1. Dysmenorrhea and PMS Patricia Crowley TCD Department of Obstetrics and Gynaecology

2. Primary Spasmodic Dysmenorrhea Painful menstruation without underlying pathology Commonest in teens/early twenties Onset 1 or more years after menarche Associated vomiting and faintness

3. Secondary Dysmenorrhea Painful menses secondary to pathology Pain may begin before bleeding and may last for entire duration Commoner 30s and 40s

4. Secondary Dysmenorrhea Endometriosis Fibroids Adenomyosis Pelvic Inflammatory Disease Uterine anomalies

9. History Taking Timing Severity Disruption in life-style Previous gynae history Contraceptive needs Wish for fertility

10. Examination Vaginal exam not essential in young female with ? Primary dysmenorrhea Vagina -?septum/ tenderness in POD Uterus- size / mobility/ position/tenderness Adnexa –tenderness/ enlargement

11. Investigations Transabdominal ultrasound with full bladder Transvaginal ultrasound –increased sensitivity Laparoscopy –gold standard for endometriosis Risks versus benefits

12. Management Primary Spasmodic Dysmenorrhea Education Prostaglandin synthetase inhibitors Combined oral contraceptive pill-choose a progestagen dominant pill “Bicycle” or “Tricycle” pill Failure to respond to Pill increases likelihood of underlying pathology

13. Premenstrual Syndrome Physiological premenstrual change All but 5% of females experience one or more symptom

14. Symptoms Physical –bloating/breast tenderness/headache Psychological-agression/agitation/crying bouts/depression/irritability

15. Measurement and Diagnosis Cyclical symptoms –character, timing, severity Degree of underlying psychological dysfunction Degree of disruption of lifestyle Usually self documented using diary/calendar

16. Aetiology No measurable abnormality in female sex hormones or prolactin Oophorectomy abolishes symptoms Cyclical HRT reproduces symptoms ? Abnormal endorphins ? Change in serotonin metabolism

17. Dimmock et al Lancet 2000 Treatment 15 RCTs SSRIs vs placebo SSRIs improve physical and psychological symptoms Both intermittent and continuous therapy beneficial

18. Treatment Temporary or permanent abolition of hormonal cycle GnRH analogue Hysterectomy and Oophorectomy Progesterone/progestagens shown to be ineffective