Self-Care or Referral?
 
 
rxPassport Pharmacy Newsletter
 
September 2015
 
 
Ensuring dysmenorrhea is optimally managed
 
Meet our patient
 
Mary (20 yo)
 
Severe menstrual pain.
 
Has tried ibuprofen 200mg, relief was far from optimal.
 
Her friends told her to use a hot water bottle on her stomach.
 
Period started at 13 years, with painful menses since
 
Not currently sexually active
 
Does not exercise, smokes 4-5 cigarettes per day
 
What would you recommend?
 
Primary or Secondary Dysmenorrhea?
 
Dysmenorrhea is classified as either primary or secondary based on if its symptoms are associated with a medical condition.
 
Primary Dysmenorrhea1
 
Lower abdomen/pelvis
 
Usually occurs with the onset of menstrual flow with 8-72 hours duration
 
Initial onset usually is shortly after menarche
 
May cause headache, nausea, vomiting, diarrhea, and back and thigh pain
 
Secondary Dysmenorrhea1
 
Pain is associated with organic disease (e.g. endometriosis, and pelvic inflammatory disease, and fibroids)
 
Onset can occur any time after menarche, with variable pain, occurring at anytime during menstrual cycle.
 
The SOGC dysmenorrhea guidelines review these causes in more detail
 
Clinical Practice Tip
 
For new onset dysmenorrhea, a urine test should be ordered to rule out pregnancy and UTI.2
 
Self-Care or Referral?
 
Primary dysmenorrhea is many times responsive to self-care treatments. A patient presenting with the following should be considered for MD referral:3
 
Any signs or symptoms of secondary dysmenorrhea
 
No improvement of symptoms with self-care options
 
Patient with gastrointestinal, renal or hepatic disease
 
Changes in pattern or severity of menstrual fluid and pain
 
Pain outside first 3 days of menses
 
Dramatic change in symptoms
 
Management of Primary Dysmenorrhea
 
The treatment of dysmenorrhea will commonly combine a combination of pharmacological and non-pharmacological options. The following table reviews the most commonly recommended non-pharmacological options.
 
Non-Pharmacological Options for dysmenorrhea
Heat (hot water bottle, patches)
Limited evidence4
 
Potential benefit with very low risk5
TENS
Device that stimulates skin with electrical currents6,7
 
Modifies perception of pain signals6,7
 
Cochrane review found it superior to placebo6
 
Adverse effects - headache, muscle vibrations, tightness and slight redness of the skin6
 
Recommendation by the SOGC as an alternative to those women who cannot tolerate pharmacological options
Smoking cessation
Strong correlation between tobacco smoke and primary dysmenorrhea8
 
Likely due to a decrease of endometrial blood flow due to vasoconstriction8,9
 
Cessation may help and can reduce risk of other diseases10
 
Consider 5A’s approach to smoking cessation outlined in the CAN-ADAPTT guidelines
 
The 3A’s approach has also been showed to be effective11
Stress reduction
Limited evidence4
 
Potential benefit due to association between stress and dysmenorrhea, especially having stress during the follicular phase (“from the first day of the menstrual cycle until the first day of the luteal phase”12)
Aerobic exercise
Limited evidence4,13
 
Potential benefit through stimulation of the release of body’s endorphins with low risk13
 
Acetaminophen and NSAIDs
 
Both NSAIDs and acetaminophen have been used for the management of dysmenorrhea.
 
NSAIDs are recommended as first line therapy by the SOGC for dysmenorrhea. There is no strong evidence supporting superiority of one NSAID over another.4 A Cochrane review (2015) found that NSAIDs or COX2 inhibitors are more effective than either placebo or acetaminophen.14
 
Recommended doses of OTC products:
 
Ibuprofen is 200 – 400 mg every 4-6 hours, or 600 – 800 mg 3 times daily as needed (maximum 3200 mg/day).3
 
Naproxen sodium is 220–550 mg BID.15
 
They are usually recommended for 3 consecutive days of the onset of pain.3 The most common adverse reaction is stomach upset and headache.14,15
 
Although less effective than NSAIDS, acetaminophen was found to be superior to placebo.16
 
Clinical Practice Tip
 
Patients are encouraged to try an NSAID for 3 menstrual cycles. If the patient does not experience significant pain reduction after the 3 cycles, she should be referred to her physician to consider other treatment options.3
 
Hormonal Contraception
 
A number of hormonal contraception products have been used for the management of dysmenorrhea with varying results. The table below reviews these options for dysmenorrhea management.
 
Hormonal Contraception for the Management of Dysmenorrhea
Combined oral contraceptives
Inhibit endometrial growth, ovulation, prostaglandin production and less uterine contractions4
 
Recommended by SOGC as possible first-line treatment when contraception is desired4
 
Cochrane Collaboration reviewed oral contraceptives and found that they are superior to placebo for decreasing dysmenorrhea.17
 
Adverse effects include breast tenderness, nausea and vomiting18
 
Contraindications include history of VTE and smokers >35 years18
Contraceptive patches and vaginal rings
Decrease dysmenorrhea similarly to oral contraceptives19
 
No strong evidence to support these two methods
Medroxyprogesterone Depot
Causes endometrial atrophy and stops ovulation4,20
 
Long term use is not advised due to its negative effect on bone mineral density20
 
Can be considered a treatment option in cases where estrogen therapy is not appropriate19
Levonorgestrel intrauterine system
Releases progestin locally, which thins the endometrial lining4
 
Leads light or no menstrual flow, and this leads to less dysmenorrhea21
 
Effective in decreasing pain, and is considered a dysmenorrhea treatment option in patients who are good candidates for this method of contraception4,22
 
Copper IUD is not recommended as it might actually worsen dysmenorrhea23
 
What is best for Mary?
 
Consider hot water bottle or patches on her stomach as it may help
 
Smoking cessation can be recommended
 
An increase in ibuprofen dose (400mg every 6 hours for 3 days) could help to reduce her symptoms
 
If she still experiences dysmenorrhea then, she should be referred to her physician for assessment and consideration of other management options.
 
 
By Azadeh Vasefi, PharmD Candidate
 
With appreciation to Mike Boivin
 
In this issue
 
Meet our Patient
 
Primary or Secondary Dysmenorrhea?
 
Self-Care or Referral?
 
Management of Primary Dysmenorrhea
 
Acetaminophen and NSAIDs
 
Hormonal Contraception
 
What is best for Mary?
 
References
 
Pharmacy Student Blog
 
References
 
1. Proctor, M. Farquhar, C. Diagnosis and management of dysmenorrhea. BMJ, 2006; 332(7550): 1134–1138.
 
2. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014; 89(5):341-346.
 
3. medSask. (2014) Dysmenorrhea - Guidelines for Prescribing NSAIDs. View source
 
4. Lefebvre, G. et al. Primary Dysmenorrhea Consensus Guideline. J Obstet Gynaecol Can, 2005;27(12):1117–1130.
 
5. Akin, M.D. et al. Continuous Low-Level Topical Heat in the Treatment of Dysmenorrhea. Obstetrics & Gynecology 2001; 97(3): 343-349.
 
6. Proctor, M. et al. Transcutaneous electrical nerve stimulation for primary dysmenorrhoea. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2002.
 
7. Mannheimer, J. et al. The Efficacy of Transcutaneous Electrical Nerve Stimulation in Dysmenorrhea. The Clinical Journal of Pain 1985; 1(2): 75-83.
 
8. Chen, Ch. et al. Prospective Study of Exposure to Environmental Tobacco Smoke and Dysmenorrhea. Environmental Health Perspectives 2000; 108(11): 1019-1022.
 
9. Parazzini, F. et al. Cigarette Smoking, Alcohol Consumption, and Risk of Primary Dysmenorrhea. Epidemiology 1994; 5(4): 469-472.
 
10. American Heart Association. (2014) Smoking & Cardiovascular Disease (Heart Disease). View source
 
11. RxBriefCase. (2015) Very Brief Advice (VBA) for Smoking Cessation: 30 Seconds to Save a Life. View source
 
12. Wang, L. et al. Stress and dysmenorrhoea: a population based prospective study. Occup Environ Med 2004; 61:1021–1026.
 
13. Brown, J. Brown, S. Exercise for dysmenorrhoea. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2010.
 
14. Marjoribanks, J. et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhea. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2015.
 
15. e-CPS: CPha. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) [product monograph]. View source
 
16. Dawood, M.Y. Khan-Dawood, F.S. Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2alpha in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea. Am J Obstet Gynecol 2007; 196(1): 35.e1-35.e5.
 
17. Womg, C.L. et al. Oral contraceptive pill as treatment for primary dysmenorrhoea. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2009.
 
18. e-CPS: CPha. Alesse [product monograph]. View source
 
19. Burnett M. Sexual Health: Dysmenorrhea. View source
 
20. Harel, Z. Dysmenorrhea in Adolescents and Young Adults: Etiology and Management. J Pediatr Adolesc Gynecol 2006; 19:363-371.
 
21. Vercellini, P. et al. A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study. FERTILITY AND STERILITY 1999; 72(3):505-508.
 
22. Ramazanzadeh, F. et al. Levonorgestrel-releasing IUD versus copper IUD in control of dysmenorrhea, satisfaction and quality of life in women using IUD. Iranian Journal of Reproductive Medicine 2012; 10(1): 41-46.
 
23. Copper IUD. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. View source
 
 
 
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