Menstrual Cycle Pains and Discomforts
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Transcript Menstrual Cycle Pains and Discomforts
Menstrual Cycle
Pains and
Discomforts
NURS 541
Objectives
Discuss issues around the diagnosing and classifying
perimenstrual signs and symptoms as ‘diseases’ or
‘syndromes’, and explore the concept of ‘cyclic
perimenstrual pain and discomforts’ (CPPD).
Describe the clinical approach to primary and
secondary dysmenorrhea.
Differentiate between the symptom clusters, diagnostic
criteria, and therapeutic approaches to Premenstrual
Syndrome (PMS), Premenstrual Dysphoric Disorder
(PMDD), and Premenstrual Magnification (PMM).
Discuss why it is important for the patient to actively
participate in the diagnosis and management
processes.
The Menstrual Cycle
Physiologic process
10% of women experience severe symptoms
Up to 85% of women experience some discomforts
Fatigue
Mood swings
Pain
Bloating
Breast tenderness
Symptom Clusters
“Turmoil”
Depression, anger, tension, guilt, tearfulness, anxiety,
nervousness, irritability, loneliness, impatience
“Fluid retention”
Weight gain, abdominal bloating, painful breasts, swelling of
hands/feet, skin disorders
“Somatic symptoms”
Nausea, fatigue, decreased food intake, abdominal pain,
headaches, decreased sexual desire, aches and pains
“Arousal”
Energy, increased sexual desire, impulsiveness, increased food
intake, cravings
Cyclic Pelvic Pain and
Discomforts (CPPD)
Dysmenorrhea
Pelvic pain/cramping associated with menses
Perimenstrual physical discomforts
Other physical discomforts that begin around time of
menses and resolve after menses begin
Perimenstrual mood discomforts
Psychological discomforts that begin around time of
menses and resolve after menses begin
Potential Etiologies
Biological basis
Increased prostaglandins => pain
Hormonal imbalances
Causes not clear or supported in the literature
Genetics and/or environmental basis
Individual genetic differences
Interaction of biology, genetics, and environment
Abnormal responses to normal physiologic changes
Psychosocial/sociocultural basis
Increased stressors, stress responses, and vulnerability
Dysmenorrhea
Primary dysmenorrhea is a diagnosis of exclusion
No other identifiable cause for pain
Begins shortly after start of menses
Suspected prostaglandin increase by endometrium
Secondary dysmenorrhea is related to another etiology
Dyspareunia
Dysuria
Infertility
Endometriosis
Fibroids
Abnormal uterine bleeding
Dysmenorrhea
Potentially significant decrease in quality of life
Loss of time at work/school
Health care provider visits
Expenses for OTC medications
Most common with young women (teens – 20’s)
Symptoms can be disabling for some (10-20%)
Premenstrual Syndrome
(PMS)
Distinct pattern of symptoms occurring before menses
(within 7 days) and lasting through first days of
menses, with little to no symptoms after menses end
(during luteal phase)
Recurrence of symptoms that influence functioning at
work, school, or in life (relationships)
Includes physical, mood, and behavioral symptoms
Premenstrual Magnification
(PMM)
Exacerbation of somatic and mood
symptoms/conditions during the late luteal or
menstrual phases
Anxiety or depressive disorders
Migraines
Seizure disorders
Irritable bowel syndrome
Asthma
Chronic fatigue
Considered a dual diagnosis – originating condition
with premenstrual magnification
Premenstrual Dysphoric
Disorder (PMDD)
A cluster of severe perimenstrual symptoms including
at least one affective symptom
Directed towards mood/behavioral changes
DSM IV diagnosis
CONTROVERSIAL!
Has to be severe in symptoms and influencing life,
work, relationships to be diagnosed
Approach for Management
Consider all potential etiologies
Biologic causes
Social, personal changes that affect health
Environmental factors
Goals
Personalized and individual
Reduction in symptoms
Improved quality of life
Focused Health History
Menstrual history
Menarche
Cycle length, regularity
Menses length
Menses bleeding quality/amount
Focused Health History
Symptom exploration
Timing of symptoms during menstrual cycle
Luteal, pre-menstrual, menstrual, follicular phases
Severity, quality of symptoms
Identification of symptom clusters
Calendar/diary of symptoms
Focused Health History
Medical history
Co-occurring conditions
Pregnancy history
Focused family history
Related to menses/PMS
Medications
Contraception or hormones?
Allergies
Social history/health behaviors
Focused Physical Exam
Abdominal exam
Assess CVA tenderness
Pelvic exam
Speculum if indicated
Bimanual exam
Laboratory studies
To test for co-occurring conditions
Anemia, thyroid, diabetes, hypoglycemia, etc
Differential Diagnosis
Cyclic pelvic pain and discomforts (CPPD)
Dysmenorrhea
PMS
PMM
PMDD
Non-cyclic pelvic/abdominal pain
Mild, moderate, severe symptoms
Dual diagnoses
Plan of Care
Setting goals
Individualized
Evidence-based
Feasibility of desired outcome
Acceptability to client
Capability of provider (you) to provide service
Plan of Care
Cyclic pain and discomforts
Over-the-counter (OTC) medications
Acetaminophen
Ibuprofen
Naproxen
Hormonal contraception
Oral contraceptives
Progestin IUD
Supplements
Calcium, magnesium, vit E, vit B1, essential fatty acids
Plan of Care
Cyclic pain and discomforts
Nutrition (low-fat, high vegetable, hydration)
Exercise
Heat application
Massage/chiropractic therapy
Acupuncture/Chinese medicine
Acupressure
Plan of Care
Mood discomforts
Supplements (calcium, vitamin D)
Massage
Behavioral relaxation (breathing, stretching)
Cognitive relaxation (meditation, biofeedback)
Environmental modification
Stress reduction
Nutrition/exercise
Acupuncture/Chinese medicine
Homeopathy
Plan of Care
Severe PMS/PMDD
Anti-depressants (during luteal phase or continually)
SSRIs shown to reduce symptoms 40-55%
Need to consider side effects
Anti-anxiolytics
Mixed evidence
Should be used with other modalities
Hormonal therapy
Micronized progesterone (mixed evidence)
Oral contraceptives (mixed evidence)
Other modalities
Light therapy
Association with seasonal affective symptoms
Traditional Chinese medicine/acupuncture
Herbal remedies
Vitex (chaste tree berry) (level 1 evidence)
Crampbark
Evening primrose oil
Questions?