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2017 HCHB_digital

Period Pain and

Period Pain and Endometriosis Period pain and other menstruation-related symptoms are collectively called dysmenorrhoea. Dysmenorrhoea affects around 70% of menstruating women and usually starts in adolescence, once periods become regular (when ovulatory menstrual cycles become established). Primary dysmenorrhoea is the most common type of dysmenorrhoea and occurs when a woman’s uterus is healthy but is behaving abnormally and causing cramps. Secondary dysmenorrhoea is the term used for dysmenorrhoea that is caused by an underlying condition or abnormality such as endometriosis, fibroids, pelvic inflammatory disease or uterine anomalies. Primary dysmenorrhoea Lower abdominal cramping is the main symptom of primary dysmenorrhoea; however, many women also suffer from additional symptoms such as: • breast tenderness or pain • depression, irritability, anxiety, or sleeplessness • facial blemishes and flushing • headaches, backaches or aching legs • loss of appetite, weakness and dizziness • nausea and vomiting. Symptoms typically begin just before or just after the start of menstrual flow, and persist for the first 24–48 hours. Period pain which causes discomfort is considered normal. Period pain which causes distress and prevents women or girls from doing activities, or going to school or work is considered abnormal and most likely due to endometriosis, and should be referred to a doctor. Endometriosis Endometriosis is a condition where tissue similar to the lining of the uterus is found growing in places outside of the uterus (eg, the ovaries, fallopian tubes, and other pelvic structures). This tissue responds to the hormones that trigger the menstrual cycle so thickens and sheds like the cells found inside the uterus. Debilitating pain during a period is the most common symptom. However, other symptoms such as bloating, diarrhoea or constipation, bladder troubles, pain associated with sexual intercourse, infertility, and very heavy bleeding (ie, having to change a tampon or pad every one to two hours) can occur. Pain may also occur intermittently throughout the month or around the time of ovulation. Although more commonly diagnosed in adults, symptom onset is usually experienced in the teen years with cases reported in menstruating girls as young as 10. Most women who suffer from endometriosis also have a female relative with the same condition, although they may not realise it. There is often a long time between first symptom onset and a definite diagnosis of endometriosis (average TREATMENT OPTIONS Category Examples Comments Oral non-steroidal anti-inflammatory agents (NSAIDs) Combination analgesics Natural / herbal products / supplements [GENERAL SALE] eg, ibuprofen 25s (Advil, Nurofen range), mefenamic acid (Ponstan), naproxen (Naprogesic) [PHARMACIST ONLY MEDICINE] eg, diclofenac 25mg (Voltaren Rapid 25) [GENERAL SALE] eg, ibuprofen + paracetamol (Maxigesic [16], Nuromol [12]) [PHARMACY ONLY MEDICINE] eg, ibuprofen + paracetamol (Maxigesic [50, 100], Nuromol [24, 48]) [PHARMACIST ONLY MEDICINE] eg, ibuprofen + codeine (Ibucode Plus, Nurofen Plus) paracetamol + codeine (Panadeine, Panadeine Extra), paracetamol + codeine + doxylamine (Mersyndol*) Calcium, black cohosh, brewer’s yeast, cramp bark, ginko, evening primrose oil, magnesium, omega-3 fatty acids, pyridoxine (vitamin B6), saffron, turmeric, vitamin D or E, vitex agnuscastus NSAIDs reduce prostaglandin production, reducing uterine contractions and pain. Start NSAID treatment at the first sign of pain or, if predictable, one to two days before the period is due. Continue taking the NSAID regularly at the recommended dose for about two days after bleeding starts. Ibuprofen is the NSAID least likely to cause stomach irritation. NSAIDs may not be suitable for people on certain other medications or with some medical conditions (eg, asthma, kidney disease – see Refer to Pharmacist). Advise customer to stop taking if stomach upsets, increased bruising or prolonged bleeding occur. See Reference Section, OTC Medicines – Precautions. Combination products may help women who experience strong period pain. Some women may get relief from a simple analgesic (eg, paracetamol), but as prostaglandins are considered a primary cause of period pain, NSAIDs are usually preferred, providing these are not contraindicated. Warn customers that codeine is an addictive substance and should not be used for more than three days at a time. Constipation or drowsiness may also occur. Monitor sales and be alert for any customers who may be misusing codeine-containing preparations. Several natural ingredients may help relieve symptoms of PMS. Magnesium may be effective at relieving premenstrual migraine, fluid retention and mood in magnesium-deficient women. Products with an asterisk have a detailed listing in the Period Pain & Endometriosis section of OTC Products, on page 254. NUROFEN ZAVANCE* IS ABSORBED UP TO THAN STANDARD NUROFEN *Applies to Nurofen Zavance tablets and caplets only. †2 tablets of Nuromol are stronger than and effective for longer than 2 tablets of paracetamol 500mg, or 2 tablets of ibuprofen 200 mg + Codeine 12.8 mg in dental pain studies. 1. Mehlisch D et al. Clinical Therapeutics 2010;32(6):1033-49. 2. Daniels S et al. Pain 2011;152:632-42. Always read the label. Use only as directed. Incorrect use could be harmful. Do not use if you have a stomach ulcer. If symptoms persist see your healthcare professional. Reckitt Benckiser, Auckland. 0800 40 30 30. TAPS DA1704JD. Page 118 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION time 8+ years) due in part to a general attitude of normalising menstrual pain, the reluctance of some women to talk about their period problems, and not recognising the wide range of presenting symptoms. Endometriosis commonly impairs quality of life and can compromise fertility. Early intervention is recommended. More information about endometriosis and treatment can be found on the Endometriosis NZ website (www.nzendo.co.nz). Endometriosis NZ also offers an award-winning presentation suitable for students in years 10–13 (All About ME). Premenstrual syndrome Premenstrual syndrome (PMS) is also known as premenstrual tension (PMT) and refers to the group of symptoms that occur around the time of ovulation (14 days or more after the first day of a woman’s last menstrual period). Symptoms include mood swings, irritability, depression, anxiety and oversensitivity, and typically resolve one or two days before menstruation starts. PMS affects up to 80% of women and, for most, symptoms are mild. However, in 5%–10% of women symptoms are so severe that they interfere with a woman’s lifestyle and functioning. This severe form of PMS is called premenstrual dysphoric disorder (PMDD). Women with PMDD should be referred to their doctor. Women with mild PMS may benefit from regular exercise, a low-fat, low-salt, caffeine and alcohol-free diet, and supplements such as pyridoxine. Initial assessment Despite the high prevalence of period pain, many girls and women do not seek medical advice or are undertreated. Pharmacy staff are in an ideal position to offer advice about regular dosing of non-steroidal anti-inflammatory drugs (NSAIDs) to manage period pain, and to advise women to seek further medical investigation for pain that does not respond to over-the-counter treatment. Direct women or girls with period concerns that are affecting their quality of life to the Endometriosis NZ website (www.nzendo.co.nz) or to a doctor who specialises in women's health. Treatment Prostaglandins are thought to be mainly responsible for period cramping and it is for this reason that NSAIDs are generally more effective than simple analgesics (such as paracetamol) for treating period pain. NSAIDs reduce prostaglandin production which leads to a reduction in uterine contractions and therefore less discomfort. Evidence has not shown any advantage of one NSAID over another; however, if one preparation does not provide relief an alternative NSAID should be tried. Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the woman have any other health conditions (eg, heart or lung problems, immunosuppression, diabetes, is breastfeeding)? • Does the woman take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/complementary medications)? • Is the lower abdominal pain described as severe or distressing? • Does the pain get worse with each period? • Does the pain last longer than the first two days of the period? • Are NSAIDs ineffective or only partially effective? • Has menstrual bleeding become increasingly heavy? • Is the pain accompanied by fever or sickness? • Is there any abnormal discharge or bleeding? • Does the pain occur at times unrelated to menstruation, or during sexual intercourse? • Is the woman in her 30s or older with new-onset period pains? • Does the woman use an intrauterine device (IUD)? • Does the woman find her moods are affecting her lifestyle? • Is the woman pregnant or postmenopausal and experiencing vaginal bleeding? • Does the woman have any allergies to medicines? • Eat a well-balanced diet, including plenty of fresh fruit and vegetables. • Drink at least six glasses of water a day (especially during menstruation). • Don’t put up with severe pain. »» Talk to a sympathetic doctor who is willing to do further investigations. Advice for customers • Physical activity may reduce period pain by improving uterine blood flow. • Applying heat (eg, a hot water bottle or wheat pack) to the lower abdomen over clothing may provide some relief. 3 CHOICES FOR PAIN RELIEF EVERYDAY PAIN RELIEF Effective relief from pain, fever and inflammation FAST PAIN RELIEF Absorbed up to 2x FASTER than standard Nurofen* STRONGER PAIN RELIEF Stronger pain relief than Paracetamol + Codeine† Page 119

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