Theratest2 Women's Health

Front 1

Premenstrual Syndrome (PMS)

Back 1

cyclic recurrence of a combo of psychological, behavioral, and physical symptoms that occur during the luteal (premenstrual phase) and resolve after start of menses

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PMS affects what

Back 2

women 20-30 years old

mood, behavior, physical function

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Risk factors for PMS

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1) females age 20-30 years old
2) overweight
3) unbalanced diet
4) nutrient deficiencies
5) stress

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Clinical presentation of emotional/mood changes during PMS

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1) depression/sadness
2) irritability/anger/hostility
3) tension/anxiety
4) food cravings

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clinical presentation of behavioral changes during PMS

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1) mood swings
2) confusion
3) forgetfulness/difficulty concentrating
4) angry outbursts

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clinical presentation of physical changes during PMS

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1) breast tenderness
2) abdominal bloating/pelvic pressure
3) fatigue/dizziness
4) nausea/vomiting/muscle aches
5) acne

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Non-Pharm treatment for PMS

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1) education on symptoms, treatment, behavior modifications
2) daily charting of symptoms
3) exercise 20-30 minutes 3-4 times/week

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OTC vitamins/minerals used for PMS

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1) calcium
2) magnesium
3) vitamin e
4) multivitamin

Front 9

Calcium for PMS

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Dose: 1200mg daily (600mg BID)

1) reduces depression, water retention, pain, food cravings, fatigue, insomnia
2) caution in h/o kidney stones and can cause constipation

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Magnesium for PMS

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DOSE: 200-400mg daily

1) decrease fluid retention, breast tenderness, bloating
2) ADR: diarrhea

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Vitamin E for PMS

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DOSE: 400 IU daily during luteal phase (days 14-28)

1) reduce breast pain and tenderness, mood symptoms

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Meds used for pain in PMS

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1) APAP
2) NSAIDS

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Pain meds used in PMS are used for

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1) headache
2) back pain
3) cramping
4) breast pain

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Meds used for weight gain in PMS

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1) sodium restriction
2) OTC diuretics (pamabrom)
3) RX diuretics (spironolactone)

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Weight gain symptoms in PMS

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1) weight gain
2) bloating
3) swelling

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Hormonal interventions used in PMS

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1) oral contraceptives
2) danazol

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Oral Contraceptives for PMS

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1) reduce painful cramps, depression, irritability, menstrual migraines

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Danazol for PMS

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DOSE: 100-200mg 1-2 times daily for SEVERE PMS (rarely used)

1) induces amenorrhea
ADRs: hirsutism, voice deepening, mood changes, acne

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GnRH agonists for severe PMS

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MOA: pituitary desensitization to GnRH - down regulation of GnRH receptors, decreases LH and FSH

1) leuprolide acetate
2) do not use for more than 6 months

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Premenstrual Dysphoric Disorder (PMDD)

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severe form of PMS marked by severe mood changes

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Diagnostic criteria for PMDD

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1) at least 5 symptoms must occur premenstrually
2) symptoms for at least 1 year
3) at least one symptom must be a marked dysphoric mood change (depressed, hopelessness, anxiety, tension)
4) interferes with work, school, social activities

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SSRIs for PMDD treatment

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*FIRST LINE*

MOA: inhibit CNS neuronal reuptake of serotonin
1) can be taken days 14-28 of cycle or continuously

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2nd line treatment for PMDD

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venlafaxine or clomipramine

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Oral contraceptives for PMDD

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YAZ - given daily for 24 days (physical and mood symptoms)

Others - improve physical but no effect on mood!

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Primary dysmenorrhea

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pain or discomfort occuring during menstruation that usually begins first day of menses

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Main symptoms of primary dysmenorrhea

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1) abdominal cramping
2) migraines
3) pain starts on day 1 of menses, peaks on highest day of flow, resolves within 3-5 days

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Risk factors for primary dysmenorrhea

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1) earlier age of menarche
2) long menstrual periods
3) obesity
4) alcohol
5) heavy menstrual periods
6) smoking

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Treatment for primary dysmenorrhea

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1) NSAIDS - 1st line
2) Oral contraceptives - 1st line

Front 29

Secondary dysmenorrhea

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pain during menstruation caused by an underlying process or disease

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Important note about Secondary dysmenorrhea

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*Must refer to a physician*

Front 31

Endometriosis

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presence of endometrial tissue outside the uterus and in other areas of hte body

*growth of small lesions that may appear on any of hte pelvic organs - become large cysts - adhere to bowel, bladder, ureter

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clinical presentation of endometriosis

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1) chronic pelvic pain in women
2) dysmenorrhea
3) painful intercourse
4) infertility

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Risk factors for endometriosis

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1) nullparity (multiple pregnancies are protective)
2) genetics
3) prolonged estrogen exposure

Front 34

Nonpharm treatment of endometriosis

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1)conservative surgery
2) definitive surgery

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Conservative Surgery for endometriosis

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*mild to moderate disease*

Recommended if infertility is an issue
Decreases pain

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Definitive Surgery for endometriosis

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*severe disease, intractable pain*

removal of uterus or ovaries
only for patients who do not wish to become pregnant

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First line medications for endometriosis

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1) NSAIDS
2) Oral contraceptives

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how do oral contraceptives help treat pain

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decrease menstrual flow and cause regression of endometrial implants

Front 39

when an infection is present

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1) increased vaginal pH
2) increased risk of ectopic pregnancy
3) increased risk of complications for pregnant women
4) increased risk of PID

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Pelvic Inflammatory Disease (PID)

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1) infection of fallopian tubes, ovaries, and/or uterus
2) SYMPTOMS: lower ab pain, pain during intercourse, dysmenorrhea, fever
3) scarring could cause infertility

Front 41

Bacterial Vaginosis

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*MOST COMMON*

Cause: unknown but polymicrobial
SYMPTOMS: bad odor, itching, thin-white/gray discharge
RISK: new/multiple partners, douching, IUD

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Treatment for Bacterial Vaginosis in Pregnant and non-pregnant women

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Metronidazole (Flagyl) 500mg PO BID x7d

Front 43

Vulvovaginal Candidiasis (Yeast Infection)

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CAUSE: candida albicans (needs moist environmen)

SYMPTOMS: itching, burning, thick-white "cottage cheese" discharge

RISK: pregnancy, DM, antibiotics/corticosteroids

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Treatment of Vulvovaginal Candidiasis (yeast infection) in non-pregnant women

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Fluconazole (Diflucan) 150mg PO x1 dose

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Treatment of Vulvovaginal Candidiasis (yeast infection) in pregnant women)

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Topical Azole x7 days

Front 46

Treatment for recurrent infections of vulvovaginal candidiasis (yeast infections) [4+ infections/year]

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1st line: fluconazole (Diflucan) 150mg PO x3days

2nd line: topical x7-14 days

Follow with: fluconazole 150mg PO weekly x6 months

Front 47

Trichomoniasis Vaginitis (STD)

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CAUSE: parasite invades vagina &/or urinary tract

SYMPTOMS: frothy yellow-green discharge, bad odor, dysuria, vulvar itiching

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Treatment of Trichomoniasis Vaginitis (STD) for pregnant and non-pregnant patients

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Metronidazole (Flagyl) 2g PO x1 day

Front 49

Chlamydia Vaginitis

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Cause: bacteria

SYMPTOMS: asymptomatic usually

RISKS: young (15-19 yrs), new/multiple partners, gonorrhea

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Treatment of Chlamydia vaginitis in pregnant and non-pregnant patients

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Azithromycin 1g PO x1day

Front 51

Normal Vaginal environment

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pH: 3.8-4.2

Discharge: white, clear

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Self-treatment of Yeast infection

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1) previous diagnosis and similar symptoms
2) >2 months since last yeast infection
3) no pain, no odor
4) not pregnant
5) >12 years old

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Patient education for treatment of bacterial vaginosis Trichomoniasis vaginitis

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1) avoid intercourse for 7 days after treatment
2) take all doses for length of treatment
3) Can experience metallic taste, dark urine w/ treatment medication
4) AVOID ALCOHOL with medication

Front 54

Treatment of Vulvovaginal candidiasis in patient with underlying conditions

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1st line: topical azole x7-14 days

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Patient education for treatment of vulvovaginal candidiasis

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1) avoid intercourse for 7 days after treatment
2) C/I in pregnancy and women <12 years old
3) only women who have been previously diagnoses should self-treat
4) 3 day rule = symptoms don't improve in 3 days, seek medical attention

Front 56

Vaginal infections in which both partners must be treated

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1) trichomoniasis vaginitis
2) chlamydia vaginitis

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Follow up with Chlamydia treatment

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re-test in 3 weeks to ensure eradication, then tested again in 3 months

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Prevention of Vaginitis

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1) Clothes: cotton/silk undies, avoid tight clothing for long times, remove wet clothes asap, change undies daily
2) Sexual health: use condoms, limit partners, Ob/Gyn annually
3) Hygeine: wash w/ mild soap, showers, avoid douche

Front 59

Perimenopause

Back 59

time period immediately prior to menopause through the first year after menopause

Symptoms: irregular menses, heavy breakthrough bleeding

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Menopause

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permanent end of menstruation and fertility following the end of ovarian follicular function

occurs after 12 months of amennorhea

age: mean 51 years ; 40-55 year range

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Early menopause

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anytime before <40 years

uterus/ovaries removed, chemotherapy, natural

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Symptoms of Menopause

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1) Vasomotor
2) Sleep Disturbances
3) Sexual Dysfunction
4) Mood Changes
5) Problems with concentration/memory
6) Genitourinary Symptoms

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Vasomotor symptoms of menopause

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1) Hot Flashes - sensation of heat in face/neck/upper chest and become generalized and last about 2-4 minutes ; first 2 years post-menopausal

2) Night Sweats, Excessive perspiration, headache

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Genitourinary Symptoms of menopause

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1) Vaginal atrophy (dryness, burning, itching)

2) Urogenital atrophy (incontinence, urinary urgency/frequency)

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Non-Pharm treatment for menopause

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1) exercise
2) weight control
3) smoking cessation
4) healthy diet

Front 66

Non-pharm treatment for hot flashes

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1) avoid triggers ( spicy foods, caffeine, hot drinks)
2) dress in layers
3) keep fan nearby
4) cool water on face, neck, wrists

Front 67

Therapeutic goal for hormone therapy

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use LOWEST effective dose for shortest amount of time for treatment goals, weighing hte benefits/risks for each patient

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Hormone therapy for Vasomotor symptoms

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Estrogen - only med approved, most effective

Progestogen - can be used alone, not as effective

Front 69

Hormone therapy for Vaginal Symptoms

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Estrogen - most effective

only symptom - low dose vaginal cream preferred

Front 70

Hormone therapy for Prevention of Osteoporosis

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Estrogen - NOT first line, high risk of fracture

Front 71

Estrogen therapy for Menopause

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for women with history of hysterectomy

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Combination therapy for menopause (ET and PT)

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for women without history of hysterectomy

relatively safe for healthy, recently postmenopausal women who have symptoms (age 50-59 or w/in 10 years of menopause) (mod-severe vasomotor)

Front 73

Estrogen therapy in Menopause

Back 73

* use lowest dose that will control symptoms
*only vaginal symptoms - use vaginal drugs first
* measuring estradiol levels to monitor therapy is not recommended
* ADRs: common-nausea, headache, breast tenderness, vaginal bleeding, bloating; severe - stroke, VTE, coronary heart disease

Front 74

Estrogen Therapy dosage forms

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1) oral
2) transdermal
3) topical (cream, gel, spray)
4) vaginal (cream, tablet, ring)

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Transdermal estradiol

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1) avoids 1st pass metabolism
2) more continuous delivery
3) lower risk of DVT, stroke, MI

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ADRs of transdermal estradiol

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1) application site reactions
2) vaginal bleeding

Front 77

Topical Estradiol products

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Topical Emulsion (estrasorb) - apply to clean dry skin on both legs (rub into high and calf for 3 minutes)

Topical Gel (Estrogel) - apply to arm from wrist to shoulder (tube or pump)

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Vaginal Estrogen Dosage forms

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Tablets (Vagifem)

Creams (Estrace or Premarin)

Rings (Estring or Femring)

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use of vaginal estrogen for relief of genitourinary symptoms

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Femring

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Progestogens used for menopause

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1) medroxyprogesterone acetate (Provera)
2) micronized progesterone (Prometrium)
3) Norethindrone acetate (Aygestin)

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use of progestogens in menopause

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for women with a uterus due to increased risk of endometrial hyperplasia and endometrial cancer if estrogen is given unopposed

recommend minimum 12-14 days

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ADRs of progestogens

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Common: irritability, depression, headache, bloating, fluid retention

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Methods of Administration for Combination Products (Estrogen and Progestins)

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1) Continuous Cyclic (E-daily, P-12-14 days)
2) Continuous- Combined (both daily)
3) Continuous Long-Cycle (E-daily, P-12-14 days 6x/year)
4) Intermittent-Combined (3 days E alternating with 3 days both)

Front 84

Risks of Hormone Therapy

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1) CV disease
2) Stroke (both ET and PT)
3) Breast Cancer (EPT not used more than 3-5 years)
4) VTE (highest risk first 1-2 yrs; EPT or ET)
5) Endometrial cancer (always use EPT)
6) Lung Cancer
7) Ovarian Cancer (risk increases with duration of HT use)
8) Gallbladder disease

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Symptoms of androgen insufficiency

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1) decreased libido
2) diminished well-being
3) loss of energy
4) decreased bone mass
5) reduced muscle strength

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Androgens for menopause (testosterone)

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Not Recommended

ADRs: virilization, fluid retention, increased lipids

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Bioidentical Hormones

Back 87

custom made hormone therapy, including individualized doses

NOT FDA regulated

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Evaluation of HT in menopause

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Prior to use: pelvic exam, med history

6 weeks: symptom relief, ADRs, withdrawal bleeding

Annually: breast exams, med history, phys exam, pelvic exam

Periodically: monthly breast exam, mammograms

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Discontinue Hormone therapy in menopause

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Taper over 6-12 weeks

Symptoms recur: try non-hormonal

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Non-hormonal Treatment for Menopause

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1) SSRIs/SNRIs

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Non-hormonal treatment for vasomotor symptoms

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1) Paroxetine (Brisdelle) -FDA approved
2) Venlafaxine
3) Gabapentin

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Non-hormonal treatment for vaginal atrophy

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Mod-Severe dyspareunia: ospemifene (Osphena)

lubricants
moisturizers

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Non-hormonal treatment for Osteoporosis

Back 93

1) Calcium w/ Vitamin D
2) Bisphosphonates

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Complementary and Alternative Therapies for Menopause

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1) Phytoestrogens
2) Herbals (Black Cohosh)