32: 33-year-old woman with painful periods Flashcards Preview

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Flashcards in 32: 33-year-old woman with painful periods Deck (25)
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1
Q

Primary dysmenorrhea

A

defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea is then defined as painful menses secondary to some pelvic pathology.

Primary dysmenorrhea is associated with increasing amounts of prostaglandins. The actual prevalence is unknown but ranges from 20-90%. Ten to fifteen percent of women feel their symptoms are severe and have to miss school or work. Dysmenorrhea usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours.

2
Q

Risk Factors for Primary Dysmenorrhea

A

Mood disorders such as depression or anxiety have been associated with dysmenorrhea, especially in adolescents. This may be a complex association as other factors may be comorbid with the mood disorder diagnosis.

There is also an association between tobacco use and dysmenorrhea.

Women who have more children are noted to have a decreased incidence of primary dysmenorrhea.

Additionally, women who report overall lower state of health or other social stressors have a tendency for dysmenorrhea. It is not associated with lower socioeconomic class.

Primary dysmenorrhea most commonly occurs in women in the teens and twenties. It is notably associated with ovulatory cycles. Classically, an adolescent will start experiencing dysmenorrhea one or two years after menarche. This is the time it takes naturally for an adolescent to develop regular ovulatory cycles. The earlier the onset of menarche the more likely dysmenorrhea may occur.

3
Q

Normal Pelvic Exam Findings

A

Unless a woman is pregnant, a normal uterus in not larger than eight weeks in size, approximately the size of a clenched fist. A normal uterus may be mildly tender on exam just prior to or during menses. A normal uterus can be tilted anteriorly (anteverted or anteflexed), midline, or tilted posteriorly (retroverted or retroflexed). An anteflexed or retroflexed uterus may be difficult to assess for size because of its position. The uterus should be smooth in contour around the entire surface area. Serosal fibroids or large mucosal fibroids may cause a “knobby” feel to the uterus.

The uterus should be mobile. The uterus is held in the pelvis by a series of ligaments on each side. With endometriosis the uterus may become nonmobile because of implants along these ligaments.

Ovaries are normally 2 x 3 centimeters in size-roughly the size of an oyster. In an obese woman the ovaries may be nonpalpable. During ovulation the ovaries may be slightly larger secondary to physiologic cysts. Caution should be taken while palpating the ovaries since the patient may have a mild sickening feeling. Mild tenderness on palpation of the ovaries is normal.

Nabothian cysts are physiologically normal on the cervix. These are formed during the process of metaplasia where normal columnar glands are covered by squamous epithelium. They are merely inclusion cysts that may come and go and are of no clinical significance. While looking at the cervix white discharge can also normally be seen coming from the os or in the vagina. If there are endometrial growths on the cervix or vagina these may be blueish.

Vaginal discharge can be normal or abnormal. Normal vaginal discharge is termed physiologic leukorrhea. This patient has no symptoms like itching, burning, or foul smelling discharge. It is normal for women to have physiologic clear to white vaginal discharge. The volume of discharge may get so heavy a woman will wear a pad for comfort; the volume may change during the course of a menstrual cycle.

4
Q

me-t-n

A

Anything longer than seven days is most likely menorrhagia.
Metrorrhagia is irregular frequent bleeding but it doesn’t have to be heavy. Menometrorrhagia that is irregular frequent and heavy bleeding.

5
Q

Premenstrual Syndrome Diagnostic Criteria

A

Premenstrual dysphoric disorder is a complex disorder that occurs at a specific time in a woman’s cycle during multiple menstrual cycles in a year.

A minimum of five symptoms need to begin the week prior to menses, start to improve during menses and then become minimal the week after menses.

The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess.

The patient must also have one of the following: food cravings, changes in sleep, being “out of control”, decreased energy, anhedonia, and some physical symptoms.

The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms for the woman. It may be helpful to get the perspective of other close contacts of the patient.

6
Q

Preconception Counseling

A
  1. Vitamin supplementation Daily supplementation with 400-800 micrograms of folic acid, as many pregnancies are unplanned. This lowers the risk for neural tube defects by over 70%.
  2. Substance abuse Substances like alcohol, tobacco, illicit drugs, and caffeine should be discontinued (or, in the case of caffeine, at least cut back).
  3. Immunizations Check for immunizations that must be given prior to pregnancy because they are live, such as MMR and chickenpox. New guidelines suggest Tdap as well.
  4. Chronic conditions Get any chronic medical problems-like diabetes, depression, or thyroid disorders-under control prior to pregnancy.
7
Q

Primary Dysmenorrhea - Presentation & Treatment

A

In a family physician’s office, primary dysmenorrhea in an adolescent is a common diagnosis.

In a woman under 20 who is not sexually active with the classic history of suprapubic pain the first two days of menses, non-steroidal anti-inflammatory medications can be started without a pelvic exam.

Ibuprofen is the gold-standard anti-inflammatory, but many other anti-inflammatories have also been proven equally efficacious when taken cyclically starting a day or two prior to the onset of menses and continuing into the first days of menses.

Choice of the specific anti-inflammatory to use should be based on cost and side effects the patient experiences. If anti-inflammatories are not effective, combination birth control pills (monophasic or triphasic) with medium-dose estrogen are effective.

A pregnancy test should be performed in an adolescent who is sexually active. Other testing should be added if the patient has any type of dysfunctional uterine bleeding or pelvic pain outside of the typical pattern.

8
Q

Treatment for Leiomyomas and Associated Symptoms

A
  • Progesterone-releasing intrauterine device (IUD) (Mirena)
  • acupuncture
  • Combined hormonal contraceptives
  • Depo-Provera
  • ParaGard IUD
  • uterine artery embolization
9
Q

Progesterone-releasing intrauterine device (IUD) (Mirena)

A

an effective option for reducing menstrual blood flow in women with menorrhagia secondary to fibroids. Another appeal is that it can be left in for five years.

In studies the progesterone-releasing IUD (levonorgestrel-releasing intrauterine system) has clearly demonstrated decreased menstrual flow in women with fibroids. In one smaller study, the device decreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Through decreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In women who hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with fewest side effects.

Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potential side effects are lower abdominal pain and breast tenderness. The risk of uterine perforation is more likely at the time of insertion. The risk of infection is within the first 20 days of insertion.

10
Q

Combined hormonal contraceptives

A

Oral contraceptives have been proven effective when used for dysmenorrhea related to anovulation only without a structural problem, especially in a woman who needs birth control.

In women with isolated dysmenorrhea, small trials have demonstrated benefit. However, a meta-analyses of these found insufficient evidence that oral combined hormonal pills are effective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause both menorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and work loss, and felt to decrease dysmenorrhea with a smaller endometrial lining.

OCPs are commonly known to patients and providers making them often the initial step in management. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, such as the Nuva-ring and the Ortho-Evra patch, are worth considering. These may not cause nausea and vomiting as they bypass the gastrointestinal system altogether. All types of combined hormonal contraceptives have slightly increased risk of venous thromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35 years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The Nuva-ring has risks of leukorrhea and vaginitis in approximately 5% of patients; the other types do not.

11
Q

Depo-Provera

A

another potential tx for leiomyomas and the symptoms associated with them. However, recent literature does demonstrate that there is bone density loss after several years of use. In addition, Depo- Provera significantly affects fertility. It may take nine to 18 months for a woman to regain regular menses after her last injection. Other side effects would include weight gain, irregular menses for weeks to several months, and potential mood changes. However, there is no risk of venous thromboembolism and this can be used in a smoker older than 35.

Hysterectomy is the definitive surgical option for women with secondary dysmenorrhea and those with menorrhagia. It is reserved for women who no longer desire to bear children.
Some surgeons will offer hysterectomy to woman with a uterus 14 to 16 weeks in size or greater whether or not the patient has symptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication for hysterectomy. For a patient who has failed other management, hysterectomy may be an option.

Myomectomy, in which the surgeon removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient’s future reproductive plans are important in distinguishing these two options. Other surgical options for dysmenorrhea unrelated to uterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy. These two treatments have insufficient evidence at this time to recommend to most women.

12
Q

ParaGard IUD

A

another effective form of bc. This device may stay inside the uterus for up to 10 years. For a woman who is not planning any more children, this may be a viable option for birth control. An advantage of the ParaGard IUD is that it has no hormones; it is made of copper. However, in women using ParaGard there is an increased risk of dysmenorrhea and menorrhagia just from the IUD. It is not a treatment for leiomyomas at all. In this case it could potentially make the symptoms worse.

13
Q

uterine artery embolization

A

must understand the potential for urgent hysterectomy, consideration of future fertility is imperative. Some consider this a relative contraindication. Post procedure the patient usually has pelvic pain for at least 24 hours, sometimes lasting up to 14 days. “Post-embolization syndrome” is a group of complaints that include pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure to consider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis of fibroids, and vaginal discharge and bleeding for up to two weeks. This treatment is usually reserved for women who cannot tolerate other hormonal treatments or who do not want those treatments for other reasons. This procedure is performed by an interventional radiologist. It is not an option for dysmenorrhea alone or for menorrhagia without uterine fibroids.

14
Q

Hormonal Birth Control Therapies

A

Progesterone-Only Intrauterine Device (IUD)
The progesterone-only IUD can stay in place for three to seven years, depending on which brand you use. You may have some irregular bleeding at the beginning for up to six months. Some women will stop bleeding altogether, and others continue having periods with less bleeding. The IUD is just taken out if you decide to try to get pregnant again. If, after five years, you decide you do not want to get pregnant, you just take it out and replace it at the same visit for another five years.

Progestin Implants
These are put under the skin and last for three years.

Ortho-Evra Patch
The patch is left in place for one week. You place a new patch weekly for three weeks, then during the fourth week you do not place any patch and have your period.

Depo-Provera Shot
The Depo-Provera shot is given every 12 weeks. If a woman on this decides to get pregnant, it may take a little longer to get pregnant after stopping the shots than if she used the IUD. It also has a higher rate of irregular bleeding at the beginning.

Vaginal Ring
The vaginal ring is placed inside the vagina and left for three weeks. Then the fourth week you remove it and have your period.

15
Q

Premenstrual Syndrome Treatment

A

Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular.

Oral contraceptives are effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. It would be appropriate to try this in a woman also needing birth control. The most favorable pill is the formulation containing ethinyl estradiol and drospirenone.

SSRI during menses are an effective treatment of premenstrual syndrome, especially if severe or mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as daily treatment for decreasing both psychologic and physical symptoms. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a woman has symptoms and continue until the start of menses or three days later. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost.

Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in women. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in women done with childbearing.

Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies the effectiveness is inconsistent. If this were to be tried on a patient, the dosing would be during luteal phase. You must be cautious about causing potential electrolyte abnormalities with this drug.

Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity.

Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been studied and shown some efficacy. These are all worth discussing with patients, although true efficacy is not proven.

16
Q

Progesterone-Releasing IUD Placement - Contraindications / Complications

A

Contraindications: Infection or cancer.

Cautions: History of headache or vascular disease.

Complications:
During the actual procedure, the patient can have pain or bleeding. There is also a risk of a uterine infection or perforation. Both of these are rare.

After the procedure is done, the patient may have some bleeding or cramping for a few days, but this usually responds to ibuprofen.

Once the IUD in place, there is a risk the uterus can expel it, or the patient may have pain with intercourse or experience irregular bleeding. Some partners can feel the string. After the patient’s next period, she should come back to have the string checked and make sure it is still in place. It is a good idea for the patient to check for the IUD strings after every menses to ensure it stays inside the uterus.

The patient should return to the clinic for any fever associated with lower abdominal pain, with or without abnormal vaginal discharge. These signs would be concerning for uterine infection.

17
Q

Evaluation of Differential of Secondary Dysmenorrhea / Menorrhagia

A

-CBC
-pregnancy test
-US
-thyroid disorders
»Thyroid disorders can also affect frequency of menses and should be considered if other causes of abnormal bleeding are excluded.

18
Q

CBC

A

A complete blood count is always a consideration when a woman seems to be bleeding more heavily than usual. Iron deficiency anemia is common in women of reproductive age, affecting between 21-67% of women with menorrhagia. It can add to the fatigue a woman feels. This type of anemia is responsive to therapy, which initially is oral iron supplementation.

19
Q

pregnancy test

A

A pregnancy test should be done on every woman of reproductive age with any changes in bleeding pattern or amount. Ectopic pregnancy can present with irregular bleeding and is life-threatening. Additionally, unusual forms of pregnancy-such as molar pregnancies-can cause heavy bleeding, abdominal pain, and uterine enlargement. Although it is acknowledged that pregnancy most commonly causes amenorrhea, these are diagnoses not to be missed.

20
Q

US

A

Ultrasound is the study of choice for pelvic pathology. The sensitivity is 60% and specificity is 93% for detecting intracavitary issues. The sensitivity for detecting intramural pathology is also high, but not as high as it is for detecting intracavitary issues.

Ultrasound has a high positive predictive value for detecting adenomyosis as well. It does not require any radiation to the ovaries (CT scans will), no intravenous dyes are needed, and it is generally painless for the patient. The pelvic ultrasound does require an intravaginal portion, and all women should be advised of this in advance.

The combination of abdominal and vaginal ultrasounds allow for reliable measurements and anatomy of the cervix, uterus, and ovaries. Ultrasound is acceptable at the initial evaluation whenever the physician thinks the patient has secondary dysmenorrhea based on clinical history and physical exam.

21
Q

Differential of Secondary Dysmenorrhea / Menorrhagia: less likely diagnoses

A

Cervical stenosis can be congenital or acquired. With congenital stenosis an adolescent will have significant dysmenorrhea which is not as responsive to nonsteroidal anti-inflammatory medications as would be expected. The menstrual flow will also be minimal. Acquired stenosis may be related to cryotherapy or LEEP procedures. This causes dysmenorrhea as the uterus is distended with blood. On exam the uterus will feel diffusely enlarged.

Inflammatory bowel disease can often be misdiagnosed as a gynecologic problem since constipation and diarrhea are symptoms associated with premenstrual syndrome. Additionally, when a woman has bloody stools during her menses, the clinical diagnosis can be more confusing. However, when there is pain with defecation and bloody stools occur at times other than during menses this diagnosis becomes clearer. Abnormal vaginal bleeding is not a typical symptom of inflammatory bowel disease.

Irritable bowel syndrome may cause crampy pain prior to and during menses, but will also occur at other times during the month. This pain is often associated with diarrhea and/or constipation.

Ovarian cysts commonly cause recurrent and chronic pelvic pain. This type of pain is more likely to occur midcycle, although the patient may have pain associated with menses. This location of this pain is typically in one of the lower quadrants and not as much midline. Ovarian cysts may come and go related to ovulation.

Mood disorders or adjustment disorders can be exacerbated by, but do not typically cause, dysmenorrhea. Dysmenorrhea is a real pain syndrome. If you treat a concurrent mood disorder it can improve the pain response.

Uterine polyps may be associated with abnormal bleeding–specifically intermenstrual or postcoital bleeding–but there will also be menorrhagia. Polyps do not typically present with dysmenorrhea, but this may occur later.

22
Q

Differential of Secondary Dysmenorrhea / Menorrhagia: Adenomyosis

A

Epidemiology: Occurs more frequently in parous than nonparous women. There may be bias in the epidemiology as diagnosis has historically been made on pathology which is more likely to have been obtained from parous women. Adenomyosis actually can be found in any woman from adolescence to menopause.

Pathophysiology: This is not completely understood. One theory is endometrial invagination, but has not been completely proven It is hypothesized that estrogen and progesterone play a role only because hormones can be treatment options.

Presentation: 60% of women complain of menorrhagia. The uterus is typically enlarged and diffusely boggy, but symmetric and should still be mobile. There may be some urinary or gastrointestinal symptoms secondary to size and mass effect on the bladder and rectum.

Diagnosis: Ultrasound may demonstrate a heterogeneously boggy uterus. MRI is more specific for diagnosis.

Management: There is not currently any surgical method to remove the discrete areas affected.

23
Q

Differential of Secondary Dysmenorrhea / Menorrhagia: chronic PID

A

Epidemiology: The exact incidence and prevalence is unknown.

Pathophysiology: PID can have a subclinical smoldering course that is considered chronic.
These patients can have significant morbidities to include infertility and pain in the lower abdomen. Many of these cases will have plasma cells on endometrial biopsy.
inflammatory disease

Presentation: Cardinal symptom is lower abdominal pain, usually unrelated to menses. However, pain that occurs just prior to or during menses is highly suggestive of dysmenorrhea. Menorrhagia (abnormal bleeding) is seen in one third of women with chronic pelvic inflammatory disease, especially subclinical disease that isn’t treated early.

24
Q

Differential of Secondary Dysmenorrhea / Menorrhagia: Endometriosis

A

Epidemiology: Endometriosis is a disorder that effects women of reproductive age. The most common age effected is 25-35 years old. The exact prevalence in the general population is unknown. Risk factors include nulliparity, early menarche or late menopause, short menstrual cycles, and long menses. Women may have protective factors that decrease the likelihood of endometriosis. These include multiparity, lactating, and late menarche.

Pathophysiology: Endometrial glands in areas other than the uterus.

Presentation: Symptoms include dyspareunia, bowel or bladder symptoms that cycle with menses, fatigue, abnormal vaginal bleeding, and some effects on fertility. Pain, either chronic pelvic pain or dysmenorrhea, occurs in 75% of patients with endometriosis and is the most common symptom. Dyspareunia is a differentiating clinical factor: it is common in women with endometriosis; it is rare in women with leiomyoma. On physical exam these patients have pain in the pain cul-de-sac, immobile and retroflexed uterus, nodules on the uterosacral ligaments, or just pain with uterine motion.

25
Q

Differential of Secondary Dysmenorrhea / Menorrhagia: Uterine leiomyomas (fibroids)

A

Epidemiology: The most common benign tumors of the uterus. These are three times more common in African American women than Caucasian women. Decreased risk of developing fibroids has been noted with oral contraceptive use, increasing parity, and smoking. Increased risk is known with early menarche, family history of fibroids, and increased alcohol use.

Pathophysiology: These are made of normal myometrial cells. They can occur within the cavity and under the endometrium (submucosal), within the myometrium (intramural), on the serosal surface (serosal), or in the cervix.

Presentation: Common symptoms of fibroids include dysmenorrhea, pressure symptoms like increased urinary frequency related to fibroid location, and potentially trouble getting pregnant. The m/c symptom associated with fibroids is menorrhagia. Many women also have anemia related to the menorrhagia. This does not cause intermenstrual bleeding. The physical exam typically has an enlarged uterus that is freely mobile. The uterus may feel “knobby” from an irregular contour, and occasionally be minimally tender on exam. It is controversial whether dyspareunia is a symptom associated with fibroids and studies are conflicting. This may depend on location of the fibroid.

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