidism. Her current medications include folic acid, MVI containing iron, phenytoin, levothyroxine, warfarin, and a SSRI. Which of the following would be the ideal contraceptive option for this patient?
A. Initiate levonorgestrel containing IUD
B. Initiate copper IUD - no hormonal option should be recommended
C. Initiate injectable depo-provera
D. Initiate oral COC - Ortho-Cyclen (0.25mg norgestimate/35 mcg EE)
E. Initiate oral POP - Norethindrone 350 mcg
A. Initiate levonorgestrel containing IUD

-needs something reliable
-no copper iud due to hx of menorrhagia
-no depo cuz has already been on it for the 3 year max
-phenytoin interacts with estrogen and progesterone
A 17 yo female presents to the pharmacy today and asks to speak to you. She states that she had unprotected intercourse and subsequently forgot to take her combination oral contraceptive yesterday, but remembered to take her dose this morning. Current medications: Seasonale (0.15mg levonorgestrel/30 mcg EE) 84 active pills, 7 placebo pills - take 1 tablet po daily. Filled 7 weeks ago.
A. Patient should take Plan B one step due to having unprotected intercourse within 7 days of missing her COC
B. Patient should take 4 Seasonale tablets now and 4 more in 12 hours to follow Yupze method of EC and save money
C. Patient should contact her PCP about obtaining a copper IUD today, this provides both EC and long term protection
D. Contact the provider on the patient's behalf to obtan a standing order for Plan B one step, then the insurance will cover at no cost
E. Patient does not require emergency contraceptive therapy at this time as long as she has been taking her pills daily and hasn't missed a dose for the last 2-3 weeks
E. Patient does not require emergency contraceptive therapy at this time as long as she has been taking her pills daily and hasn't missed a dose for the last 2-3 weeks
What is secondary dysmenorrhea?
(10%)
-pain associated with a pelvic pathology
-endometriosis, cervical stenosis, pelvic infection, uterine or cervical polyps, uterine fibroids
Goals of dysmenorrhea treatment?
1. Improve overall quality of life
2. Decreased miss school days/work days
What are the symptoms of dysmenorrhea?
Crampy, pelvic pain shortly before or with onset of menses, typically lasting 8-72 hours

Other symptoms:
-lower back pain
-headache
-diarrhea
-fatigue
-nausea/vomiting
Lab assessment for dysmenorrhea?
-pelvic exam and screening for STDs in sexually active females
-rule out gonorrhea and chlamydia
-consider ultrasound to rule out masses, lesions, ovarian cysts, endometriosis
-consider miscarriage for new onset dysmenorrhea
Nonpharm dysmenorrhea treatment option?
Topical heat
1st line pharm dysmenorrhea treatment?
-combination oral contraceptives
-depo-medroxyprogesterone acetate
-levonorgestrel-containing IUD (Mirena)
Other options for pharm dysmenorrhea treatment?
NSAIDs:
-diclofenac 50mg PO TID
-ibuprofen 800mg PO TID
-naproxen 550mg "load"
-celecoxib 400mg "load"
Naproxen "load" for dysmenorrhea treatment? Celecoxib "load"
550mg started 1-2 days before onset then 275mg PO up to 4x a day

Celecoxib 400mg started 1-2 days before onset then 200mg every 12 hours during menses
What are some limitations to NSAIDs for dysmenorrhea?
-increase blood pressure
-fluid retention
-have to take it three times a day
-"load" requires patient to know when their cycle is going to come
Treatment algorithm for dysmenorrhea treatment?
What is the definition of endometriosis?
Chronic relapsing inflammatory disorder characterized by endometrial tissue outside of the uterus with increased pain secondary to:
-increased concentration of inflammatory markers
-increased nerve density at lesion sites
Pathophysiology of endometriosis?
Retrograde menstruation through fallopian tubes
-endometrial tissue deposited in the peritoneal cavity

-increased concentration of inflammatory markers
-increased nerve density at lesion sites
Prevalence of endometriosis?
Occurs in 10% of females
-higher in women with infertility (38-50%) or pelvic pain (60-80%)

Genetic associations
-7-10x higher in women with 1st degree relatives with severe disease

90% of women have retrograde menstruation and only 10% develop endometriosis
What things put a woman at increased risk for endometriosis?
-early menarche ≤ 11 years
-shorter menstrual cycles <27 days
-heavy, prolonged menstruation
-tall, thinner women
-woman's birth history (lower weight, multiple fetal gestation, in utero toxin exposure)
-altered pelvic anatomy
-alcohol use
-caffeine consumption
What things put a woman at decreased risk for endometriosis?
-higher # of pregnancies
-increased duration of lactation
-regular exercise (>4 hours/week)
-diets high in fruits and vegetables
-cigarette smoking
-higher body mass
Symptoms of endometriosis?
-dysmenorrhea
-dyspareunia
-infertility
-menorrhagia

-chronic pelvic pain
-ovulation pain
-sacral back pain
-cyclic or premenstrual bowel or bladder complaints
-chronic fatigue
Physical exam to diagnosis endometriosis?
Laparoscopic exam!!!! - only definitive diagnostic

Best observed during menstruation:
-pelvic tenderness
-tender uterosacral ligaments
-enlarged ovaries
-pelvic masses or nodules
-fixed, retroverted uterus
What does a laparoscopic exam identify for endometriosis?
Lesions on the ovaries, serosal surfaces, or peritoneum

Small lesions to large cysts
Endometriosis treatment for asymptomatic endometriosis?
Watchful waiting or expectant management
6 factors guiding initial treatment of endometriosis?
1. Patient's primary complaint
2. Location and extent of disease
3. Desire for future fertility
4. Cost of therapy
5. Contraindications to therapy
6. Side effect profiles
1st line choice for treating endometriosis/
Pharmacologic treatment!
-minimizes surgical complications and risks (at the end of the day, many patients end up with a hysterectomy)
Nonpharmacologic treatment of endometriosis?
If pregnancy is desired --> surgical removal of lesions
-reserved for medication failure or infertility!!!!
-disease is relapsing in nature and lesions can return

If no pregnancy is desired --> hysterectomy
Progestin +/- estrogen options for treatment of endometriosis?
Combination hormonal contraceptives:
-oral combination OCs
-vaginal
-transdermal
-extended cycle oral OC

Progestin only:
-depot
-levonorgestrel IUD (ages 16+)
-oral (last line since pt can still ovulate)

*USE LOWEST EFFECTIVE DOSE OF ESTROGEN
Other pharm options for treatment of endometriosis?
-NSAIDs --> efficacy limited, Rx strength may be required
-Danazol
-GnRH agonists (goserelin, leuprolide)
-aromatase inhibitors
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