R EVIEW USING P ATIENT C ASES Women’s Health Block 1/13/16

C ASE #1 HPI: T. F. is a 19 yo female who presents to university student health clinic for an evaluation of painful menstrual “cramps.” She reports that she has been experiencing lower abdominal cramps since last night, when her menstrual cycle started. She rates the pain as 8 out of 10 and has had to miss her morning classes. She also reports lower back pain but denies any other associated symptoms. T. F. gives a history of suprapubic and back pain associated with menstrual cycles since menarche at age 12. The pain begins during the first day of each menstrual cycle and usually lasts for the next 2 days. The pain is most severe on the first day and has caused her to miss class. She denies pain with bowel movements or urination. She reports that the menstrual pain subsided during high school when she played field hockey and experienced very light menstrual periods. It has since returned as she is less active in college and her menstrual periods are heavier.

C ASE #1 CONT. PMH: Occasional mild headaches with menses; not sexually active FH: No relevant history SH: Smokes ½ ppd; denies alcohol or illicit drug use Allergies: NKDA Medications: None Vital signs: Weight: 130lbs; height: 5’5”; BP: 118/74; P: 82; T: 98.6 o F; RR: 12 Physical Exam: Pelvic exam WNL Lab values: last PAP test 6 months ago WNL

Q UESTION 1: W HAT IS T.F.’ S MOST LIKELY DIAGNOSIS ? 1. Dysmenorrhea 2. Endometriosis 3. Osteomyelitis 4. PMS/PMDD 5. Toxic shock syndrome

Q UESTION 2: H OW WOULD YOU CLASSIFY T. F.’ S CONDITION ? 1. Primary dysmenorrhea 2. Secondary dysmenorrhea 3. Tertiary dysmenorrhea

Q UESTION 3: W HAT IN T. F.’ S HISTORY TELLS US SHE HAS PRIMARY DYSMENORRHEA ? 1. Onset of menarche 2. PAP test normal 3. Pelvic exam WNL 4. Social history

Q UESTION 4: W HAT RISK FACTORS DOES T.F. HAVE FOR PRIMARY DYSMENORRHEA ? 1. Age 2. Inactivity/lack of exercise 3. Smoking 4. 1 and 2 only 5. 1 and 3 only 6. 2 and 3 only 7. All of the above

Q UESTION 5: N ONPHARMACOLOGIC METHODS ARE LARGELY INEFFECTIVE IN TREATMENT OF DYSMENORRHEA ? 1. True 2. False 3. There aren’t any nonpharmacologic methods for this condition

Q UESTION 6: N ONPHARMACOLOGIC METHODS FOR THE TREATMENT OF DYSMENORRHEA INCLUDE ALL OF THE FOLLOWING EXCEPT 1. Exercise 2. Heating pad/patches 3. Low fat/vegetarian diet 4. Ice packs

Q UESTION 7: W HAT IS THE FIRST DRUG OF CHOICE FOR PHARMACOLOGIC TREATMENT FOR DYSMENORRHEA ( WHEN THERE ARE NO OTHER CONSIDERATIONS )? 1. APAP 2. Hydrocodone 3. NSAIDs 4. Oral contraceptives 5. Vitamin B1 (thiamine)

Q UESTION 8: W HEN SHOULD NSAID THERAPY FOR THE TREATMENT OF DYSMENORRHEA BEGIN ? 1. Initiate therapy one week prior to symptoms 2. Begin therapy when symptoms appear or day one of period 3. Treat continuously throughout the month

Q UESTION 9: W HEN IS IT APPROPRIATE TO USE ORAL CONTRACEPTIVES AS TREATMENT FOR DYSMENORRHEA ? 1. First line therapy 2. After NSAID treatment failure 3. Patient wants contraception 4. 1 and and and 3 7. All of the above

Q UESTION 10: W HICH OF THE FOLLOWING IS A SCIENTIFICALLY PROVEN EFFECTIVE TREATMENT FOR DYSMENORRHEA ? 1. Vitamin B1 2. Magnesium 3. Vitamin E 4. Acupressure 5. All of the above 6. None of the above

C ASE #2 HPI: BT is a 38 year old female who presents to your pharmacy counter today to buy her MVI. She tells you that for the past six months she has been having problems. About a week before menses each month, she experiences breast tenderness, irritability, mood swings, fatigue, depression, insomnia, and she has been crying a lot more than usual. These symptoms generally go away a day or two after her period starts. She misses some days of work each month due to her Sx, and this is making it increasingly difficult for her to get her work done on time. This has significantly increased her stress levels and she is having conflict with her husband ending in shouting matches. She denies having had any psychiatric issues such as depression or mood swings in her past.

C ASE #2 CONT. PMH: BT does not have any relevant past medical history. She suffers from seasonal allergies, which are well-controlled through medications as well as occasional headaches, which are also controlled through medication. She does not take any oral contraceptives. She and her husband use condoms with spermicide for contraception. FH: Mother is A&W with PMH significant for post-partum depression, DM, HTN, and HL. Father is deceased from MI at age 68 and had suffered from depression. She has one sister who is A&W and suffers from severe PMS each month, which she treats with oral contraceptives. SH: BT denies any tobacco and illicit drug use. She admits to drinking ‘1-2 alcoholic drinks per night at the most’. Allergies: PCN- pt develops a rash when taken Medications: loratadine 10 mg: 1 po qam for allergies, MVI : 1 po qam with breakfast, ibuprofen : mg po prn HA Labs: You have not obtained any lab values at this point.

Q UESTION 1: W HAT IS BT ’ S MOST LIKELY DIAGNOSIS ? 1. Dysmenorrhea 2. PMS 3. PMDD 4. Endometriosis

Q UESTION 2: WHICH DIAGNOSIS IS MORE COMMON IN THE UNITED STATES ? 1. PMDD 2. PMS

Q UESTION 3: ACCORDING TO THE DSM - V CRITERIA, WHICH OF THE FOLLOWING SYMPTOMS IS ONE OF THE FOUR THAT MUST BE PRESENT FOR A POSITIVE DIAGNOSIS ? 1. marked anxiety, tension, feelings of being “keyed up” or “on edge” 2. decreased interest in usual activities (e.g., work, school, friends, hobbies) 3. marked change in appetite, overeating, or specific food cravings 4. a subjective sense of being overwhelmed or out of control 5. physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” weight gain

DSM-V C LASSIFICATION OF PMDD

Q UESTION 4: A CCORDING TO THE DSM-V CRITERIA, _____ SYMPTOMS MUST BE PRESENT FOR ____ CONSECUTIVE CYCLES TO HAVE A POSITIVE DIAGNOSIS. 1. Three, two 2. Three, six 3. Five, two 4. Five, six

COPE

Q UESTION 5: WHAT ARE BT ’ S RISK FACTORS FOR DEVELOPING PMDD ? 1. Family history 2. Stress level 3. Alcohol use 4. 1 and 2 5. All of the above

Q UESTION 6: ALL OF THESE NON - PHARMACOLOGICAL INTERVENTIONS CAN ALLEVIATE BT ’ S SYMPTOMS EXCEPT : 1. Increase low-intensity exercise 2. Increase intake of complex carbohydrates 3. Reduce sodium intake 4. Increase caffeine intake

Q UESTION 7: WHAT IS THE FIRST - LINE PHARMACOLOGICAL TREATMENT FOR PMDD ? 1. APAP 2. NSAIDs 3. OCP 4. SSRI

T HERAPIES FOR PMS/PMDD Non-pharmacologic Dietary supplements Analgesics and diuretics Antidepressants Anti-anxiety agents Oral contraceptives GnRH agonists Progesterone Herbals