Transcript DYSMENORRHEA

DYSMENORRHEA
SALWA NEYAZI
COSULTANT OBSTETRICIAN GYNECOLOGIST
PEDIATRIC & ADOLESCENT GYNECOLOGIST
DYSMENORRHEA
WHAT IS DYSMENORRHEA?
Painful menstruation
WHAT IS ITS INCIDENCE?
50-75 %
WHAT ARE THE TWO MAIN CATEGORIES?
1- Primary painful menstruation without
associated pelvic disease
2-Secndary  painful menstruation caused by
pelvic pathology
DYSMENORRHEA
HOW TO EVALUATE A PATIENT WITH
DYSMENORRHEA?
1-History
2-Physical examination  should be completely Normal
in Pt with 1ry dysmen, however if evaluated during
the pain uterus & cx will be mildly tender
3-Investigations  not required if Hx & physical
examination are consistent with 1ry dysm
*U/S
*HSG
*Laparoscopy
*Hystroscopy
*D&c
Allow the physician to
confirm presence or
absence of pelvic disease
1RY DYSMENORRHEA
PRIMARY DYSMENORRHEA
Usually begins few hrs before or with the onset
of menstruation then gradually decrease
+ve family Hx
The pain is crampy/ colicky , in the lower abdomen
most intense in the midline lasts for 12-72 hr
Started with ovulatory cycles 6-12 M after menarche
Associated symptoms
-Back pain & pain in the upper thighs
60%
-Nausea /vomitting 90%
-Diarrhea
60%
-Fatigue / malaise 85%
-Headache (tension or migraine)
45%
-Dizziness, nervousness, fainting in sever cases
1ry DYSMENORRHEA
WHAT IS THE CAUSE OF 1RY DYSMEN ?
-Prostaglandin (PG F2α) release from endometrial cells
uterine smooth muscle contraction, increased intra
uterine pressure & some degree of uterine ischemia
-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
1ry DYSMENORRHEA
WHAT IS THE TREATMENT OF 1RY DYSMEN?
1-NSAID  1st line 80% effective
*Propionic a derivatives  Ibuprofen
Naproxen
*Fenamates  Mefenamic acid “Ponstan”
2-ORAL CONTRACEPTIVES  90% effective
If NSAID are not effective or contraindicated
3-FOLLOW UP
Some Pt may require combining both drugs
 Consider 2ry Dysm if no improvement with
therapy
1ry DYSMENORRHEA
WHAT IS THE MECHANISM OF ACTION OF
THESE DRUGS?
1- NSAID
Inhibits prostaglandin production
Antagonistic action at the receptor “Ponstan”
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)
1ry DYSMENORRHEA
WHAT ARE THE SIDE EFFECTS OF NSAID?
Gastric irritation
Nausea
GIT ulceration
↑ Bleeding time
Nephrotoxicity
Fenamates  blurred vision, headache &
dizziness
Bronchospasm in Pt with bronchial asthma
Hypersensitivity reaction
Autoimmune hemolytic anemia
TREATMENT OF 1RY DYSMENORRHEA
WHAT CAN BE DONE TO IMPROVE THE
EFFECTIVNESS OF NSAID?
-Changing the type of inhibitor
-Starting the medication 24 hrs before the
onset of cramps & continued for 2-3 days
after the flow has started
WHAT ELSE MAY BE HELPFUL TO IMPROVE 1RY
DYSMENORRHEA ?
-To continue normal activities
-Gentle abdominal massage
-Local heat
- Regular exercise
-Avoid stress, lack of sleep & caffeine
1ry DYSMENORRHEA
HOW TO MANAGE A PT WHO CONTINUES TO
HAVE PROBLEM ?
Investigations to R/O 2ry dysmenorrhea
If results are normal
- Codeine may be helpful
under close supervision to avoid addiction
-Acupuncture
SECONDARY
DYSMENORRHEA
2RY DYSMENORRHEA
Hx
-Older patients with onset of symptoms
several years after menarche
-Recurrent pelvic infections
-IUCD
-Recent pelvic surgery
-Heavy periods
-Irregular cycles
Physical examination
May help in Dx by finding abnormalities that
point to a pelvic disease
CAUSES OF 2RY DYSMENORRHEA
Endometriosis
Endometritis
Adhesions
Mullerian anomalies
Adenomyosis
Endometrial polyp
Submucous fibroid
Cx stenosis
Pelvic congestion
Conditioned behavior
Stress & tension
2RY DYSMENORRHEA
HOW TO EVALUATE PT WITH 2RY DYSMEN ?
CBC ESR
Cultures for std
U/S
HSG  if intruterine scarring or fibroid is
suspected
Laparoscopy
Hysteroscopy
D&C
TREATMENT OF 2RY DYSMENORRHEA
Treat the cause
2RY DYSMENORRHEA
CX STENOSIS
Cx stenosis  ↑ Intrauterine pressure during
menses
 Retrograde menstruation 
endometriosis
Cx stenosis
-Congenital
-2ry to cervical injury  *electrocautery
*cryocautery
*conization
*infection
Scanty menstrual flow & sever cramping
through out the menstrual cycle
CX STENOSIS
Dx
Internal os scarred & impossible to pass
uterine sound or even very thin probe
Rx
-D&C
-The problem frequently recurs  repeat
procedure
-Vaginal delivery afford morelasting cure
Pt with large endocervical polyp will have the same
presentation
ENDOMETRIOSIS
Endometriosis  Ectopic endometrial tissue
Adenomyosis Endometrial tissue in the
myometrium
Hx  Sever dysmenorrhea
Infertility
Dysparunea
Pelvic examination
Evidence of endometriosis in vagina or cx
Tenderness
Thickening / nodules of rectovaginal
septum or uterosacral ligament
Ovarian (chocolate) cyst
ENDOMETRIOSIS
Dx
-Laparoscopy or laparotomy
-Direct biopsy of vaginal or cx lesion
Rx
To supress menstruation by medication
Cauterization of endometriotic spots
Analgesics
PELVIC INFECTION & ADHESIONS
PID & Pelvic abscess  adhesions  pelvic pain
Hx  Acute episodes of pain begins with menses
& continues
Pain may involve the entire abdomen
Examination
-Sever tenderness on palpation of the
uterus & cx motion (cx excitation)
-Purulent cx discharge
Associated findings
-Fever
-↑↑ WBC & ESR
PELVIC INFECTION & ADHESIONS
Infections due to other conditions such as
Appendicitis & IUCD  Create similar response
Pain due congestion, edema & adhesions due to the
inflammatory process
Rx  Appropriate antibiotics
Surgical  release of adhesions
TAH BSO
PELVIC CONGESTION SYNDROME
Engorgement of the pelvic vasculature
Pain  Burning or throbbing
Worse at night
Worse after standing for a long time
Examination
Vasocongestion of the vagina & cx
Uterine enlargement & tenderness
Dx  Laparoscopy  Congestion of the uterus
 Varicosities of broad ligament & pelvic side
wall veins
Rx  Medroxyprogestrone acetate
TAH BSO
PREMENSTRUAL SYNDROME
PMS
WHAT IS PMS ?
A group of physical, emotional & behavioral
symptoms that occur in the 2nd half (luteal phase)
of the menstrual cycle often interfere with work
& personal relationships followed by a period
entirely free of symptoms starting with
menstruation
WHAT THE INCIDENCE OF PMS ?
40% Significantly affected at one time or
another
2-3%  Sever symptoms with impact on their
work & lifestyle
5% by the American psychiatric
association definition
PMS
WHAT SYMPTOMS ARE ASSOCIATED WITH PMS?
PHYSICAL SYMPTOMS
-Bloated feeling
-Wt gain
-Breast pain & tenderness
-Skin disorders “acne”
-Hot flushes
-Headache
-Pelvic pain
-Changes in bowel habits
-Joint or muscle pain
-edema
EMOTIONAL / PSYCHOLOGIC SYMPTOMS
OF PMS
Irritability
Aggression
Tension
Anxiety
Depression /  interest in the usual activities
Lethargy
Insomnia or hypersomnia
Change in appetite  overeating or food craving
Crying
Change in lipido
Thirst
Loss of concentration
Poor coordination, Clumsiness, accidents
ETIOLOGY
DO WE KNOW WHAT CAUSES PMS ?
No, many theories have been postulated, most of
them have to-do with various hormonal alterations
Vit B6 deficiency
Multifactorial psychoendocrine disoreder
Alterations in the serotoninergic neuronal
mechanism in the CNS (serotonin deficiency)
Ovulation / progestrone production are important
in this syndrome  Drugs that inhibit ovulation 
relief of PMS symptoms
Antiprogestrone RU486  No relief
ETIOLOGY
Abnormal response of the CNS to the normal
fluctuations of estrogen & progestrone during
the menstrual cycle
Administration of estrogen & progestrone to
women with PMS whose ovaries were suppressed
with GnRH agonist analogues  development of
PMS symptoms
BIOPYCHOSOCIAL MODEL
Hormonal changes of the luteal phase of the
menstrual cycle, that is the ↑↑ estradiol &
progestrone act as a trigger to stimulate the
development of PMS symptoms in women who are
biologically, socially & psychologically predisposed
to develop PMS
Biological explanation  abnormal response of the
CNS to the hormonal changes could be related to
serotonin or γ-aminobutyric acid
Social explanation  mimicking the behavior of
other important females in her life, social
expectations or pressure from others
Psychological explanation  rejection of the
female role or that PMS could be a variation
of other common affective disorder
EVALUATION
Pt should keep a diary of her symptoms throughout 2-3 menstrual cycles  then the physician
should review these symptoms with the Pt to
determine what seems to be causing her the most
difficulty
Complete Hx & physical examination to R/O any
medical problem
DX
DIAGNOSTIC CRITERIA FOR THE PMDD
(PreMenstrual Dysphoric Disorder) in the Diagnostic
Statistical Manual for Mental Disorders
Requires 5 of the following
-Depressed mode
-Anexiety
-Labile mode
-Irritability
-Change in appetite - Lethargy
-Sleep disturbance -Out of control
-Lack of interest
-Physical sympt
*Occur in the week before menses in
most menstrual cycles
*Disappear few days after the onset
of menses
*Impair social, occupational function
or the ability to interact with others
TREATMENT
1- SUPPORTIVE
Counseling & education  the physician should
reassure the Pt that her symptoms are real &
can be treated
The goal is to provide the Pt with greater
control over her life
Life style changes such as exercise & dietary
modifications
2-MEDICATIONS
The selection of medications should be
tailored to the Pt main symptoms
LIFE STYLE CHANGES
Adequate rest & sleep
Aerobic exercise  20-30 min 3-7 times/wk 
-↑ β-endorphins in the brain
-Distract the women from her emotional feelings
Healthy diet  Avoid fasting
Frequent small meals
↑ Complex carbohydrates
 Simple sugars, Salt & Caffeine
Avoid fat free diet
High protein diet
MEDICAL THERAPY
SYMPTOMATIC Rx
1- Bloating & feeling of fluid retention  Diuretics
(spironolactone)
2-Cramping, back pain, heat intolerance 
Antiprostaglandines
3-Breast tenderness  Bromocriptine
4-Depression, anxiety, irritability  Alprazolam
0.25 mg bd
SSRI Fluoxetine (Prozac) 5-20 mg/D (D20-28)
MEDICAL THERAPY
SUPPRESSION OF OVULATION
1-Danazol 200 mg QID D 20-28
2-Oral Contraceptives
3-Medroxyprogestrone acetate 10 mg BID/TID
contiuously
MISCILANEOUS Rx
1-Micronized progestrone 100mg AM
200mg PM
D 20-28
2-Multiple Vitamines
3-Pyridoxine B6  50 mg/ day or B-complex
4-Ca Carbonate 1200mg/D
5-Prime rose oil γ linolenic acid