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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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