Self-Care Therapeutics – Menstrual Disorders Comprehensive Notes

Dysmenorrhea

Background & Epidemiology

Defined as difficult or painful menstruation
One of the most common gynecologic complaints in the U.S.
- > $90\%$ of young menstruators affected
- $15{-}20\%$ of teens report severe pain
- ≈ $600$ million work-hours lost each year

Normal vs. Primary Dysmenorrhea Physiology

Normal menses
- Prostaglandins & leukotrienes → rhythmic uterine contractions + vasoconstriction → controlled bleeding & expulsion of menstrual fluid
Primary dysmenorrhea
- ↑ Prostaglandins/leukotrienes → strong, frequent contractions
- Vasoconstriction → uterine ischemia + tissue hypoxia → pain

Etiology

Primary (idiopathic): poorly understood; prostaglandin & leukotriene surge
Secondary (pathologic): endometriosis, PID, ovarian cysts, uterine tumors, cervical stenosis, IBD, congenital abnormalities

Clinical Presentation

Cyclic pain beginning with menses
- Continuous dull ache, spasmodic cramps (suprapubic/lower abdomen)
- Radiation: lower back, upper thighs
Associated prostaglandin-mediated symptoms
- N/V/D, fatigue, dizziness, bloating, headache

Treatment Goals

Provide complete or significant symptom relief
Minimize disruption of daily activities/work/school

Exclusions to Self-Care (Figure 9-2)

Severe dysmenorrhea or menorrhagia
Symptoms inconsistent with primary dysmenorrhea (suggest secondary cause)
History of PID, infertility, irregular cycles, endometriosis, ovarian cysts
Use of intrauterine contraception (IUC)
Aspirin/NSAID allergy or intolerance
Concomitant warfarin, heparin, lithium
Active GI disease (PUD, GERD, UC)
Bleeding disorder

Non-Pharmacologic Interventions

Adequate sleep
Local heat (pad, Thermacare, hot bath)
- Faster onset than drugs; synergistic with NSAIDs
Regular aerobic exercise
Smoking avoidance
Increased fish / omega-3 intake → ↓ pro-inflammatory cytokines

OTC Pharmacologic Therapy

Acetaminophen
- Weak prostaglandin inhibitor; suitable only for mild pain
- Dose: $1000\,\text{mg}$ PO QID (max daily $4\,\text{g}$ )
NSAIDs (first-line)
- MOA: competitive COX-1/COX-2 inhibition → ↓ prostaglandins
- Efficacy: $66{-}90\%$ obtain relief within first cycle
- Start at menses onset or $1{-}2$ days prior if previous inadequate relief
- Schedule dosing (not PRN) for $48{-}72$ h
- OTC dosing
- Ibuprofen $200{-}400\,\text{mg}$ $q4{-}6h$ (MDD $1200\,\text{mg}$ )
- Naproxen $220{-}440\,\text{mg}$ load then $220\,\text{mg}$ $q8{-}12h$ (MDD $660\,\text{mg}$ )
- Rx options / when intolerant to non-selective NSAID
- Celecoxib: $400\,\text{mg}$ loading, then $200\,\text{mg}$ $q12h$
- Common ADRs: GI upset (mitigate w/ food), headache, dizziness
- Trial length: $3{-}6$ cycles before deeming failure; may switch NSAIDs/increase dose within this window

Prescription Options (when contraception acceptable or NSAIDs fail)

Combined Oral Contraceptives (COC)
- < $35\,\mu\text{g}$ ethinyl estradiol + norgestrel/levonorgestrel (extended cycle preferred)
Injectable Medroxyprogesterone Acetate (MPA) – Depo-Provera $IM/SC$ q12 wk
Levonorgestrel Intrauterine System (LNG-IUS) – Mirena $6$ yrs, Kyleena $5$ yrs, Skyla $3$ yrs

Treatment Algorithm (simplified)

Begin non-drug measures ± OTC NSAID monthly
If inadequate & contraception desired → trial COC $2{-}3$ cycles
If inadequate & contraception not desired → escalate to Rx NSAID dose or consider MPA/LNG-IUS
Continue effective therapy; re-evaluate regularly

Patient Counseling Pearls

Primary dysmenorrhea = normal physiologic variant
NSAIDs are preferred; initiate with first cramp or 1-2 d prior
Take on fixed schedule w/ food
Combine with heat/exercise
Switch NSAID or seek care if pain worsens/new symptoms develop

Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD)

Definitions

PMS: cyclic physical, emotional, behavioral symptoms in luteal phase; resolve by end of menses, absent during follicular week
PMDD: severe PMS; ≥ $5$ symptoms (≥ $1$ mood-related: depression, anxiety, mood lability, irritability) causing social/occupational impairment
Molimina: normal mild premenstrual symptoms without impairment

Symptom Comparison (Table 9-3)

Onset: last $5$ d before menses (molimina) vs. entire luteal week (PMS/PMDD)
Duration: < $1$ wk (molimina/PMS) vs. < $2$ wk (PMDD)
Impact: none → mild/moderate → significant (PMDD)

Exclusions to Self-Care (Figure 9-3)

Severe PMS or any PMDD
Uncertain symptom pattern (timing vs. menses)
Symptom onset coinciding with OCP or hormone therapy initiation
Contraindications to proposed self-care agents (e.g., caffeine in PUD)

Treatment Goals

Educate patient on cyclic nature
Relieve or markedly improve symptoms to minimize distress, relationship disruption, absenteeism

Non-Pharmacologic Measures

Regular exercise
Diet: ↓ salt/simple sugars, caffeine, alcohol; ↑ complex carbs; low-fat diet
Stress management: CBT, relaxation, light therapy, acupuncture, massage

OTC / Supplement Options (evidence-based focus)

Calcium + Vitamin D
- Dose: Calcium $500{-}600\,\text{mg}$ BID (goal $1000{-}1300\,\text{mg/day}$ ); Vit D ≥ $600\,\text{IU/day}$
- Improves mood swings, food cravings, physical sx within $2$ cycles
- ADR: nausea, constipation
Pyridoxine (Vitamin B6)
- $100\,\text{mg}$ PO daily; several cycles for effect
- High doses $2{-}6\,\text{g}$ → neuropathy (paresthesia, bone pain, weakness)
Magnesium (pyrrolidone)
- $300{-}360\,\text{mg}$ PO daily during premenstrual interval
- Source foods: spinach, nuts, legumes, whole grains
- ADR: diarrhea
Vitamin E (for mastalgia – possible benefit)
NSAIDs (effective if dysmenorrhea prominent)
Diuretics
- Pamabrom $50\,\text{mg}$ QID or caffeine $100{-}200\,\text{mg}$ q3-4h
- Only if actual weight gain/edema, not mere bloating
Combination “PMS” products (Midol, Pamprin) NOT recommended (unnecessary ingredients, antihistamines ineffective for mood)
Complementary herbs (evidence variable)
- Chaste-tree berry, Ginkgo (likely), St. John’s wort/saffron (possible), evening primrose (not effective)

Prescription Therapy for PMDD / Severe PMS

First-line: SSRIs (daily or luteal-phase)
- Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline
- Caution: Paroxetine & Fluoxetine ↑ congenital malformations $2{-}3.5\times$ if used early pregnancy
SNRI: Venlafaxine (daily or luteal-phase)
COC: Drospirenone $3\,\text{mg}$ + ethinyl estradiol < $30\,\mu\text{g}$ (Yasmin, Yaz, Beyaz)
Leuprolide (GnRH agonist) – last-line due to cost, IM route, hypo-estrogenic SEs

Follow-Up & Counseling

Symptom diary/calendar to confirm cyclic pattern & monitor response
OTC agents require several cycles; reinforce adherence
Red flags → referral: persistent/worsening sx, neurologic signs on B6, interference with relationships/work

Amenorrhea

Definitions

Primary: no menarche by $16$ yr (with normal secondary sexual characteristics) or by $14$ yr (without secondary development)
Secondary: absence of menses for $\ge 3$ cycles or $\ge 6$ mo in previously menstruating person

HPO Axis Physiology

Hypothalamus → GnRH → pituitary
Pituitary → FSH & LH → ovaries
Ovaries → estrogen & progesterone → endometrium & feedback

Etiologies (pregnancy = most common)

Hypothalamic suppression (↓ GnRH): anorexia, excessive exercise, stress
Hyperprolactinemia (pituitary): antipsychotics, verapamil, hypothyroidism
Ovarian failure: premature follicle loss, chemo/radiation
Uterine disorders: adhesions, congenital anomalies
Chronic anovulation: PCOS, thyroid disease

Clinical Presentation

Amenorrhea ± infertility, vaginal dryness, ↓ libido
Signs: absent/cessation of menses, low/high body weight changes, acne/hirsutism/alopecia (androgen excess), acanthosis nigricans (insulin resistance)

Diagnostic Work-Up (rule out pregnancy first!)

Labs: Urine pregnancy test, TSH, prolactin
- If androgen excess: free/total testosterone, 17-OHP, lipids
- If ovarian failure: FSH, LH
Progesterone challenge, pelvic US for anatomy

Treatment Goals

Initiate/maintain normal puberty & cycles, protect bone density, restore ovulation/fertility, relieve hypo-estrogenic symptoms

Algorithm Highlights

Negative pregnancy test → identify cause
Anorexia/exercise: ↑ weight/↓ exercise → high-estrogen COC (> $35\,\mu\text{g}$ EE) or CEE or estradiol patch
Hyperprolactinemia: dopamine agonist (Bromocriptine) $q8{-}12h$
PCOS
- Pregnancy desired: weight loss + Clomiphene citrate + Metformin
- No pregnancy desired: weight loss + Metformin + COC (< $30{-}35\,\mu\text{g}$ EE) with low-androgen or anti-androgen progestin (desogestrel, norgestimate, drospirenone)
Unknown/other: Progestin (MPA) to induce withdrawal bleed → follow with combined estrogen/progestin

Drug Table Highlights

COC (high estrogen $30{-}40\,\mu\text{g}$ ) – daily PO
Conjugated equine estrogen (Premarin) – days $1{-}25$ PO
Ethinyl estradiol patch (Alora, Climara, etc.)
MPA (Provera) $PO$ days $14{-}25$ of cycle
Bromocriptine (Parlodel) $PO$ $q8{-}12h$

General/Monitoring

Calcium + Vitamin D supplementation due to low estrogen
Expect menses within $1{-}2$ mo
Monitor BMD and prolactin (if applicable)

Heavy Menstrual Bleeding (HMB)

Definition & Etiology

Blood loss > $80\,\text{mL}$ / cycle OR menses > $7$ d
Differential: pregnancy (intrauterine/ectopic), miscarriage, von Willebrand disease, hypothyroidism, uterine fibroids/polyps/malignancy

Clinical Features

Symptoms: heavy/prolonged flow, fatigue, lightheadedness, ± dysmenorrhea
Signs: orthostasis, tachycardia, pallor
Labs: CBC, ferritin, coagulation studies when indicated
Imaging: pelvic US/MRI, PAP, endometrial biopsy

Goals

Reduce flow, correct anemia/hypotension, improve QOL, avoid surgery

Algorithm Summary

NSAIDs during menses (if no contraception desired)
If contraception desired → LNG-IUS or COC
If NSAID fails & no contraception → Tranexamic acid during menses or luteal MPA
Refractory → surgical (ablation, hysterectomy)

Pharmacologic Options & Dosing

NSAIDs (Ibuprofen, Naproxen, Celecoxib) – same dosing as dysmenorrhea; ↓ blood loss $20{-}50\%$
Tranexamic Acid (Lysteda) $1.3\,\text{g}$ PO q8h for $4{-}7$ d per cycle; ↓ $26{-}60\%$
COC – daily; ↓ $40{-}50\%$
LNG-IUS (Mirena) – $6$ yr; ↓ $79{-}97\%$ (most effective/cost-effective)

Monitoring

Flow reduction expected within $1{-}2$ mo
Check Hgb/Hct baseline & ≤ $3$ mo

Abnormal Uterine Bleeding with Ovulatory Dysfunction (AUB-O)

Definition & Pathophysiology

Heavy/irregular bleeding due to chronic anovulation → unopposed estrogen → continuous endometrial proliferation → unpredictable shedding

Common Causes

PCOS (most frequent; androgen excess + metabolic risk)
Immature HPO axis (adolescents)
Perimenopause (intermittent estrogen decline)
Others: pregnancy, hypothalamic dysfunction, hypothyroidism

Clinical Presentation

Irregular, heavy, prolonged bleeding
PCOS signs: acne, hirsutism, obesity
Perimenopause: vasomotor sx, vaginal dryness
Diagnostics similar to HMB + PCOS labs (testosterone, glucose, lipids) or FSH (perimenopause)

Goals

Acute control of bleeding
Long-term cycle regulation, prevention of complications (osteopenia, infertility), improved QOL

Treatment Algorithm

Pregnancy desired
- Weight loss + Metformin ± Clomiphene citrate (ovulation induction)
No pregnancy desired
- COC with < $30{-}35\,\mu\text{g}$ EE + low-androgen (desogestrel, norgestimate) or anti-androgen (drospirenone) progestin
- Alternatives when estrogen CI: intermittent or depot MPA, LNG-IUS

PCOS-Specific Notes

Metformin: ↑ insulin sensitivity → ↓ androgens, ↑ ovulation; continues through pregnancy to cut miscarriage risk
Expect ovulation resumption within $3{-}6$ mo

Drug Reference Tables (Top 200 highlights)

Dysmenorrhea / HMB NSAIDs & Analgesics

Acetaminophen (Tylenol) – Analgesic/antipyretic – PO QID
Ibuprofen (Advil/Motrin) – NSAID – OTC $q4{-}6h$ / Rx $q6{-}8h$
Naproxen (Aleve) – NSAID – $q8{-}12h$
Celecoxib (Celebrex) – COX-2 NSAID – $q12h$

Hormonal Contraceptives

COC (Levonorgestrel: Levora 28, Aviane 28; Extended: Seasonale, Seasonique)
- Daily PO
Injectable MPA (Depo-Provera; Depo-SubQ 104) – IM/SC q12 wk
LNG-IUS (Skyla $3$ y, Kyleena $5$ y, Mirena/Liletta $6$ y)

PMS OTC Supplements

Calcium + Vit D (various)
Pyridoxine: $100\,\text{mg}$ daily
Magnesium $300{-}360\,\text{mg}$ daily (pyrrolidone)

PMDD Prescription

SSRIs: Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft) – daily or luteal only
SNRI: Venlafaxine (Effexor) – same schedules
Drospirenone COC: Yasmin 28, Yaz, Beyaz – days $1{-}21$ each cycle

Amenorrhea Agents

High-estrogen COC – $30{-}40\,\mu\text{g}$ EE
Premarin (CEE) – days $1{-}25$
Estradiol patch (Alora, Climara, Estraderm, Vivelle-Dot)
MPA (Provera) – days $14{-}25$
Bromocriptine (Parlodel) – $q8{-}12h$

HMB-Specific

Tranexamic Acid (Lysteda) – $1.3\,\text{g}$ q8h $4{-}7$ d/cycle

AUB-O / PCOS

Low-androgen/antiandrogen COCs: Desogen 28 (desogestrel), Ortho Tri-Cyclen Lo (norgestimate), Yaz (drospirenone)
Metformin (Glucophage/Fortamet) – daily PO
MPA oral/injectable (Provera, Depo-Provera)

Global Course Objectives (per syllabus)

Design patient-specific treatment plans for menstrual disorders
Identify self-care exclusions & referral points
Select appropriate prescription agents when self-care inadequate
Integrate non-pharmacologic strategies
Evaluate onset, ADRs, monitoring, dosing of regimens

Follow-Up Checkpoints Across Disorders

Dysmenorrhea: assess pain control each cycle; if NSAID trial adequate after $3{-}6$ cycles
PMS: reassess after $2{-}3$ cycles; maintain symptom diary
Amenorrhea: expect menses within $1{-}2$ mo of therapy start; monitor BMD, prolactin
HMB: repeat CBC/Hct by $3$ mo; observe flow reduction in $1{-}2$ mo
AUB-O/PCOS: evaluate ovulation/bleeding pattern after $3{-}6$ mo; monitor metabolic parameters

Quick Reference – When to Refer STAT

Severe pain/bleeding, secondary dysmenorrhea features, heavy flow causing syncope, suspected pregnancy, neurologic adverse effects (e.g., vit B6 neuropathy), new/worsening symptoms despite therapy, contraindication to OTC options