Valerie Robinson D.O.

Dysmenorrhea – painful menstruation Symptoms – Recurrent episodes of uterine cramps and lower abdominal pain during menstrual cycle. Primary dysmenorrhea – occurs in the absence of a disease process. Common in adolescents and nulliparous women Secondary dysmenorrhea – occurs with a disorder causing the symptoms. More common in women in their 30s-40s DEFINITION

Multiple risk factors may include Age less than 30 BMI less than 20 Smoking Menarche before age 12 Longer menstrual cycles/bleeding Irregular or heavy cycles History of sexual assault Family history of dysmenorrhea Protective factors may include Young age at first childbirth High parity Advancing age PRIMARY DYSMENORRHEA

Recurrent episodes of uterine cramps, lower abdominal pain, nausea, vomiting, diarrhea, headache, backache during menstrual cycle. Usually begins in adolescence after ovulatory cycles begin. (Usually 2-5 years after menarche) Prevalence is 60-93% in adolescents The defining symptom is crampy pelvic pain that is intermittently intense and may range from mild to severe pain. Pain occurs with most or all menstrual cycles and may begin 1-2 days before bleeding starts. Pain occurs midline and may radiate to back or thighs. PRIMARY DYSMENORRHEA SYMPTOMS

At the beginning of the menstrual cycle, the sloughing endometrial lining releases prostaglandins, specifically E2 and F2-alpha The prostaglandins stimulate uterine contractions Prostaglandins also stimulate the GI tract, causing nausea, vomiting, diarrhea Contractions are frequent and uncoordinated and result in high intrauterine pressures When the intrauterine pressure exceeds the arterial pressure, uterine ischemia develops Ischemia of uterine tissue causes it to form anaerobic metabolites that in turn stimulate pain fibers. PRIMARY DYSMENORRHEA PATHOGENESIS

Rule out likely causes of secondary dysmenorrhea (PID, endometriosis, adenomyosis, fibroids) Does it respond to treatment? If no relief after 3 months of tx, start thinking secondary. PRIMARY DYSMENORRHEA DIAGNOSIS

NSAIDs – are prostaglandin synthetase inhibitors Patients with severe symptoms should take NSAIDs prior to menses Hormonal contraceptives – suppress ovulation, thin endometrium, and thereby decrease prostaglandin production Copper IUDs may increase dysmenorrhea Adjunct tx – heat packs, exercise, relaxation techniques, TENS unit Nitrates, calcium channel blockers and magnesium are under study d/t tocolysis PRIMARY DYSMENORRHEA TREATMENT

May occur well after menarche Abnormal uterine bleeding Pain may not be midline Absence of nausea, vomiting, diarrhea, and back pain Dyspareunia Dyschezia Progression of symptoms SECONDARY DYSMENORRHEA SYMPTOMS

PID Endometriosis Adenomyosis Fibroids Ovarian cysts Adhesions Obstructive endometrial polyps SECONDARY DYSMENORRHEA CAUSES Obstructive congenital malformation Cervical stenosis IUD Pelvic congestion IBS IBD Psychogenic

PID: pelvic pain, occurs during or shortly after menses, dyspareunia, AUB, vaginal or urethral discharge, cervical motion tenderness, adnexal tenderness Endometriosis: premenstrual spotting, dyspareunia, dyschezia, progressive course. Uterosacral ligament nodularity, thickening, or tenderness, cervical stenosis, adnexal mass Adenomyosis: typically after age 35, may be related or unrelated to cycle, bulky, mildly tender uterus Fibroids: more common in women >30. Dyspareunia, noncyclic pain, menorrhagia, enlarged and irregularly shaped uterus, usually nontender Testing is based on suspicion Urine HCG if new-onset Culture for GC/CT Pelvic ultrasound Rarely, diagnostic laparoscopy SECONDARY DYSMENORRHEA DIAGNOSIS

PID – tx the STD. May need laproscopic lysis of adhesions Endometriosis – Progesterone IUD, GnRH agonist (nafarelin or leuprolide) Adenomyosis –progesterone IUD, GnRH agonist, aromatase inhibitors, hysterectomy Fibroids – watch and wait, NSAIDs, hormonal contraception, GnRH agonists, antiprogestin (mifepristone), myomectomy, hysterectomy Ovarian cysts, Adhesions, Obstructive endometrial polyps, IUD – Remove IBS/IBD – treat the cause Psychogenic - psychotherapy SECONDARY DYSMENORRHEA TREATMENT

Banikarim, Chantay, MD, MPH. “Primary dysmenorrhea in adolescents.” UpToDate. Updated August 28, 2012 Smith, Roger P., MD and Andrew M. Kaunitz MD. “Primary dysmenorrhea in adult women: Clinical features and diagnosis.” UpToDate. Updated March 1, Smith, Roger P., MD and Andrew M. Kaunitz MD. “Treatment of primary dysmenorrhea in adult women.” UpToDate. Updated April 24, Stewart, Elizabeth A., MD. “Overview of treatment of uterine leiomyomas (fibroids).” UpToDate. Updated February 27, Stewart, Elizabeth A., MD. “Uterine adenomyosis.” UpToDate. Updated September REFERENCES

The curse Aunt Flo coming for a visit That time of month Having the painters in Checking into the Red Roof Inn Lady days Monthlies Mother Nature’s gift Planting cotton Red letter day COLLOQUIALISMS