1. Menstrual Cycle Pains and Discomforts NURS 541

2. Objectives  Discuss issues around the diagnosing and classifying perimenstrual signs and symptoms as ‘diseases’ or ‘syndromes’, and explore the concept of ‘cyclic perimenstrual pain and discomforts’ (CPPD).  Describe the clinical approach to primary and secondary dysmenorrhea.  Differentiate between the symptom clusters, diagnostic criteria, and therapeutic approaches to Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD), and Premenstrual Magnification (PMM). Discuss why it is important for the patient to actively participate in the diagnosis and management processes.

3. The Menstrual Cycle  Physiologic process  10% of women experience severe symptoms  Up to 85% of women experience some discomforts  Fatigue  Mood swings  Pain  Bloating  Breast tenderness

4. Symptom Clusters  “Turmoil”  Depression, anger, tension, guilt, tearfulness, anxiety, nervousness, irritability, loneliness, impatience  “Fluid retention”  Weight gain, abdominal bloating, painful breasts, swelling of hands/feet, skin disorders  “Somatic symptoms”  Nausea, fatigue, decreased food intake, abdominal pain, headaches, decreased sexual desire, aches and pains  “Arousal”  Energy, increased sexual desire, impulsiveness, increased food intake, cravings

5. Cyclic Pelvic Pain and Discomforts (CPPD)  Dysmenorrhea  Pelvic pain/cramping associated with menses  Perimenstrual physical discomforts  Other physical discomforts that begin around time of menses and resolve after menses begin  Perimenstrual mood discomforts  Psychological discomforts that begin around time of menses and resolve after menses begin

6. Potential Etiologies  Biological basis  Increased prostaglandins => pain  Hormonal imbalances  Causes not clear or supported in the literature  Genetics and/or environmental basis  Individual genetic differences  Interaction of biology, genetics, and environment  Abnormal responses to normal physiologic changes  Psychosocial/sociocultural basis  Increased stressors, stress responses, and vulnerability

7. Dysmenorrhea  Primary dysmenorrhea is a diagnosis of exclusion  No other identifiable cause for pain  Begins shortly after start of menses  Suspected prostaglandin increase by endometrium  Secondary dysmenorrhea is related to another etiology  Dyspareunia  Dysuria  Infertility  Endometriosis  Fibroids  Abnormal uterine bleeding

8. Dysmenorrhea  Potentially significant decrease in quality of life  Loss of time at work/school  Health care provider visits  Expenses for OTC medications  Most common with young women (teens – 20’s)  Symptoms can be disabling for some (10-20%)

9. Premenstrual Syndrome (PMS)  Distinct pattern of symptoms occurring before menses (within 7 days) and lasting through first days of menses, with little to no symptoms after menses end (during luteal phase)  Recurrence of symptoms that influence functioning at work, school, or in life (relationships)  Includes physical, mood, and behavioral symptoms

10. Premenstrual Magnification (PMM)  Exacerbation of somatic and mood symptoms/conditions during the late luteal or menstrual phases  Anxiety or depressive disorders  Migraines  Seizure disorders  Irritable bowel syndrome  Asthma  Chronic fatigue  Considered a dual diagnosis – originating condition with premenstrual magnification

11. Premenstrual Dysphoric Disorder (PMDD)  A cluster of severe perimenstrual symptoms including at least one affective symptom  Directed towards mood/behavioral changes  DSM IV diagnosis  CONTROVERSIAL!  Has to be severe in symptoms and influencing life, work, relationships to be diagnosed

12. Approach for Management  Consider all potential etiologies  Biologic causes  Social, personal changes that affect health  Environmental factors  Goals  Personalized and individual  Reduction in symptoms  Improved quality of life

13. Focused Health History  Menstrual history  Menarche  Cycle length, regularity  Menses length  Menses bleeding quality/amount

14. Focused Health History  Symptom exploration  Timing of symptoms during menstrual cycle  Luteal, pre-menstrual, menstrual, follicular phases  Severity, quality of symptoms  Identification of symptom clusters  Calendar/diary of symptoms

15. Focused Health History  Medical history  Co-occurring conditions  Pregnancy history  Focused family history  Related to menses/PMS  Medications  Contraception or hormones?  Allergies  Social history/health behaviors

16. Focused Physical Exam  Abdominal exam  Assess CVA tenderness  Pelvic exam  Speculum if indicated  Bimanual exam  Laboratory studies  To test for co-occurring conditions  Anemia, thyroid, diabetes, hypoglycemia, etc

17. Differential Diagnosis  Cyclic pelvic pain and discomforts (CPPD)  Dysmenorrhea  PMS  PMM  PMDD  Non-cyclic pelvic/abdominal pain  Mild, moderate, severe symptoms  Dual diagnoses

18. Plan of Care  Setting goals  Individualized  Evidence-based  Feasibility of desired outcome  Acceptability to client  Capability of provider (you) to provide service

19. Plan of Care  Cyclic pain and discomforts  Over-the-counter (OTC) medications  Acetaminophen  Ibuprofen  Naproxen  Hormonal contraception  Oral contraceptives  Progestin IUD  Supplements  Calcium, magnesium, vit E, vit B1, essential fatty acids

20. Plan of Care  Cyclic pain and discomforts  Nutrition (low-fat, high vegetable, hydration)  Exercise  Heat application  Massage/chiropractic therapy  Acupuncture/Chinese medicine  Acupressure

21. Plan of Care  Mood discomforts  Supplements (calcium, vitamin D)  Massage  Behavioral relaxation (breathing, stretching)  Cognitive relaxation (meditation, biofeedback)  Environmental modification  Stress reduction  Nutrition/exercise  Acupuncture/Chinese medicine  Homeopathy

22. Plan of Care  Severe PMS/PMDD  Anti-depressants (during luteal phase or continually)  SSRIs shown to reduce symptoms 40-55%  Need to consider side effects  Anti-anxiolytics  Mixed evidence  Should be used with other modalities  Hormonal therapy  Micronized progesterone (mixed evidence)  Oral contraceptives (mixed evidence)

23. Other modalities  Light therapy  Association with seasonal affective symptoms  Traditional Chinese medicine/acupuncture  Herbal remedies  Vitex (chaste tree berry) (level 1 evidence)  Crampbark  Evening primrose oil

24. Questions?