Disorders of Menstruation Lecture Notes

Disorders of Menstruation

• Concepts apply to trans people who menstruate.

  Review of the Menstrual Cycle

• Part 1

• Controls female reproductive physiology.

• Cycle length is variable (21-40 days, average 28 days).

• Women menstruate ~360-400 times from menarche to menopause.

• Every cycle ~30-90 mL blood is shed.

• Phases:

• Follicular (Proliferative) Phase

• Ovulatory Phase

• Luteal (Secretory) Phase

• Menarche:

• Start

• Any age: 10-14 years old, average 12

• Based on genetics and environment

  Hypothalamic-Pituitary-Ovarian (HPO) Axis

• Dynamic relation between hypothalamus, anterior pituitary, and ovary.

• The rate and amplitude of GnRH pulses from the hypothalamus determine which hormone is released by the pituitary.

• Hypothalamus releases GnRH.

• Anterior pituitary produces LH, FSH

• Ovary produces estradiol, inhibin, and progesterone.

• Negative feedback loops: estradiol, inhibin, and progesterone inhibit hypothalamus and anterior pituitary.

• Day 1: menses start.

• Day 7: one follicle releases a dominate to grow.

• Follicle and estrogen are stimulating LH hormone

• Day 13: LH surge, releasing of mature egg from ruptured follicle.

• Day 14: ovulation.

• Day 21: corpus luteum grows until 21 days and makes progesterone.

• Corpus luteum dies at day 28.

• Low levels of estrogen and progesterone

  The Menstrual Cycle - Progesterone drop

• As the progesterone level drops:

• the corpus luteum begins to degenerate;

• the endometrium begins to break down, its cells committing apoptosis;

• the inhibition of uterine contraction is lifted, and

• the bleeding and cramps of menstruation begin.

  The Menstrual Cycle - Study

• 2019 study (n= 612, 613)

• Mean follicular phase length: 16.9 days

• Mean luteal phase length: 12.4 days

• Mean cycle length decreased by 0.18 days and mean follicular phase length decreased by 0.19 days per year of age from 25 to 45 years

• Mean variation of cycle length per woman was 0.4 days or 14% higher in women with a BMI of over 35 relative to women with a BMI of 18.5–25

• Between women, the follicular phase can range in length from days to weeks.

• Thus, how long the follicular phase is for a particular individual determines menstrual cycle length.

• Corpus luteum only viable for 14 days unless pregnancy occurs.

• Egg is only viable for 24 hours after being released from follicle.

• Variation:

• Health and genetics

  Dysmenorrhea

• Part 2

  True or False Questions about Dysmenorrhea

• Dysmenorrhea is the term used for painful menstruation. (True)

• There is more than one type of dysmenorrhea. (True)

• Dysmenorrhea is a type of acute cyclic pelvic pain. (True)

• Mittelschmerz is a type of chronic cyclic pelvic pain. (False)

• An ectopic pregnancy presents as acute noncyclic pelvic pain. (True)

• Endometriosis is the most common cause of primary dysmenorrhea. (False)

• Estrogen levels are inversely related to primary dysmenorrhea pain severity. (False)

• Cigarette smokers have the same incidence of dysmenorrhea as non-smokers. (False)

• Dysmenorrhea is positively associated with stress & a family history of dysmenorrhea. (True)

• Dysmenorrhea therapy is likely to be fully effective after the first cycle of treatment. (False)

  Learning Objectives

• Define dysmenorrhea and differentiate between primary and secondary disease.

• Identify possible causes and risk factors for pelvic pain pathologies.

• Evaluate the status of a patient with dysmenorrhea and decide on an appropriate management plan, including referral to other healthcare providers.

• State goals of therapy to treat and/or prevent dysmenorrhea.

• Develop an individualized, evidence-based plan by comparing available treatment options.

• Provide nonpharmacologic education about dysmenorrhea.

• Establish monitoring parameters and a follow-up plan to assess suggested therapies for efficacy and safety.

• Goal: Provide students with the knowledge and tools necessary to provide exemplary care (OTC or prescribing consults) for patients presenting with dysmenorrhea.

  Suggested Resources

• Burnett M, Lemyre M. No. 345-Primary Dysmenorrhea Consensus Guideline. J Obstet Gynaecol Can. 2017;39(7):585-595.

• ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol. 2018;132(6):e249-e258.

• Nakhla N. Disorders Related to Menstruation. In: Krinsky DL, Ferreri SP, Hemstreet BA, et al., eds. Handbook of Nonprescription Drugs 20th ed. Washington, DC: American Pharmacists Association; 2020.

• Kho KA, Shields JK. Diagnosis and Management of Primary Dysmenorrhea. JAMA. 2020;323(3):268-269.

• Dysmenorrhea Algorithm in MAPflow

  Approach to Assessment of Patients with Pelvic Pain

  Lower Abdominal or Pelvic Pain

• Pain can vary from mildly irritating to incapacitating

• Pain is one of the most common problems affecting women of reproductive age

• Pain may reflect pelvic disease but may also reflect non-gynaecological disorders that refer pain to the pelvis

• Acute Pelvic Pain: Pain lasts < 3 months

• Chronic Pelvic Pain: Pain lasts ≥ 3 months

• Pharmacists are well-positioned to triage patients presenting with pelvic pain as a chief complaint and educate them on evidence-based therapies as well as when medical care should be consulted.

  Pelvic Pain Causes

• Dysmenorrhea and endometriosis are the two most common causes.

• Focus of lecture will be on dysmenorrhea, it is vitally important to understand (and be able to rule out) the other conditions that can present similarly

• Cyclic pelvic pain

• Dysmenorrhea

• Endometriosis

• Mittelschmerz (mid-cycle pain during follicle rupture)

• Noncyclic pelvic pain

• Pelvic inflammatory disease

• Ruptured or hemorrhagic ovarian cyst, endometrioma, or ovarian torsion

• Ectopic pregnancy

• Endometritis

• Acute growth or degeneration of uterine myoma

• Threatened abortion

• Pelvic congestion syndrome

• Adhesions and retroversion of the uterus

• Pelvic malignancy

• Vulvodynia

• Chronic pelvic inflammatory disease

• Tuberculous salpingitis

• History of sexual abuse

  Condition Overview - Dysmenorrhea

• Dysmenorrhea is the most common gynecologic problem among adolescent and young adult women.

• Occurs 93% of women

• Goes down at more birth

  Dysmenorrhea Classification

• Primary Dysmenorrhea

• Women goes a die after

• Irregular preggo birth pattern

• No ovulation occurs

• Older individuals

• No obvious family history

• Cause of young

• Strong pain, just no family history, random

  Impact on Quality of Life

• Dysmenorrhea is the leading cause of school absenteeism and lost working hours among adolescent girls and young women.

  Did You Know?

• Despite its high prevalence and severity, most women do not seek medical care for this condition, so it remains commonly undertreated.

• Treatment has the potential to improve quality of life and decrease time lost from school or work.

• 6% of adolescents receive medical advice on dysmenorrhea treatment, while 70% self-treat.

  Primary Dysmenorrhea Etiology

• Prostaglandins

• Leukotrienes

• Nitric oxide?

• Vasopressin?

• Endometriosis is of PG related to pain

• NSAIDS to control PG related pain

• Lysing contributes 3- Loot

• 2.4 times highs in women with dysmenorrhea

  Clinical Presentation

• Cyclic pain with menstruation

• Range of symptoms

• Lower mid-abdominal pain or cramping

• Nausea/vomiting

• Dizziness

• Diarrhea

• Headache

• Pain occurs a few hours before or just after menstruation begins and lasts 48-72 hours.

• Pain is most intense over lower abdomen but may radiate to the back & inner thighs.

  Role of Other Factors

• Risk Factors

• Young age (<30)

• Nulliparity

• Early menarche

• Smoking

• Stress

• Positive family history

• Protective Factors

• Exercise

• Higher parity

• Use of hormonal contraceptives, especially if they have not had a pregnancy or are on birth control

• Early period

  Minor Ailment Service Framework

• Patient requests assistance with a complaint

• Is the RPh competent & knowledgeable in managing the complaint?

• Is RPh intervention in the best interest of the patient?

• Is the ailment within the scope of RPh?

• (If no to one or more) -> Refer patient to another HCP

• (If yes to all) -> Does patient consent to the minor ailment service

• (If no) -> OTC consult

• (If yes)->

  • Evaluate the situation
  • Collect history of presenting complaint, patient's health & medication history
  • Collect
  • Offer a private space for consultation
  • Verify patient's self-diagnosis
  • Assess
  • Use shared decision-making to develop a care plan
  • Plan results in ≥1 of the following:
    • Referral
    • Wait-and-see approach
    • Prescribe drug and/or recommend non-pharm therapy
  • Implement
    • Issue the Rx (if applicable)
    • Advise patient of option to fill elsewhere
    • Educate patient on care plan
    • Documentation & notification of patient's PCP should occur in a timely manner if drug therapy is initiated to ensure continuity of care
  • Establish monitoring parameters
  • Schedule and complete follow-up to evaluate safety & efficacy of care plan
  • Refer to another HCP as required

  Collect Questions

• Obtain demographic info – patient’s age

• Obtain history on presenting illness – Symptoms over a series of different menstrual cycles

  • Onset of pain, location of pain, type/intensity of symptoms help you to rule out if it is primary or secondary dysmenorrhea.

• Obtain patient history information

  • Medical and gynecologic (menstrual, sexual, preg) history
  • Medication history
  • Medication allergies or sensitivities
  • Social history

• A focused history and assessment are usually sufficient to make the diagnosis of primary dysmenorrhea.

Information Gathering

• S
  • What type of pain?
  • Dull or sharp pain?
  • Is this pain right now?
  • Are they menstruating?
• C
  • Pain severity (stabbing pain?)
  • Nausea?
  • Vomiting?
• H History
  • Has this happened before?
  • Compare to last time
• O Onset
• L Location
• A Aggravating
• R Relieving

Information Gathering

• History of the pain (aka: menstrual history)
  • Age at menarche; length of time elapsed between menarche and dysmenorrhea onset
  • Menstrual cycle assessment: length & regularity of cycles; last menstrual period
  • Menstrual flow assessment: duration & amount of bleeding; correlation with pain symptoms
  • Note: the pain in PD is similar from one cycle to the next

Information Gathering

• H

  • Pregnancy?
  • Cardiovascular

• Hypertension or gynecology need?

  • Contraceptive use?
  • Sexual activity use exercise?

• Smoking

  • Nicotine causes vasoconstriction
  • Causes more pain
    • Stress relieving

  Analyze Gathered Info

• Ascertain that presenting symptoms are characteristic of primary dysmenorrhea

• Assess for patient factors that are consistent with primary dysmenorrhea

• Ask if the patient has received a previous dysmenorrhea diagnosis

  • Have you talked to your physician before?

  Assess

• Differentiate between PD and SD characteristics

• Assess for presence of red flag signs and symptoms

• Rule out other diagnoses

• Refer

  Dysmenorrhea Classification

• Characteristic: Primary Dysmenorrhea vs Secondary Dysmenorrhea

• Age at onset:

  • 6-12 months after menarche but typically within 2 years after menarche (13-17 years of age) vs Variable but at least 2 years after menarche; (typically mid-late 20s or older or pain begins after years of normal cycles)

• Cause:

  • Idiopathic vs Associated with pelvic pathology

• Menses:

  • Regular – normal blood loss vs Irregular – menorrhagia and inter-menstrual bleeding more common

• Pattern and duration of dysmenorrhea pain:

  • Onset just prior to or coincident with onset of menses; pain lasting 2-3 days with each or most menses vs Vary according to cause; change in pain pattern or intensity may indicate secondary disease

• Pain at other times of menstrual cycle:

  • No vs Yes; may occur before, during, or after menses

• Response to NSAIDs and/or OCs:

  • Yes vs Depends on the cause; generally, response to OTC NSAIDs is often inadequate or absent

• Other possible associated symptoms:

  • Fatigue, HA, nausea, dizziness, backache, irritability, depression, and changes in appetite may occur at the same time as dysmenorrhea pain vs Vary according to cause of secondary dysmenorrhea; may include dyspareunia, pelvic tenderness

• If patient is old, takes contraceptive but stop it, then it's SD

• Myes of is at 25 bi contraceptives could ve masked symptons

  • Patient is 25
    • Do NOT refer immediately

  Pelvic Pain: Differential Diagnosis

• Type of Condition & Examples:

  • Other gynecologic conditions
    • Primary Dysmenorrhea
    • Mittelschmerz
    • Pregnancy
    • Spontaneous abortion
  • Life- or organ-threatening conditions
    • Ectopic pregnancy
    • Acute placental abruption
    • Appendicitis
    • Uterine rupture
    • Ovarian and fallopian tube torsion
    • Pelvic trauma
  • Non-gynecological causes of pelvic pain (Genitourinary)
    • Interstitial cystitis
    • Urinary tract infection
    • Urolithiasis
  • Non-gynecological causes of pelvic pain (Bowel)
    • Irritable bowel syndrome
    • Inflammatory bowel disease
    • Constipation
    • Adhesions (from previous surgeries)
  • Secondary dysmenorrhea
    • Endometriosis
    • Adenomyosis
    • Leiomyoma (fibroids)
    • Ovarian cysts and tumors
    • Cervical stenosis
    • Salpingitis
    • Pelvic inflammatory disease
    • Pelvic congestion syndrome
    • Congenital malformations
    • Insertion of intrauterine device (IUD) within last 6 months
    • Obstructive anomaly of the reproductive tract (hymenal, vaginal, or müllerian)
  • Non-gynecological causes of pelvic pain (Musculoskeletal)
    • Hernia
    • Fibromyalgia
    • Myofascial pain
    • Neuropathic pain
    • Pelvic floor myalgia
    • Abdominal wall muscle strain
  • Non-gynecological causes of pelvic pain (Psychological)
    • Anxiety, depression
    • Physical, emotional, sexual abuse
    • Somatization
    • Substance use

  Differential Diagnosis (cont’d)

• Condition

  • Endometriosis
    • Pain extends to premenstrual or postmenstrual phase or may be continuous; Onset is usually in the 20s or 30s but may start in teens; Deep dyspareunia, premenstrual spotting, infertility
      • Estrogen dependent so pain gets worse where estrogen is low
      • Most common cause
  • Adenomyosis
    • Pain (in 25% of women) is sharp, knife-like +/- severe cramping during menstruation
      • Abnormal uterine bleeding (in 60% of women), infertility
      • Chronic baneigh
  • Leiomyoma (fibroids)
    • Pain is associated with a dull pelvic dragging sensation
      • Enlarged abdomen
      • Being tumour
      • Risk of infertility
      • If not tectect: scantissue dalopment
  • Pelvic inflammatory disease (PID)
    • Pain may initially be menstrual, but often extends into the premenstrual phase with each cycle
      • May have intermenstrual bleeding, dyspareunia
      • Infection of Lormine of pelvic orasvarius, utters

  Patient Assessment: Red Flags

• Fever, chills, or other signs of a systemic infection

• Intrauterine device insertion in the last 6 months

  • IVD Lit can dislodge + pierce causing pain, maybe not be sterile procedure infection)

• Pain occurs outside the first 3 days of menses or persisting for more than 5 days

• Sudden onset of pain with bleeding or menarche

• Unilateral or non-midline abdominal or pelvic pain

• Patient reports palpable abdominal or pelvic lump

• Changes in severity or pattern of the pain and menstrual fluid

• Gynecological symptoms (e.g., amenorrhea, menorrhagia, dyspareunia, post-coital bleeding)

  • (not getting period bleeding a lot pain during course bleeding everytime you have intercourse)

• New onset of pain with bleeding in patient with history of pain-free periods

  Plan

• Canadian study of women treating PD

  • 77% nonRx analgesics
  • 14% Rx analgesics
  • 14% used oral contraceptives
  • 14% NHPs
  • 40% heat
  • 14% did nothing

• Many women self-treat their menstrual pain using non-prescription agents, they frequently undertreat, which can negatively impact their quality of life

  Goals of Therapy

• Symptom resolution or improvement

• Minimize the disruption of usual activities

• Suppress disease progression

• Identify patients who may have underlying issues requiring further medical evaluation

  Pharmacotherapy Plan

• 1st line options: NSAIDs and hormonal contraceptives

• Treatment choice influenced by:

  • Hormonal contraception desire
  • Previous medication experience(s)
  • Contraindications to medication use
  • Risk-to-benefit ratio
  • Other patient preferences (e.g., cost)

• For most women, drug therapy is required, and non-pharmacologic measures are used adjunctively

  • Pharmacists can only Edfornsaid-G- prescribe for NSAID

  Treatment Algorithm

• Is contraception desired?

• Is NSAID contraindicated?

• Is NSAID therapy warranted and desired?

• 3-7 is rating

• 37 is rating severe

  Nonpharmacologic Adjunctive Therapy

• Exercise

• Tobacco cessation

• Topical heat therapy

  • Vasodilation

• Transcutaneous electrical nerve stimulation (TENS)

• Stress

• 150mins/week ->not full cessutiv can help too increase blood flow

• Heat works quickly ->becoming bigger not a lot of evidence

• .be

  Clinical Pearls

• A pelvic examination is not necessary prior to initiating therapy.

• Regular exercise is likely to improve dysmenorrhea symptoms.

• Always recommend local heat as adjunctive dysmenorrhea therapy.

Nonprescription Pharmacologic Therapy

• First line options:
  • Ibuprofen
    • $200 – 400$ mg every 6 to 8 hours, maximum daily dose $1200$ mg/day
  • Naproxen sodium
    • $220$ mg every 8 to 12 hours, maximum daily dose $440$ mg/day
• Second line options (Used for mild primary dysmenorrhea):
  • Ibuprofen + Acetaminophen
    • $125/250$mg: 2 tabs every 8 hours (6 tablets)
    • $97.5/325$mg: 2-3 tabs every 6 hours (12 tablets)

FDC analgesics

• Ibuprofen 125 mg + Acetaminophen 250 mg
  • Take 2 tablets TID. Maximum daily dose = 6 tablets.
    • If a patient has tried acetaminophen and had some or good success for PD, you may consider switching to this fixed dose combination analgesic as it contains a first- line therapeutic agent (ibuprofen) and is indicated for mild pain. Combogesic is a Schedule II agent.
• Take 1-2 tablets QID. If pain does not respond to 2 tablets, 3 tablets may be taken at subsequent doses. Maximum daily dose = 12 tablets. If a patient has tried acetaminophen and had some or good success for PD, you may consider switching to this fixed dose combination analgesic as it contains a first-line therapeutic agent (ibuprofen) and is indicated for mild-to-moderate pain.
• Fixed doe

Nonprescription Pharmacologic Therapy

• Second line options (Used for mild primary dysmenorrhea):
  • Acetaminophen
    • $650 – 1000$ mg every 4 to 6 hours, maximum daily dose $4000$ mg/day
  • Aspirin
    • $325 – 650$ mg every 4 to 6 hours, maximum daily dose $4000$ mg/day

Nonprescription Pharmacologic Therapy (First and Second Lines)

• First line options:
  • Ibuprofen: $200 – 400$ mg every 6 to 8 hours, maximum daily dose $1200$ mg/day
  • Naproxen sodium
• Second line options:
  • Acetaminophen: $650 – 1000$ mg every 4 to 6 hours, maximum daily dose $4000$ mg/day

Extra Strength Menstrual Midol® Complete contains:

• Acetaminophen $500$ mg

• Caffeine $60$ mg

• Pyrilamine maleate $15$ mg

• The adult dose is 2 caplets with water, every 4 hours as needed.
  Do not exceed 8 caplets per day as it is hazardous. If symptoms persist for more than 5 days, see your doctor.

• Teen Midol® Complete contains:

  • Acetaminophen $325$ mg
  • Caffeine $60$ mg
  • Pyrilamine maleate $15$ mg

• The dose for adults 12 years and older is 2 caplets with water, every 4 hours as needed. Do not exceed 12 caplets per day as it is hazardous. If symptoms persist for more than 5 days, see your doctor.

• Extra Strength PMS Midol® Complete contains:

  • Acetaminophen $500$ mg
  • Pamabrom $25$ mg
  • Pyrilamine maleate $15$ mg

• The adult dose is 2 caplets with water at the first sign of discomfort, usually 4 to 6 days prior to menstruation. Repeat every 4 hours as needed. Do not exceed 8 caplets per day as it is hazardous.
  If symptoms persist for more than 5 days, see your doctor.
  Maximum Strength Pamprin® Menstrual Pain Relief contains:

• Acetaminophen $500$ mg

• Pamabrom $25$ mg

• Pyrilamine maleate $15$ mg

• Tylenol® Menstrual:
  Not helpful for menstral crump

  Prescription Pharmacologic Therapy

• Used for moderate primary dysmenorrhea

  • NSAIDs
  • Combined Oral Contraceptives (COCs)

• First-line for patients seeking contraceptionContinuous use of COCs is often successful if cyclic use fails

• Combination of NSAID + COC

  • This combo therapy will fail ~10% of patients

• Progestin-only Contraceptives

  • Levonorgestrel intrauterine system: highly effective for PD & endometriosis pain
  • Medroxyprogesterone Depot Injection: alternative in women who cannot tolerate estrogen; who are >35 years; women who smoke

• prescription strength

• If above OtC amount, prescribe it , don't tell the them to ignore otc guidlines

Prescription Pharmacologic Therapy

• Effective NSAID treatment:

  • Initiated with the start of menses
  • Should not be necessary for > $2-3$ days per month

• Ontario prescribing regulations

  • NSAID must fall under the following AHFS classification: Central Nervous System Agents: Analgesics and Antipyretics. Nonsteroidal Anti-inflammatory Agents. Other Nonsteroidal Anti-inflammatory Agents (28:08.04.92)
    • Hormonal contraceptives are outside of the scope of Ontario pharmacists

  Prescription Pharmacologic Therapy: NSAIDs

  • Drug, Recommended Adult Dose, Maximum Daily Dose (Rx)
    Drug , Recommended Adult Dose, ,Maximum Daily Dose (Rx)\Ibuprofen, $600 – 800$ mg every eight hours OR Loading dose of $800$ mg, then $400 – 800$ mg every 8 hours , $2400$ mg/day
    Mefenamic acid,Loading dose of $500$ mg initially, then $250$ mg every 6 hours ,$1250$ mg/day with loading dose on day 1; $1000$ mg/day on subsequent days
    Naproxen base (immediate release),Loading dose of $500$ mg initially, then $250$ mg every 6 to 8 hours OR $500$mg BID, $1250$ mg/day with loading dose on day 1; $1000$ mg/day on subsequent days
    Naproxen sodium,Loading dose of $550$ mg initially, then $275$ mg every 6 to 8 hours OR DS tablet: $550$ mg BID,$1375$ mg/day
    Ketoprofen (immediate release), $25 – 50$ mg TID-QID ,$50$ mg per dose, $300$ mg/day
    Diclofenac potassium,Loading dose of $100$mg, then $50$mg every 6 to 8 hours ,$200$mg/day with loading dose on day 1; $100$mg/day on subsequent days
    Flurbiprofen,$50$ mg QID, $200$ mg/day
    Clinical trials do this -
    -give 5 day supply

  Prescription Pharmacologic Therapy: NSAIDs (Not Approved)

  • Celecoxib
    *Not Health Canada approved but studies supports it

  Disclaimer for NSAIDs

  *Avoid in patients with renal failure, peptic ulcer disease,
  congestive heart-failure, and ASA-sensitive asthma (exception:
  celecoxib).
  *Use cautiously in patients with pre-existing CVD, cerebrovascular
  disease, or those with risk factors for cardiovascular disease (e.g.,
  hypertension, hyperlipidemia, diabetes mellitus and smoking).

  Prescription Pharmacologic Therapy: Other

  *Drug Class and Agent(s)
  *Combined hormonal contraceptives (CHCs) Combined oral contraceptive (COC) pills or the vaginal ring are ideal first-line options for women wishing for contraception Continuous or extended-cycle regimens decrease menstrual period frequency and may result in a more rapid onset of pain reduction, thus are generally preferable to cyclic regimens. The patch is also useful but may not be as effective at relieving dysmenorrhea as COC
  *Progestin-only medications
  *Levonorgestrel intrauterine device (IUD)
  *Etonogestrel implantable rod Approved in Canada in 2020 but not indicated for dysmenorrhea (used off-label)
  *Depot medroxyprogesterone is a treatment option for women who cannot tolerate estrogen and in those >35 y/o. It may also be used for SD treatment. To promote overall bone health, encourage adequate calcium (total of 1200 mg elemental calcium from all sources) and vitamin D supplementation (1000 IU daily) in women on DMPA therapy

  Clinical Pearls

*NSAIDs administered with regular dosing regimens should be considered first-line treatment for most women.
*All currently available NSAIDs are of comparable efficacy and safety.
*Select hormonal contraceptives should be offered to women who are not currently planning pregnancy.
Opposite wire ImataPine

# Natural Health Products

• Product Recommended Adult Dose, Comments
• Ginger $750 – 2000$ mg during the first 3 to 4 days of, Hest evidence may cause diareah
  Thiamine (Vitamin B1) 100 mg/day for 3 months, protectioe
  Magnesium 360 mg starting three days before the period has begun.Lacing protection
  Fish oils 1000 mg of EPA and 720 mg DHA; Takes up to 3, Omega 6 precisor of period , exca need cramps
  Cholcalciferol (Vitamin D3) A single 300,000 IU dose of cholecalciferol 5 days before menses.Women should be counseled to ingest the RDA

*Pharmacotherapeutic Comparison

It is unknown whether NSAIDs or COCs are superior to one another in treating dysmenorrhea The combination may be beneficial but will fail ~10-20% of patients

• Ask about previously tried therapies

• Patients may perfer to:

  • use an NSAID they are familiar with
  • try another agent if adverse effects were experienced previously