Transcript dysmenorrheax

Abdullah Baghaffar
1

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
2
1- Primary  painful menstruation not associated
with pelvic pathology
2- Secondary  painful menstruation caused by
pelvic pathology
3

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
4
5

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
6
7

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
8

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
9

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
10
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.
11
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
12
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)
13
14

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
15
◦ 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
16












Endometriosis
Chronic PID
Adhesions
Mullerian duct anomalies
Adenomyosis
Endometrial polyp
Fibroids
Ovarian cysts
Pelvic congestion
Imperforate hymen, transverse vaginal septum
Cervical stenosis
IUCD - copper
17
◦ 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
18
◦ 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.
19
◦ Adenomyosis, Fibroid Tumors
Uterus is generally clinically and symmetrically enlarged and
may be mildly tender; dysmenorrhea is associated with a dull
pelvic dragging sensation.
20
◦ Pelvic Congestion
A dull, ill-defined pelvic ache, usually worse premenstrually,
aggravated by standing, relieved by menses; often a history
of sexual problems.
21
1. History
◦
◦
◦
◦
◦
◦
◦
◦
◦
Pain analysis
Associated symptoms
Menstrual history
Gravidity and parity status
Infertility
Previous pelvic infections
Dyspareunia
Pelvic surgeries, injuries or procedures
Sexual history
22
2. Examination
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.
23
3. Investigation
◦
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
24


Treating the underlying disease
The treatments used for primary dysmenorrhea are
often helpful
25
26

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.
27

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.
28

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
29
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:
◦ Affective
1.
2.
3.
4.
5.
6.
Depression
Angry outbursts
Irritability
Anxiety
Confusion
Social withdrawal
30
◦ Somatic
1.
2.
3.
4.
5.
2.
3.
Fatigue
Breast tenderness
Abdominal bloating
Headache
Swelling of the extremities
Symptoms relieved within four days of onset
of menses
Symptoms present in the absence of any
pharmacologic therapy, drug or alcohol use
31
4.
5.
Symptoms occur reproducibly during two
cycles of prospective recording
Patient suffers from identifiable dysfunction
in social or economic performance
32



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
33
◦ 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
34

PMDD is described as a more severe form of PMS
with specific diagnostic criteria

Treatment with SSRIs (first line) highly effective
35
36