Menstrual Disorders Handout 2024.pdf

MENSTRUAL DISORDERS Kalumi Ayala, Pharm.D., AAHIVP, TTS Clinical Assistant Professor, Pharmacy Practice Department 1 2 3 Identify the potential negative health implications of menstrual disorders Recommend appropriate pharmacologic interventions for patients with menstrual disorders Design a monitor...

MENSTRUAL DISORDERS Kalumi Ayala, Pharm.D., AAHIVP, TTS Clinical Assistant Professor, Pharmacy Practice Department 1 2 3 Identify the potential negative health implications of menstrual disorders Recommend appropriate pharmacologic interventions for patients with menstrual disorders Design a monitoring plan to assess the pharmacotherapeutic efficacy for the treatment of menstrual disorders LECTURE OBJECTIVES MENSTRUAL DISORDERS Amenorrhea Heavy Menstrual Bleeding Dysmenorrhea AMENORRHEA AMENORRHEA Primary amenorrhea: Secondary amenorrhea Absence of menses by age 16 in the presence of normal secondary development Absence of menses by age 14 in the absence of normal secondary sexual development Absence of menses for three cycles or for 6 months in a previously menstruating woman Most common cause of amenorrhea is unrecognized pregnancy Recent significant weight loss/gain Presence of acne, hirsutism, hair loss or acanthosis nigricans Symptoms Signs AMENORRHEA CLINICAL PRESENTATION Cessation of menses Infertility Vaginal dryness Decreased libido AMENORRHEA RISK Decreased bone development AMENORRHEA EVALUATION Laboratory Tests: Other tests: Pregnancy test Serum FSH and LH Thyroid-stimulating hormone Prolactin  Progesterone challenge  Pelvic ultrasound If Polycystic Ovarian Syndrome (PCOS) suspected: Free and total testosterone Dehydroepiandrosterone Fasting glucose Fasting lipid panel AMENORRHEA TREATMENT Goals Restore menstrual cycle Preserve bone density Prevent bone loss Restore ovulation Improve fertility (if desired) General treatment approach Identify underlying cause and treat accordingly Non-pharmacologic recommendations If related to anorexia: Exercise reduction Weight gain AMENORRHEA TREATMENT Amenorrhea secondary to excessive exercise/anorexia Lifestyle changes* Weight gain Decrease exercise *First line intervention Psychotherapy* Cognitive Behavioral Therapy (CBT) Pharmacotherapy Estrogen replacement therapy AMENORRHEA TREATMENT Estrogen replacement therapy  COC (30-40 mcg of estrogen)  CEE (0.625-1.25 mg by mouth daily on days 1-26 of the cycle)*  Add cyclic progesterone: medroxyprogesterone acetate 10 mg PO on days 14-26  Ethinyl estradiol patch (50 mcg/24hr)* *add progesterone therapy in women with an intact uterus to reduce the risks of endometrial hyperplasia COC: combined oral contraception; CEE: Conjugated equine estrogen AMENORRHEA TREATMENT Hyperprolactemia Dopamine agonist Bromocriptine 2.5 mg by mouth two to three times daily Cabergoline 0.25 mg by mouth twice weekly Unknown cause Progestin (to induce withdrawal bleeding) followed by CHC Progesterone 100-200 mg IM or medroxyprogesterone acetate 10 mg PO daily for 5-10 days Treatment algorithm for amenorrhea. (CHC, combination hormonal contraceptive; IUD, intrauterine device; PCOS, polycystic ovary syndrome.) Reproduced with permission from DiPiro JT, Yee GC, Posey lM, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. 11th ed. New York City: McGraw-Hill; 2020. Citation: Chapter 50 Menopause and Menstruation-Related Disorders, Chisholm-Burns MA, Schwinghammer TL, Malone PM, Kolesar JM, Bookstaver P, Lee KC. Pharmacotherapy Principles & Practice, 6e; 2022. Available at: https://ppp.mhmedical.com/content.aspx?bookid=3114&sectionid=261475803 Accessed: March 09, 2023 Copyright © 2023 McGraw-Hill Education. All rights reserved FOLLOW-UP/MONITORING Follow-up should occur every 3-6 months or sooner if needed Menses should occur within 1-2 months of therapy Monitor for:  Return of menses  Quality of life  Medication: ADRs  Bone mineral density testing (if longstanding amenorrhea or if secondary to hypoestrogenism)  Prolactin levels (baseline, weekly and with dose adjustments) HEAVY MENSTRUAL BLEEDING HEAVY MENSTRUAL BLEEDING Menstrual blood loss >80 mL per cycle or menstrual bleeding lasting > 7 days per cycle May be caused by:  Ectopic pregnancy  Miscarriage  Hypothyroidism  Bleeding disorders  Gynecologic malignancies or fibroids HEAVY MENSTRUAL BLEEDING Clinical Presentation Complications Symptoms: Iron deficiency anemia  Heavy/prolonged menstrual flow  Fatigue  Lightheadedness Signs:  Orthostasis  Tachycardia  Pallor HEAVY MENSTRUAL BLEEDING EVALUATION Laboratory tests to consider:  CBC  Ferritn  Hemoglobin/hematocrit Other tests:  Pelvic ultrasound and imaging  PAP smear  Endometrial biopsy  Hysteroscopy  Sonohysterogram HEAVY MENSTRUAL BLEEDING TREATMENT Goals Reduce menstrual blood flow, prevent or correct iron-deficiency anemia, improve quality of life, and defer the need for surgical intervention General treatment approach Contraception desired GI problems (GERD, PUD, NSAIDs induced bleeding) Bleeding disorders Non-pharmacological recommendations Surgery HEAVY MENSTRUAL BLEEDING TREATMENT NSAIDS Used only during menses Ibuprofen Naproxen Antifibrinolytic agent Contraception Used only during menses Tranexamic acid Needs renal adjustment Increased risk for VTE Continuous treatment Progestin Only Levonorgestrel IUD (LNG-IUD) Combined hormonal contraception (CHC) Contraception Desired? NO YES Continue NSAIDS YES NSAIDs LNG-IUD Effective? Effective? NO Tranexamic acid or progesterone started YES Continue LNGIUD NO CHC Consider if above treatment not working Endometrial ablation Endometrial ablation FOLLOW-UP/MONITORING Follow-up should occur every 3-6 months or sooner if needed Decrease of menstrual blood flow should occur within 1-2 cycles of initiating therapy Monitor for:  Amount of blood flow (monitor decline in number of feminine products use)  Quality of life  Hemoglobin/hematocrit (if anemia present)  Medication: ADRs DYSMENORRHEA DYSMENORRHEA MOST COMMON GYNECOLOGIC COMPLAINT PELVIC PAIN WITH CRAMPS OCCURS DURING OR BEFORE MENSTRUATION DYSMENORRHEA TREATMENT Goals Relieve pelvic pain Improve quality of life Reduce amount of lost school and work days General treatment approach Consider if patient would like contraception or not Non-pharmacologic recommendations Topical heat therapy Exercise Dietary changes DYSMENORRHEA TREATMENT NSAIDS Initial treatment choice unless contraception desired Ibuprofen Naproxen Contraception Consider this option if contraception desired or if NSAIDS contraindicated or no longer effective CHC Depot medroxyprogesterone acetate (DMPA) LNG-IUD If GI problems, use celecoxib NO NSAIDS (ibuprofen, naproxen) Contraception Desired? YES CHC X 2-3 cycles YES Continue CHC NO DMPA or LNG-IUD Effective? FOLLOW-UP/MONITORING Follow up 1-2 months after initiation of therapy Monitor for improvements in  Quality of life  Reduction of time lost in work/school  With NSAID use:  Monitor for pain improvement and ADRs  With contraception use:  Monitor for improvement and ADRs A 20 YO woman came to the clinic complaining of not having her period for the past 3 months. Patient reports that she has lost 40 pounds over the past 2 months by doing intermittent fasting for 12 hours and caloric intake restriction to 1,200 Kcal per day. She has been using a natural bariatric system. In addition, she reports exercising about 1 hour daily. Patient denies any medical conditions or taking any prescription medications. Patient denies smoking or drinking alcohol. Pregnancy was ruled out. Other labs were within normal limits. What would be the best recommendation to manage this patient’s amenorrhea? A. Decrease amount of exercise B. Refer to a nutritionist to improve caloric intake C. Refer to psychologist for CBT D. All of the above A 22 YO woman presents for a follow-up for heavy menstrual bleeding. She reports she has been taking naproxen for the last 6 months. She states that the naproxen seems to have helped with the bleeding; however, her periods are heavy and require a change in supersize tampon every 3 hours. She also states that she has been feeling tired all the time for the past month. She is not sexually active, and she does not take any medications. Her past medical history includes a DVT 2 years ago. Which of the following would be the best option for the treatment of this patient’s heavy menstrual bleeding? A. Continue Naproxen B. Change to Ibuprofen C. Consider Levonorgestrel-IUD D. Consider Tranexamic acid A 26 YO woman presents to clinic complaining of “very painful periods for the past several months.” She is currently not taking any medications. She states medication allergy to NSAIDS. She states she has tried acetaminophen for pain but would like something else that can help and provides contraception as well. Which of the following would be the best option for the treatment of this patient’s dysmenorrhea? A. Levonorgestrel IUD (Mirena®) B. Acetaminophen 1000 mg PO TID C. Copper IUD (Paragard®) D. Ibuprofen 800 mg PO TID QUESTIONS? Contact info: Dr. Kalumi Ayala [email protected] This Photo by Unknown Author is licensed under CC BY-NC-ND