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Dysmenorrhea
Abdullah Baghaffar
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Dysmenorrhea is defined as Painful menstruation
The term dysmenorrhea is derived from the Greek words:
◦ dys, meaning difficult/painful/abnormal
◦ meno, meaning month
◦ rrhea, meaning flow
Definition:
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1- Primary painful menstruation not associated with pelvic pathology
2- Secondary painful menstruation caused by pelvic pathology
Classification
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50-75 % of women report dysmenorrhea
Typical age range for primary dysmenorrhea is between 17 and 22 years
Secondary dysmenorrhea is more common in older women
Epidemiology
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Primary Dysmenorrhea
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During menstruation, Prostaglandin F2α is released from endometrial cells uterine smooth muscle contraction, some degree of uterine ischemia.
This is associated with painful and sometimes debilitating cramps.
PG production during the 1st 48-72 hrs of menses
PG may also cause hypersensitization of pain terminals to physical & chemical stimuli
Behavioral, cultural & psychological factors influence the Pt reaction to pain
Etiology
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Starts with ovulatory cycles 6-12 M after menarche
Begins few hrs before or with the onset of menstruation and usually lasts 48 -72 hrs
The pain is crampy/ colicky , usually strongest in the lower abdomen and may radiate to the back or inner thighs
Features of Primary Dysmenorrhea
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Associated symptoms
-Back pain & pain in the upper thighs 60%
-Nausea /vomiting 89%
-Diarrhea 60%
-Fatigue / malaise 85%
-Headache 45%
-Dizziness, nervousness, fainting in severe cases
Features of Primary Dysmenorrhea
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The following risk factors have been associated with more severe episodes of dysmenorrhea:
◦ Earlier age at menarche
◦ Long menstrual periods
◦ Heavy menstrual flow
◦ Smoking
◦ Positive family history
Risk factors
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1. NSAID 1st line 80% effective Ibuprofen (400 mg q 6 hrs) Naproxen(250 mg q 6 hrs) Mefenamic acid (500 mg q 8 hrs)
2. ORAL CONTRACEPTIVES 90% effective If NSAID are not effective or contraindicated
Some Pt may require combining both
drugs. Consider 2ry Dysmenorrhea if
no improvement with therapy.
Management
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3. Tocolytics: ◦ Resistant cases may respond to tocolytic agents eg.
salbutamol, nifedipine
4. Progestogens◦ Especially medroxyprogestrone acetate or dydrogesterone
in daily high doses may also be beneficial in resistant cases
5. Nonpharmacologic pain management:◦ Acupuncture
◦ Transcutaneous electrical stimulation
◦ Psychotherapy, hypnotherapy and heat patches
6. Surgical procedures◦ Presacral neurectomy
◦ Uterosacral nerve ablation
◦ Have been largely abandoned
Management
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Mechanism of Action 1- NSAID
◦ Inhibits prostaglandin production◦ Antagonistic action at the receptor ◦ Should be used with the start of pain regularly for
2-3 days
2- Oral Contraceptives◦ Endometrial thickness◦ PG through inhibition of ovulation & change the
hormonal status to that of the early proliferative phase (which has the lowest level of PG)
Management
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Secondary Dysmenorrhea
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Features which may indicate secondary dysmenorrhea:
◦ Dysmenorrhea occurring during the first or second cycles after menarche, which may indicate congenital outflow obstruction
◦ Dysmenorrhea beginning after the age of 25 years
◦ Pelvic abnormality with physical examination
Secondary Dysmenorrhea
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◦ Dysmenorrhea not limited to the menses
◦ Less related to the first day of flow
◦ Little or no response to therapy with NSAIDs, OCs, or both.
◦ Usually associated with other symptoms such as dyspareunia , infertility or abnormal vaginal bleeding
Secondary Dysmenorrhea
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Endometriosis Chronic PID Adhesions Mullerian duct anomalies Adenomyosis Endometrial polyp Fibroids Ovarian cysts Pelvic congestion Imperforate hymen, transverse vaginal septum Cervical stenosis IUCD - copper
Causes Of Secondary Dysmenorrhea
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◦Endometriosis:
Pain extends to premenstrual or post menstrual phase or
may be continuous, may also have deep dysparueunia,
premenstrual spotting and tender pelvic nodules
(especially on the uterosacral ligaments); onset is usually
in the 20s and 30s but may start in teens
Causes of secondary dysmenorrhea:
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◦Pelvic inflammation
Initially pain may be menstrual, but often with each cycle
it extends into the premenstrual phase; may have
intermenstrual bleeding, dyspareunia and pelvic
tenderness.
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◦Adenomyosis, Fibroid Tumors
Uterus is generally clinically and symmetrically enlarged
and may be mildly tender; dysmenorrhea is associated
with a dull pelvic dragging sensation.
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◦Pelvic Congestion
A dull, ill-defined pelvic ache, usually worse
premenstrually, aggravated by standing, relieved by
menses; often a history of sexual problems.
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◦ Pain analysis◦ Associated symptoms◦ Menstrual history◦ Gravidity and parity status◦ Infertility◦ Previous pelvic infections◦ Dyspareunia◦ Pelvic surgeries, injuries or
procedures◦ Sexual history
Evaluation
1. History
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A pelvic exam is indicated at the initial evaluation which
should be performed to exclude uterine irregularities, cul
du sac tenderness or nodularity that may suggest
endometriosis, PID or pelvic mass. It should be
completely normal in a Pt with 1ry dysmenorrhea,
however if evaluated during the pain uterus & cx will be
mildly tender.
Evaluation2. Examination
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◦ Not required if History & physical examination are consistent with 1ry dysmenorrhea
◦ The following can performed to exclude organic causes of dysmenorrhea:
Cervical culture to exclude STDs
WBC count to exclude infection, ESR
HCG level to exclude ectopic pregnancy
Abdominal or transvaginal ultrasound
Hysterosalpingograms
Other more invasive procedures such as laparoscopy , hysteroscopy, D&C
Evaluation
3. Investigation
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Treating the underlying disease
The treatments used for primary dysmenorrhea are often helpful
Management
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PREMENSTRUAL SYNDROME
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PMS is a group of physical, emotional &
behavioral symptoms that occur in the 2nd half
(luteal phase) of the menstrual cycle often
interferes with work & personal relationships
followed by a period entirely free of symptoms
starting with menstruation.
Definition
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the incidence of PMS in the United States range from 30 to 50% of women of childbearing age
It is estimated that 75 to 80 percent of all women experience some PMS symptoms during their lifetime.
Epidemiology
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Incompletely understood
Multifactorial
Genetics likely play a role
CNS-mediated neurotransmitter interactions with sex steroids (progestrone, estrogen and testosterone)
Serotonergic dysregulation- currently most plausible theory
ETIOLOGY
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1. At least one of the following affective and somatic symptoms during the five days before menses in each of the three prior menstrual cycles:
◦ Affective1. Depression 2. Angry outbursts3. Irritability4. Anxiety5. Confusion6. Social withdrawal
Diagnosis
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◦ Somatic1. Fatigue2. Breast tenderness3. Abdominal bloating4. Headache5. Swelling of the extremities
2. Symptoms relieved within four days of onset of menses
3. Symptoms present in the absence of any pharmacologic therapy, drug or alcohol use
Diagnosis
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4. Symptoms occur reproducibly during two cycles of prospective recording
5. Patient suffers from identifiable dysfunction in social or economic performance
Diagnosis
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A thorough history and physical examination should be performed to rule out any other medical causes
Goal: symptom relief No proven beneficial treatment, suggestions
include:◦ Psychological support◦ Diet/supplements
Avoid sodium, simple sugars and caffeine Calcium 1200-1600 mg/d magnesium 400-800 mg/d Vit E 400 IU/d Vit B6
◦ Regular aerobic exercise
Management
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◦ Medications NSAIDs for discomfort and pain
Spironolactone for fluid retention
SSRI antidepressants
Progesterone suppositories
OCP for somatic symptoms
Danazol
GnRH agonists if severe PMS unresponsive to other treatments
◦ Herbal remedies
Management
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PMDD is described as a more severe form of PMS
with specific diagnostic criteria
Treatment with SSRIs (first line) highly effective
Premenstrual Dysphoric Disorder
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