Symptoms 20: Women's Health - Dysmenorrhea And Contraception

Front 1

Case 1:
- 19 yo woman presents w/ 6-month hx of lower midabdominal pain
- Pain is colicky, radiates to back, begins w/ onset of menses and lasts 2-4 days
- Associated w/ headache and nausea
- Misses college classes several days each month because of severity
- Menarche began at 14, menses regular for past 3 years
- Not sexually active
- Normal secondary sexual characteristics

Based on history, which one of the following is the most likely diagnosis?
a) Endometriosis
b) Primary dysmenorrhea
c) Pelvic inflammatory disease (PID)
d) Premenstrual syndrome (PMS)
e) Chronic pelvic pain

Back 1

Primary dysmenorrhea

Front 2

What is the most common gynecologic problem in women of all ages and races? How prevalent?

Back 2

Primary dysmenorrhea
- Prevalence is as high as 90%

Front 3

What is the significance of Primary dysmenorrhea?

Back 3

- One of the most common gynecologic problems
- One of the most common causes of pelvic pain
- One of the most common causes of absenteeism in young women

Front 4

What are the characteristics of Primary dysmenorrhea?

Back 4

- Sharp spasms in lower abdomen / suprapubic area
- Associated symptoms: nausea, vomiting, diarrhea, headache, fatigue
- Onset of pain within hours of menstrual flow onset and peaks on day of heaviest flow

Front 5

What is the effect of progesterone on reproductive cycle?

Back 5

Stimulates prostaglandin production in endometrium

Front 6

What happens when progesterone drops in reproductive cycle?

Back 6

- Endometrium sloughs
- Releases vasoconstricting prostaglandins
- Vasoconstriction of branches of uterine artery
- Decreased blood flow and local ischemia

Front 7

How do prostaglandins affect the uterus?

Back 7

- Uterine hypoxia or uterine "angina" which produces pain of dysmenorrhea

Front 8

How do you treat primary dysmenorrhea?

Back 8

NSAIDs (inhibit cyclooxygenase → ↓ decrease prostaglandin levels)

Front 9

What is secondary dysmenorrhea? What is the most common cause?

Back 9

Dysmenorrhea with an identifiable pelvic abnormality:
- Most common endometriosis

Front 10

What happens in endometriosis?

Back 10

Endometrial tissue implants found in extra-uterine sites

Front 11

What are the signs / symptoms of endometriosis?

Back 11

- Dyspareunia, lower back pain, infertility
- Exam: uterus less mobile, feels fixed, adnexal mass

Front 12

What is the preferred diagnostic test for endometriosis?

Back 12

Laparoscopy

Front 13

When is endometriosis most common?

Back 13

Women age 25-29

Front 14

Is a pelvic examination required as part of the work-up for all women with dysmenorrhea?

Back 14

No
- Not essential in adolescents who have NEVER had sexual intercourse and symptoms fit primary dysmenorrhea
- However, pelvic exam is indicated if they are sexually active or if symptoms suggest endometriosis

Front 15

What are some other causes of secondary dysmenorrhea?

Back 15

- Adenomyosis
- Pelvic inflammatory disease (PID)

Front 16

What happens in Adenomyosis?

Back 16

Presence of endometrial glands within myometrium

Front 17

What are the signs / symptoms of Adenomyosis?

Back 17

- Menorrhagia
- Intermenstrual bleeding
- Enlarged, tender uterus

Front 18

How do you diagnose Adenomyosis?

Back 18

Transvaginal US, sometimes MRI

Front 19

What are the signs / symptoms of Pelvic Inflammatory Disease (PID)?

Back 19

- Sexually active
- Fever > 101 degrees
- Abnormal mucopurulent discharge
- Cervical motion tenderness
- Uterine tenderness
- Elevated ESR or CRP
- Labs: + Chlamydia trachomatis or Neisseria gonorrhea

Front 20

What infections are associated with Pelvic Inflammatory Disease (PID)?

Back 20

Chlamydia trachomatis or Neisseria gonorrhea

Front 21

Which of the following clinical features distinguishes pelvic inflammatory disease (PID) from dysmenorrhea?
a) Dysuria
b) Abdominal bloating
c) Hypotension
d) Cervical motion tenderness
e) Normal erythrocyte sedimentation rate (ESR)

Back 21

Cervical motion tenderness

Front 22

Which one of the following is the first-line treatment for primary dysmenorrhea?
a) Combined oral contraceptives
b) Levonorgestrel-releasing intrauterine system (Mirena IUD)
c) Nonsteroidal anti-inflammatory drugs
d) Depot medroxyprogesterone (Depo-Provera)
e) Topical heat

Back 22

Nonsteroidal anti-inflammatory drugs

Front 23

When is a pelvic exam indicated in a patient with dysmenorrhea?

Back 23

- If patient is sexually active - high risk of PID in adolescents
- If symptoms suggest endometriosis

Front 24

How do you calculate positive predictive value?

Back 24

TP / (TP + FP)

Front 25

How do you calculate negative predictive value?

Back 25

TN / (TN + FN)

Front 26

How does Premenstrual Syndrome (PMS) compare to Primary Dysmenorrhea?

Back 26

Compared with primary dysmenorrhea:
• both involve abdominal symptoms with menses & are cyclic
• Both may be so severe they interfere with quality of life & daily function

PMS:
---sx’s occur late in luteal phase, just prior to onset of menses & resolve soon after menstrual flow begins
---+abdominal bloating, breast tenderness, irritability, fatigue

Front 27

What NSAIDs can be used in the treatment of primary dysmenorrhea?

Back 27

- Celecoxib
- Ibuprofen
- Mefenamic acid
- Naproxen

Front 28

Case 1:
- Your 19 year old patient is now home on her Summer Break and she comes in to see you for follow-up:
- She has been trying Ibuprofen 600 mg during her period, usually 2 to 3 times a day; but she’s still having cramping & heavy bleeding.
- She also mentions that she has a new boyfriend; they are using condoms “sometimes”

Which of the following would you recommend as the next step?
a) Continue the NSAIDs only
b) Discontinue the NSAIDs and begin oxycodone
c) Add combined oral contraceptive
d) Switch to a selective serotonin reuptake inhibitor (SSRI) like fluoxetine (Prozac)
e) Recommend she undergo pelvic laparoscopy

Back 28

Add combined oral contraceptive

Front 29

What are the types of hormonal contraceptives approved for treating primary dysmenorrhea?

Back 29

- Combined oral contraceptives (monophasic or multiphasic)
- Extended-cycle oral contraceptives
- Other hormonal contraceptives: Nexplanon (implant), Nuvaring, Mirena, Depo-Provera

Front 30

What are the types of IUDs? How long do they work?

Back 30

- Mirena (Levonorgestrel-releasing, light periods, quick return to fertility after removal, lasts up to 5 years)
- Paraguard (copper, lasts up to 10 years)

Front 31

Who can use an IUD?

Back 31

- Can be used in nulliparous patients
- Can be used even if patient has history of STI
- Don't use if current PID or PID in last 3 months

Front 32

What are the types of implantable contraceptive methods? How long does it work?

Back 32

Nexplanon (etonogestrel implant - single tube)
- Lasts for 3 years

Front 33

What are the types of contraceptive methods given via a patch? Who can use this?

Back 33

Ortho-Evra (transdermal contraceptive patch)
- Don't use in a women with body weight >198 pounds

Front 34

What kind of contraceptives can be used in women with breast cancer?

Back 34

Only can use copper IUD

Front 35

What kind of contraceptives can be used in women a history of breast cancer?

Back 35

- Can use copper IUD
- All other hormonal BCs are not usually recommended unless copper IUD is not available or acceptable

Front 36

You counsel the patient on her choices for contraception. Which of the following statements regarding the initiation of combined oral contraceptives in this patient is TRUE?
a) She must wait until the Sunday after her next period begins to start her pills
b) If she develops any breakthrough bleeding, she should stop the pills immediately
c) Weight gain is a likely side effect
d) Combined oral contraceptives may improve cholelithiasis
e) Estrogen may improve her acne

Back 36

Estrogen may improve her acne

Front 37

What medical conditions may often improve with hormonal contraceptives?

Back 37

- Acne
- Coagulation defects (eg, menstrual porphyria)
- Dysmenorrhea
- Endometriosis
- Hirsutism
- Iron-deficiency anemia
- Irregular menses
- Menorrhagia
- Menstrual migraines
- Polycystic ovary syndrome
- Premenstrual syndromes
- Some seizures disorders

Front 38

When should patient begin the pill / patch / ring / injection?

Back 38

- If first day of LMP is ≤5 days ago - start method today
- If >5 days ago, check for pregnancy, if no unprotected sex since LMP, start today
- If >5 days ago and unprotected sex since LMP, other options

Front 39

Which of the following is a contraindication to the use of the intrauterine device (IUD)?
a) Current pelvic inflammatory disease (PID)
b) Nulliparity
c) History of chlamydia infection 2 years ago
d) Cigarette smoking
e) Obesity

Back 39

Pelvic Inflammatory Disease:

Smoking is a contraindication for drugs with estrogen and especially if they are >35 yo.

Front 40

Case 1:
• You and your patient discuss contraception choices and she decides to start combined oral contraceptives
• Her LMP was one week ago; her pregnancy test is negative. You give her a RX for Aviane (ethinyl estradiol/levonorgestrel). She starts it same day.
• 6 weeks later she calls your office on Monday morning and tells you that her boyfriend took her on a weekend trip to celebrate her 20th birthday and she forgot to take her birth control pills with her. She is worried about becoming pregnant

What can she do??

Back 40

Emergency Contraception:
- Provide patient with prescription or pills before the need for use:

Front 41

What happens when patients are given emergency contraception in advance?

Back 41

– Increase the rate & timeliness of use in young women & adolescents
– Does not increase rates of STI’s
– Does not increase rates of unprotected intercourse or
change use of routine contraception
– Has not led to decreased rates in pregnancy (Most patients do not know how to use, where to get it)

Front 42

Emergency contraception (EC) decreases the risk of unintended pregnancy after unprotected sexual intercourse or failure of routine contraception. While each method has a different level of effectiveness, EC is most effective if used within which time frame?
a) 6 hours
b) 12 hours
c) 3 days
d) 5 days
e) 7 days

Back 42

12 hours

For most, ideal is 12 hours (except for IUD); it may be used UP TO 72 hours.

Front 43

What are the methods of emergency contraception?

Back 43

- Combined oral contraceptive
- Levonorgestrel (split dose)
- Levonorgestrel (single dose) = Plan B
- Ulipristal
- Intrauterine copper device = Paraguard

Front 44

What are the characteristics of the Yuzpe method for emergency contraception?

Back 44

2 doses of an estrogen / progestin oral contraceptive (take 12 hours apart)

Front 45

What are the advantages and disadvantages of the Yuzpe Method of emergency contraception?

Back 45

- Advantage: patient can use pills they already have, can use within 72 hours
- Disadvantage: a lot of pills, common to have nausea and vomiting, considering pre-treating with anti-emetic

Front 46

What are the characteristics of use of Levonorgestrel for emergency contraception?

Back 46

- Effectiveness: use within 72 hours
- Interferes with LH peak
- Single dose or split dose
- May or may not be behind the counter or available w/ or w/o prescription

Front 47

What are the characteristics of use of Ulipristal (Ella) for emergency contraception?

Back 47

Progesterone receptor modulator - binds to progesterone receptor and inhibits / delays ovulation; effective regardless of LH peak (unlike levonorgestrel)

Advantages: Use up to 5 days (higher degree of efficiacy from 72-120 hours)

Disadvantages: requires perscription

Front 48

What are the characteristics of use of the Copper IUD for emergency contraception?

Back 48

- Effective for up to 7 days after
- Advantage: non-hormonal, provides long-term contraception
- Disadvantage: cost, plus requires placement in office

*Prevents pregnancy by interfering with fertilization AND PREVENTING IMPLANTATION (may be a problem for some women ethically / religiously)

Front 49

Which of the following best describes the effects of giving women advanced provision of emergency contraception?
a) Women are more likely to not use routine birth control
b) It has resulted in decreased pregnancy rates
c) It increases the timeliness of emergency contraception use
d) It has been shown to increase the rates of sexually transmitted infections
e) It may have teratogenic effects if taken inadvertently by a pregnant patient

Back 49

It increases the timeliness of emergency contraception use