Dysmenorrhea Abdullah Baghaffar

Definition: 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

Classification 1- Primary  painful menstruation not associated with pelvic pathology 2- Secondary  painful menstruation caused by pelvic pathology

Epidemiology 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

Primary Dysmenorrhea

Etiology 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

Features of Primary Dysmenorrhea 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 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

Risk factors 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

Management 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 3. Tocolytics: 4. Progestogens 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 Mechanism of Action 1- NSAID 2- Oral Contraceptives 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)

Secondary Dysmenorrhea

Secondary Dysmenorrhea 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 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

Causes Of Secondary Dysmenorrhea 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: 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

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.

Adenomyosis, Fibroid Tumors Uterus is generally clinically and symmetrically enlarged and may be mildly tender; dysmenorrhea is associated with a dull pelvic dragging sensation.

Pelvic Congestion A dull, ill-defined pelvic ache, usually worse premenstrually, aggravated by standing, relieved by menses; often a history of sexual problems.

Evaluation Pain analysis Associated symptoms Menstrual history Gravidity and parity status Infertility Previous pelvic infections Dyspareunia Pelvic surgeries, injuries or procedures Sexual history

Evaluation 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.

Evaluation 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

Management Treating the underlying disease The treatments used for primary dysmenorrhea are often helpful

PREMENSTRUAL SYNDROME

Definition 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. Premenstrual syndrome T1- A group of physical, emotional & behavioral symptoms that occur in the second half of the menstrual cycle F2-It starts before the menses & continues untill ovulation T 3-40% of women are significantly affected at one time or another T 4- 2-3% of women will have sever symptoms that will affect their work & lifestyle

Epidemiology 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.

ETIOLOGY 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 F 5- PMS is a psychiatric disorder & it is not related to the hormonal changes of the menstrual cycle

Diagnosis 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 Depression Angry outbursts Irritability Anxiety Confusion Social withdrawal F 5-

Diagnosis Symptoms relieved within four days of onset of menses Somatic 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

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

Management 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 Treatment of PMS T 1-The selection of medications should be tailored to the patients main symptoms

Management Medications Herbal remedies 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

Premenstrual Dysphoric Disorder PMDD is described as a more severe form of PMS with specific diagnostic criteria Treatment with SSRIs (first line) highly effective

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