4.8 Menstruation Disorders - Terrell

How is amenorrhea defined?

No menstrual bleeding for at least 90 days

what is primary amenorrhea?

Absence of menses by age 15 (never menstruated)

What is secondary amenorrhea?

Absence of menses for 3 cycles or 6 months in someone who previously menstruated

What is hypothalamic amenorrhea?

Amenorrhea caused by disruption of GnRH secretion due to stress, weight loss, or excessive exercise

What is the general presentation of patients with amenorrhea?

No acute physical distress

What are common symptoms of amenorrhea? (3)

Cessation of menses

Vaginal dryness

Decreased libido

What are common signs of amenorrhea? (6)

No menses for more than 3–6 months

Recent significant weight loss or gain

Acne

Hirsutism

Hair loss

Acanthosis nigricans

What lab tests are used to evaluate amenorrhea?

FSH

LH

TSH

Prolactin

What is the first step in the treatment of amenorrhea?

Perform a pregnancy test

After ruling out pregnancy, what is the next step in managing amenorrhea?

Identify the underlying cause and treat appropriately

If amenorrhea is due to an anatomic cause, how is it treated?

Correct the structural abnormality (surgical or procedural)

If amenorrhea is due to ovarian insufficiency or low estrogen, what is the treatment?

Estrogen + progestin therapy

If hyperprolactinemia is the cause of amenorrhea…

1. what class of drugs is used

2. name the options for treatment

3. which option is first line

1. Dopamine agonists

2. cabergoline and bromocriptine

3. cabergoline

If hypothalamic dysfunction (stress, weight loss, exercise) is the cause, what is the treatment approach?

lifestyle modification (weight restoration, reduce stress/exercise)

How is the ethinyl estradiol patch dosed for amenorrhea?

weekly

Why must estrogen always be given with a progestogen?

To reduce the risk of uterine (endometrial) cancer

What is a major benefit of estrogen therapy in amenorrhea?

Reduces risk of osteoporosis

What are major adverse effects of estrogen therapy?

Increased risk of VTE

Breast tenderness

Breast enlargement

What is the expected outcome after starting estrogen + progestin therapy?

period starts within 1-2 months of treatment

What should be monitored during estrogen therapy?

Lipids and blood pressure

What is the role of progestins in amenorrhea? and how are they administered?

Induce withdrawal bleeding in secondary amenorrhea;

Given for 5–10 days, followed by withdrawal bleeding

What is the most effective and preferred progestin for amenorrhea?

Oral medroxyprogesterone acetate (Provera)

What are the progestin options for amenorrhea?

Oral medroxyprogesterone acetate (Provera)

Norethindrone

Micronized progesterone (Prometrium)

Vaginal gel (Crinone)

What should be monitored during dopamine agonist therapy?

Baseline and weekly prolactin levels

How is dosing adjusted for dopamine agonists when treating amenorrhea?

increase dose until period resumes

How long should dopamine agonist therapy be continued when treating amenorrhea?

6-12 months (up to 2 years)

What are common adverse effects of dopamine agonists?

• Nausea

• Dizziness

• Headache

• Hypotension

HMB is classified as what type of condition?

A type of abnormal uterine bleeding (AUB)

How is heavy menstrual bleeding defined?

Blood loss greater than 80 mL per cycle
OR

Bleeding longer than 7 days per cycle

What must always be ruled out first in HMB?

preg

What is the general presentation of patients with heavy menstrual bleeding?

No acute physical distress

What are common symptoms of HMB?

Heavy or prolonged menstrual flow

Fatigue

Lightheadedness (if severe blood loss)

Dysmenorrhea

What are common signs of HMB?

Orthostasis

Tachycardia

Pallor

What labs are used to evaluate HMB?

CBC

Ferritin

Hemoglobin

Hematocrit

What imaging/tests may be used in HMB evaluation?

Pelvic ultrasound

MRI

Pap smear

Biopsy

Hysteroscopy

What nonpharmacologic treatment options exist for HMB?

Surgical options (endometrial ablation and hysterectomy)

What determines the choice of treatment for HMB?

Desire for pregnancy

What is the first-line treatment option for HMB in patients who desire pregnancy or cannot use hormones?

NSAIDs

What is the treatment option for HMB in patients who desire pregnancy or cannot use hormones, who did not see effects from NSAIDs?

tranexamic acid or luteal phase progesterone

what is the refractory treatment option for HMB in pts who desire pregnancy or cannot use hormones?

consider CHC or LNG-IUS

or conservative endometrial ablation surgery

What are treatment options for HMB in patients who do NOT desire pregnancy?

CHC or LNG IUS

What are treatment options for HMB in patients who do NOT desire pregnancy, who tried CHC and LNG IUS but they were ineffective?

consider other CHC or progestin only options

what are the refractory HMB treatment options if the pt does not want to get pregnant?

conservative endometrial ablation surgery

NSAIDs for HMB:

1. when can they be used

2. examples

3. avoid with which two dx states?

4. cost

1. only during period

2. any of them

3. PUD or GERD

4. cheap

When are progestin-only options used in HMB?

When there is a contraindication to combined hormonal contraceptives

is 14 day or 21 day more effective for HMB when using norethindrone acetate or MPA?

21 days

What is the most effective treatment option for HMB?

Levonorgestrel intrauterine system (IUS)

How are combined hormonal contraceptives (CHCs) used in HMB?

Used continuously

What combined hormonal contraceptive is FDA-approved for HMB?

Four-phasic estradiol + dienogest (Natazia)

What is Myfembree used for?

Heavy menstrual bleeding due to uterine fibroids in premenopausal women (also used for endometriosis)

How is Myfembree dosed and what is the maximum duration?

One tablet daily; maximum 24 months

Why is Myfembree limited to 24 months of use?

Risk of continued bone loss that may not be reversible

What are important adverse effects and precautions of Myfembree?

Thrombotic events, alopecia, vasomotor symptoms, increased lipids, HA

Define PMS

Cyclic symptoms in the last week of the menstrual cycle that resolve with onset of menses;

requires at least 1 moderate-to-severe somatic or psychiatric symptom for ≥3 months

Define PMDD (premenstrual dysphoric disorder)

Severe form of PMS with ≥5 symptoms in the last week before menses that improve after onset;

at least 1 symptom must be affective

What is the initial treatment approach for PMS/PMDD?

start with minimally invasive or non-systemic options

What lifestyle modifications are recommended for PMS/PMDD?

Reduce caffeine, sugar, and sodium intake

Increase exercise

Vitamin and mineral supplements

What supplements are used for PMS/PMDD?

V B6

Calcium carbonate

When should pharmacologic therapy be started for PMS/PMDD?

If symptoms persist after 2 months of lifestyle changes and symptom charting

What is first-line pharmacologic therapy for PMDD?

SSRIs

Which SSRIs are used for PMS/PMDD?

Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline

How can SSRIs be dosed for PMDD?

Continuously or only during the luteal phase (similar efficacy)

What is an alternative to SSRIs for PMS/PMDD?

Venlafaxine

Which antidepressant is NOT effective for PMS/PMDD?

bupropion

How do combined hormonal contraceptives (CHCs) affect PMS symptoms?

Improve physical symptoms but not mood symptoms

What CHC is specifically effective and FDA-approved for PMDD?

Monophasic CHC with ethinyl estradiol 20 mcg + drospirenone 3 mg

When should patients be followed up after starting therapy for PMS/PMDD?

Within 1–3 menstrual cycles

What monitoring is required with CHCs containing drospirenone?

serum K (check within the first month if the pt is on any other K increasing meds)

What is dysmenorrhea?

Crampy pelvic pain occurring with or just prior to menses

What types of treatment options are available for dysmenorrhea?

• Noninvasive/nonpharmacologic

• Hormonal

• Nonhormonal pharmacologic

What factors influence treatment choice for dysmenorrhea?

• Desire for pregnancy

• Level of sexual activity

• Adverse effects

• Cost

What are nonpharmacologic treatment options for dysmenorrhea?

heat therapy, exercise, low fat vegetarian diet, transcutaneous electric nerve stimulation

What is the treatment of choice for dysmenorrhea? and why?

NSAIDs, direct analgesia

Which drugs are most commonly used for dysmenorrhea?

naproxen and IBU (same efficacy)

What are important counseling points for NSAIDs in dysmenorrhea?

GI side effects

Take with food

What is an alternative if naproxen and IBU are not tolerated or contraindicated when treating dysmenorrhea?

celecoxib

What are next-line options if NSAIDs are contraindicated when treating dysmehorrea?

Combined hormonal contraceptives (CHCs)

Then depot medroxyprogesterone acetate or LNG-IUD