1. Dysmenorrhoea
Dr.
AHMED JASIM
A. PROF

2. Dysmenorrhoea
Is defined as painful menstruation and it is very common complaint.
Dysmenorrhoea can be classified as:
1. primary Dysmenorrhoea (primary spasmodic)(is the commoner type).
2. Secondary Dysmenorrhoea (congestive, acquired).

3. Primary dysmenorrhoea

4. Primary dysmenorrhoea
Presence of painful menstruation where there is no underlying pathology.
The prevalence of dysmenorrhoea is high. 72% of women reported dysmenorrhoea in their life.

5. Primary dysmenorrhea Aetiology:
There are a number of factors that may have an aetiological role.
1. Endocrine:
Ovulatory cycle are necessary for development of primary dysmenorrhoea.
2. Abnormal uterine activity
Primary dysmenorrhoea is associated with uterine hypercontractility and a high resting tone between contractions which may be mediated by increased
Prostaglandin levels or vasopressin.
3. Psychological:
It is unlikely but it may influence individual perception to painful stimuli.

6. Diagnosis:
Diagnosis is usually based on history and normal findings on clinical examination.

7. History:
It is usually occurs in girls or young women. It appears 6–12 months after the menarche when ovulatory cycles begin to become established (The early cycles after the menarche are usually anovular and tend to be painless).
The pain usually begins just prior to, or on the first day of the period. It lasts for several hours or continuo throughout the first and second day.
It is usually described as a colicky (spasmodic, crampy) lower abdominal pain and intense in suprapubic region associated with backache radiated to lower limb and there may be associated gastrointestinal disturbances such as diarrhoea and vomiting and other symptoms such as nausea, fatigue, and headache. Severe pain occur in small number of women and leads to absence from work or education.

8. Primary dysmenorrhea
If symptoms are typical of primary dysmenorrhoea, a therapeutic trial may be embarked on before considering any examination and investigation especially in adolescents.

9. Primary dysmenorrhea Examination:
General examination : no abnormal finding.
Abdominal examination: no abnormal finding
pelvic examination in married patient : no abnormal finding.

10. Investigation: Investigation requested in these condition:
1. When clinical evaluation raises strong suspicion of underlying pathology.
2. When symptoms of primary dysmenorrhoea are not alleviated by
combined oral contraceptive pills and / or NSAID therapy.
Investigation by ultrasound examination or magnetic resonance imaging (MRI) or laparoscopy or hysteroscopy according to history and differential diagnosis as no need to do all investigation in most of cases.

11. Primary dysmenorrhea treatment
A. Reassurance and explanation.
B. Using heating pads or taking a warm bath may help to decrease pain.

12. C. Medical treatment: Ant prostaglandins (NSAIDs): non-steroidal anti-inflammatory drugs
1. Acts via their suppression of menstrual fluid prostaglandins.
NSAIDs drugs such as ibuprofen (400mg every 6hours), mefenamic acid (500 mg every 8 hours), naproxen 250mg every 6 hours), and aspirin are all effective. Ibuprofen is the preferred analgesic because of its favorable efficacy and safety profiles.

13. (NSAIDs):
They are usually taken during the first few days of menstruation. The advantage of starting treatment at the onset of menstruation is that it prevents the patient treating herself when she is unknowingly pregnant which would only become apparent when a period is missed.

14. THE COMBINED ORAL CONTRACEPTIVE PILL
It is given especially when fertility control (contraception) is required.
They are thought to act by inhibiting ovulation and decreasing endometrial production of prostaglandins and leukotrienes by inducing endometrial atrophy and therefore reducing the amount of endometrial tissue available to produce these mediators. Extended cycle use minimize the number of withdrawal bleeding episodes.

15. THE COMBINED ORAL CONTRACEPTIVE PILL
Extended cycle oral contraceptive (Seasonale) is a 91-day oral contraceptive. Tablets containing the active hormones are taken for 12 weeks (84 days), followed by 1 week (7 days) of placebo tablets. it is particularly useful for women who experience symptoms associated with the withdrawal bleed such as severe dysmenorrhoea.
3. Combination of both NSAIDs and Combined oral contraceptive pill.

16. Combination of both
Combination of both NSAIDs and Combined oral contraceptive pill

17. 4. progestins
a. Medicated intrauterine device (levonorgestrel intrauterine system (LNG-IUS) (Mirena)):
effective treatment for women who have a contraindication to either NSAIDs or the combined oral contraceptive.

18. b. medroxy progesterone acetate Depot (Depo-Provera) 150 mg Intra-Muscular (I.m.) every 12 weeks.
Clinically they are effective since they render most women amenorrhoeic.

19. desogestrel
new progestogen only contraceptive pills. It effectively inhibit ovulation and relieve symptoms of dysmenorrhoea.

20. other drugs under evaluation or clinical trial studies used are:
a. vasopressin receptor antagonist:
b. Tocolytics agent:
can reduce uterine contractility and thus are potentially effective.
These are:
a. Beta-adrenergic agonists
b. calcium channel blockers
c. Transdermal glyceryl trinitrate has also been evaluated
d. vitamin E
e. omega-3 polyunsaturated fatty acids beneficial in the management of dysmenorrhoea in adolescents.

21. D. Other measures:
Psychotherapy.
Hypnotherapy.
Transcutanous nerve stimulation (acupuncture).

22. Surgery:
E. Surgery:
It may provide long term relief and used rarely in patients resistant to drug therapy.
ablation of uterine nerve.
presacral neurectomy.

23. Secondary dysmeonrrhoea
Presence of painful menstruation in the presence of an identifiable pathologic cause .

24. It is usually due to one of following:
Endometriosis.
Adenomyosis.
Pelvic inflammatory disease (PID).
Asherman's syndrome (intrauterine adhesions).
Cervical stenosis (may result from conization).
Acquired fixed retroversion of uterus.
Uterine fibroids.

28. Management:
It is easily diagnosed from history.

29. History Secondary dysmenorrhoea is easily diagnosed from history.
It develops in older women (in their 30s or 40s). it may appear after some years of painless menstruation.
The pain is often more severe prior to menstruation. The pain begins a few days prior to menstruation and continuo throughout the period and even after the menses. It is less related to the first day of flow. The pain is often a dull ache felt in lower abdomen and back and sometimes extending to the thighs.
It is usually associated with dysparunia, infertility, abnormal uterine bleeding.

30. Clinical examination may not determine cause.

31. Investigations:
May help to identify cause and choosing it according to case:
*Pelvic ultrasound show ovarian endometriosis and fixity of ovaries in PID.
*Hysterosalpingogram useful to identify intrauterine adhesion.
*Microbilogical cultures:
From endocervix, peritoneal fluid if PID is suspected.
*Laproscop

32. Treatment:
*Treatment of underlying cause (discussed in other lectures).
*Treatment used of primary dysmenorrhoea are often helpful.
*In patient with intractable dysmenorrhea , hysterectomy with bilateral
oopherectomy may be needed.