Transcript Dysmenorrhoea,dyspareunia & PMS

Dr hashmi hajrasi
Consultant in OBS & GYN
MBBCh, DGO, MRCOG, D’MAS
By the end of the lecture the student is
expected to
 understand the definition, possible causes of
dysmenorrhoea, dyspareunia and impact on
women’s life
 Know how to investigate and come up with a
diagnosis
 Treatment options and effectiveness
 Have
a basic knowledge on PMS in term of
the common symptoms, possible theories
behind its occurrence
 Know how to reach a diagnosis using
symptom chart and exclusion
 Know the commonly suggested treatment
options and their efficacy
 Defined
as painful menstruation.
 Although some pain during period is normal,
pain that is sever enough to limit normal
activity or requires medication is abnormal
and requires evaluation.
 Affects about 50% of menstruating women
and regarded as sever in 10% of sufferers
 Dysmenorrhoea is the leading cause for
absence from school or work
 Primary
dysmenorrhoea: occurs in otherwise
healthy women with no organic cause
 Secondary
dysmenorrhoea: due to an
underlying disease or structural uterine
abnormality
 Onset
a few years after menarche
 Cycles are regular
 Pain for less than 2 days
 Cramping pain radiating to the thighs
 Nausea and other GI symptoms
 relieved after childbirth
 Prostaglandins & leukotrins play a major role
Causes :
 endometriosis
 adenomyosis
 chronic pelvic inflammatory disease
 Pelvic congestion syndrome
 pelvic adhesions
 IUD
 fibroids
 History
 Physical
 Is
examination:
pelvic examination needed?
Recommended in all cases except if
not sexually active with typical
primary dysmenorrhoea
Investigations needed ?
 Pelvic Ultrasound if


clinical pelvic examination abnormal
symptoms suggestive of secondary
dysmenorrhoea but PV not conclusive or not
possible
 Laparoscopy

Sometimes needed
 Simple
analgesics: paracetamol, NSAID
 Hormonal
therapy: as a second line when
simple analgesia fails. COCP are 90%
effective
 Treat
the underlying cause
 NSAID’s
 Hormonal contraceptives
 Pre-sacral neurectomy in selected cases
 Defined
as pain during or after intercourse
 It is not a disease ,but rather a symptom of
an underlying physical or psychological
disorder
 Could be superficial at entrance of the
vagina or deep in the pelvis on deep
penetration
Superficial dyspareunia:
 Vaginismus
 Vaginal infection
 Episiotomy scars & narrowed vagina
 Insufficient vaginal lubrication
 Atrophic vagina due to menopause
Recurrent or persistent involuntary
spasm of the musculature of the outer
third of the vagina that interferes with
intercourse”
Etiological background
 lack of sex education/information
 negative attitudes about sexuality
 sexual abuse or trauma
Deep dyspareunia:
 PID
 Endometriosis
 Ovarian cysts
 Ectopic pregnancy
 Pelvic congestion
 Aimed
at identifying & properly treating the
underlying cause
 Adequate foreplay or k-y gel for vaginal
dryness
 Topical oestrogen for atrophic vagina
 surgery may sometimes be required for
vaginal prolapse or inadequate vagina
 Insertion
of a graduated set of dilators in the
vagina
 psychotherapy
Distressing physical, psychological and behavioural
symptoms, not caused by organic disease, which
regularly recur during the same phase of the
menstrual (ovarian) cycle and which significantly
regress or disappear during the remainder of the
cycle
Magos & Studd (1984)
 Affects
30-40% of women of child bearing age
but in 10% the symptoms are so sever and
disabling (premenstrual Dysphoric dysorders
(PMDD)
 Over 150 symptoms have been documented
but the three most prominent are ,
irritability, tension & dysphoria (unhappiness)
Is poorly understood but a major role played
by
 Cyclical ovarian activity
 Estradiol
 Progesterone
 Neurotransmitters serotonin & GABA
PMDD may be viewed as a more severe form of
PMS
Rapkin A. Psychoneuroendocrinology. 2003.
Disorders
Pre-menstrual
Minor
symptoms
More common/
Less severe
PMS
(Pre-menstrual
Syndrome)
Moderate
symptoms
PMDD
(Pre-menstrual
Dysphoric
Disorder)
(Sever symptoms)
Less common/
More severe
Percent
Estimated #
(in millions)
Minor PM
symptoms
70 – 90%
43 – 55
PMS
20 – 40%
12 – 25
3 – 8%
2–5
PMDD
Ginsberg KA, et al. 2000.
Follicular Phase
Ovulation
Symptoms occur
Luteal Phase
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Days of Menstrual Cycle
Malone DC. Am J Manag Care. 2005
Dickerson LM et al. Am Fam Physician. 2003.
more…
More than 150 symptoms associated with PMS
Physiological
Behavioral
Malone DC. Am J Manag Care. 2005
Dickerson LM et al. Am Fam Physician. 2003.
Psychological
Occur in luteal phase
Resolves near the start of menstruation
Creates problems or impairment
Not better explained by another diagnosis
Johnson SR. Obstet Gynecol. 2004; Rapkin AJ. Am J Manag Care. 2005; ACOG. ACOG Practice
Bulletin No. 15. 2000; Dickerson LM et al. Am Fam Physician. 2003.
List the symptoms you have in the left column. Circle the dates of your menstrual period. Fill in the boxes on
the days your symptoms occur. Indicate severity by filling in the boxes as shown: Mild, Moderate, Severe
Day of the month
Symptoms
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Download from:
www.arhp.org/menstrualsymptomschart
more…
Kaur G, et al. Cleve Clin Med. 2004.
Johnson SR. Obstet Gynecol. 2004.
Kaur G, et al. Cleve Clin Med. 2004.
Johnson SR. Obstet Gynecol. 2004.
“…no single
intervention is effective
for all women.”
Dimmock PW et al
Lancet 2000
Dimmock PW et al. Lancet. 2000.
Steiner M. Am Fam Physician. 2003.
 General
advice about diet, exercise & stress
reduction should be considered before
starting specific treatment
 Women
with marked underlying
psychopatology should see a psychiatrist
 Symptom
diary should be used to assess the
effect of treatment
Eat frequent and
smaller portions of
foods high in complex
carbohydrates
Johnson SR. Obstet Gynecol. 2004.
Vitamin B6, up to 100 mg per day*
Vitamin E, up to 600 IU per day*
Calcium carbonate with vitamin D
Magnesium, up to 500 mg per day
NSAIDS
*limited benefit
Bhatia SC et al. Am Fam Physician.2002; Bowman MA. 2000. Freeman EW, Sondheimer SJ. J
Clin Psychiatry. 2003; Endicott J et al. Patient Care. 1996; Johnson WG et al. Psychosom Med.
1995; Rapkin AJ. Am J Manag Care. 2005.
Aerobic exercise/Yoga
 Relaxation and stress management
 Anger management
 Self-help support groups
 Therapy (individual, couples, cognitivebehavioral, )
 Smoking cessation
 Regular sleep

 Selective
serotonin re-uptake inhibitors
(SSRI) ....e.g Fluoxetine significantly reduces
tension, irritability & dysphoria (4-6 times
better )
 Progestogens
 COCP
 Diuretics
 Antidepressants
 danazole
 GnRH A
 Hysterectomy
& BSO
 Dysmenorrhoea
is not uncommon complaint.
Detailed history & gynae examination
together with pelvic USS and sometimes
laparoscopy enables diagnosis appropriate
treatment
 Dyspareunia can be very distressing and a
cause for broken sexual life. It may be
confused with vaginismus though this is
largely due to fear of pain .previous H/O
sexual abuse or trauma must be sought but
an organic must be excluded
 PMS
can be confused with so many other
conditions and diagnosis sometimes by
exclusion. PMS diary helps to establish
diagnosis and assess severity of symptoms
 Treatment requires multidisciplinary team
approach involving gynaecologist,
psychotherapist, social worker, self-support
groups and husband support
 Pharmacological agents help to alleviate
symptoms but eventually oophorectomy may
be required