Dysmenorrhea - PowerPoint Presentation

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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/abnormalmeno, meaning monthrrhea, 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 dysmenorrheaTypical 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 DysmenorrheaSlide6

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 1

st

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 Dysmenorrhea8Slide9

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 Dysmenorrhea9Slide10

The following risk factors have been associated with more severe episodes of dysmenorrhea:Earlier age at menarcheLong menstrual periods

Heavy menstrual flowSmokingPositive family historyRisk factors

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1. NSAID

 1

st

line 80% effectiveIbuprofen (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, nifedipine4.

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

Management12Slide13

Mechanism of Action

1- NSAIDInhibits prostaglandin productionAntagonistic 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 DysmenorrheaSlide15

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 yearsPelvic abnormality with physical examinationSecondary

Dysmenorrhea15Slide16

Dysmenorrhea not limited to the mensesLess 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 bleedingSecondary Dysmenorrhea16Slide17

EndometriosisChronic PIDAdhesions

Mullerian duct anomaliesAdenomyosisEndometrial polyp

F

ibroidsOvarian cystsPelvic congestionImperforate hymen, transverse vaginal septumCervical 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 statusInfertilityPrevious pelvic infections

DyspareuniaPelvic surgeries, injuries or procedures

Sexual history

Evaluation

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HistorySlide23

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.Evaluation

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2. ExaminationSlide24

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, ESRHCG level to exclude ectopic pregnancyAbdominal or transvaginal ultrasound

HysterosalpingogramsOther more invasive procedures such as laparoscopy , hysteroscopy, D&C

Evaluation

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3. Investigation

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Treating the underlying diseaseThe treatments used for primary dysmenorrhea are often helpful

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PREMENSTRUAL SYNDROMESlide27

PMS is a group of physical, emotional & behavioral symptoms that occur in the 2

nd half (luteal phase) of the menstrual cycle often interferes with work & personal relationships followed by a period entirely free of symptoms starting with

menstruation.

Definition27Slide28

the incidence of PMS in the United States range from 30 to 50% of women of childbearing ageIt is estimated that 75 to 80 percent of all women experience some PMS symptoms during their lifetime.

28EpidemiologySlide29

Incompletely understoodMultifactorial

Genetics likely play a roleCNS-mediated neurotransmitter interactions with sex steroids (progestrone, estrogen and testosterone)

Serotonergic

dysregulation- currently most plausible theoryETIOLOGY

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At least one of the following affective and somatic symptoms during the five days before menses in each of the three prior menstrual cycles:

AffectiveDepression Angry outburstsIrritability

Anxiety

ConfusionSocial withdrawalDiagnosis

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SomaticFatigue

Breast tendernessAbdominal bloatingHeadacheSwelling of the extremities

Symptoms relieved within four days of onset of menses

Symptoms present in the absence of any pharmacologic therapy, drug or alcohol use31

DiagnosisSlide32

Symptoms occur reproducibly during two cycles of prospective recordingPatient suffers from identifiable dysfunction in social or economic performance

32DiagnosisSlide33

A thorough history and physical examination should be performed to rule out any other medical causesGoal: symptom relief

No proven beneficial treatment, suggestions include:Psychological supportDiet/supplementsAvoid sodium, simple sugars and caffeineCalcium 1200-1600 mg/

d

magnesium 400-800 mg/dVit E 400 IU/dVit

B6Regular aerobic exercise Management

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MedicationsNSAIDs for discomfort and pain

Spironolactone for fluid retentionSSRI antidepressantsProgesterone suppositoriesOCP for somatic symptoms

Danazol

GnRH agonists if severe PMS unresponsive to other treatmentsHerbal remedies34

ManagementSlide35

PMDD is described as a more severe form of PMS with specific diagnostic criteriaTreatment with SSRIs (first line) highly effective

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Premenstrual

Dysphoric DisorderSlide36

Thank you for listening..

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