1. Dysmenorrhea and Pre-menstrual syndrome (PMS)

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

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

4. Secondary Dysmenorrhea EndometriosisEndometriosis FibroidsFibroids AdenomyosisAdenomyosis Pelvic Inflammatory DiseasePelvic Inflammatory Disease Uterine anomaliesUterine anomalies

5. Nerves around Uterus, Cervix and Ovaries

7. Nerve around Endometriosis (in peritoneum, not in endometrioma) Peritoneal endometriosis innervated by sensory Aδ & C, cholinergic & adrenergic nerve fibers (IHC study) (Tokushige et al, Hum Reprod, 2006) Nerve fibers not found in ovarian endometrioma (IHC study) (Al-Fozan et al, Fertil Steril, 2004)

8. Deep Infiltrating Rectovaginal Endometriosis

12. Bicornuate uterus Hematosalpinx Hematocolpos Cervical orifices Vaginal Stenosis Vagina

13. History Taking TimingTiming SeveritySeverity Disruption in life-styleDisruption in life-style Previous gyn historyPrevious gyn history Contraceptive needsContraceptive needs Wish for fertilityWish for fertility

14. Examination Vaginal exam not essential in young female with Primary dysmenorrheaVaginal exam not essential in young female with Primary dysmenorrhea Vagina -septum/ tendernessVagina -septum/ tenderness Uterus- size / mobility/ position/tendernessUterus- size / mobility/ position/tenderness Adnexa – tenderness/ enlargementAdnexa – tenderness/ enlargement

15. Investigations Transabdominal ultrasound with full bladderTransabdominal ultrasound with full bladder Transvaginal ultrasound – increased sensitivityTransvaginal ultrasound – increased sensitivity Laparoscopy – gold standard for endometriosisLaparoscopy – gold standard for endometriosis Risks versus benefitsRisks versus benefits

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

17. Adolescent Endometriosis 症狀 : Dysmenorrhea, acyclic pain (or both), dyspareunia, G-I pain 診斷：超音波 ( 不必然要內 診，測 serum CA-125?) 藥物治療 : OCP, NSAID 。無 效則腹腔鏡手術 病灶 : (1) 外觀 : clear, red and white 。 (2) 80% 屬 minimal to mild stage 術後 : GnRH-a (!), add-back 長期追蹤 (ACOG, committee opinion, 2005)

18. Premenstrual Syndrome Physiological premenstrual changePhysiological premenstrual change All but 3-5% of ovulating females experience one or more symptomAll but 3-5% of ovulating females experience one or more symptom Remitting completely inn the postmenstrual week (Berek & Novak ’ s Gynecology)Remitting completely inn the postmenstrual week (Berek & Novak ’ s Gynecology)

19. Symptoms Physical – bloating/breast tenderness/headachePhysical – bloating/breast tenderness/headache Psychological-aggression/agitation/crying bouts/depression/irritabilityPsychological-aggression/agitation/crying bouts/depression/irritability Depressed mood, hopelessness, self-deprecation Anxiety, tension Affective liability Anger, irritability, interpersonal conflict Decreased interest in usual activities Difficulty concentrating Decreased energy Appetite changes or cravings Changes in sleep Feeling overwhelmed or out of control Physical symptoms such as breast tenderness, headache, bloating

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

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

22. Treatment 15 RCTs SSRIs vs placebo15 RCTs SSRIs vs placebo SSRIs improve physical and psychological symptomsSSRIs improve physical and psychological symptoms Both intermittent and continuous therapy beneficialBoth intermittent and continuous therapy beneficial ( (Dimmock et al Lancet 2000) Lifestyle modification: (some benefits for some women)Lifestyle modification: (some benefits for some women) Elimination of caffeine from the diet Elimination of caffeine from the diet Smoking cessation Smoking cessation Regular exercise Regular exercise Regular meals and a nutritious diet Regular meals and a nutritious diet Adequate sleep Adequate sleep Stress reduction Stress reduction

23. Treatment Temporary or permanent abolition of hormonal cycleTemporary or permanent abolition of hormonal cycle GnRH analogueGnRH analogue Hysterectomy and OophorectomyHysterectomy and Oophorectomy Progesterone/progestagens shown to be ineffectiveProgesterone/progestagens shown to be ineffective

24. Non-contraceptive Benefits of Oral Contraceptive Pills Dysmenorrhea Mittelschmerz Metrorrhagia Premenstrual syndrome Hirsutism Ovarian and endometrial cancer Functional ovarian cysts Benign breast cysts Ectopic pregnancy Acne EndometriosisDysmenorrhea Mittelschmerz Metrorrhagia Premenstrual syndrome Hirsutism Ovarian and endometrial cancer Functional ovarian cysts Benign breast cysts Ectopic pregnancy Acne Endometriosis AmenorrheaAmenorrhea Dual suppression in IVF programDual suppression in IVF program

25. 成份： Estrogen & Progestin Low-dose : ＜ 30~35μg EE Higher dose: 50 μg EE

26. World Health Organization Precautions for the Use of OCs ( 世界衛生組織對使用避孕藥的提醒 ) Category 4 (refrain from use) Venous thromboembolism* Cerebrovascular or coronary artery disease* Structural heart disease Diabetes with complications Breast cancer* Pregnancy* Lactation ( 35 years and smoke 20 cigarettes or more per day Hypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease)Category 4 (refrain from use) Venous thromboembolism* Cerebrovascular or coronary artery disease* Structural heart disease Diabetes with complications Breast cancer* Pregnancy* Lactation ( 35 years and smoke 20 cigarettes or more per day Hypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease) Category 3 (exercise caution) Postpartum 35 years and smoke fewer than 20 cigarettes per day History of breast cancer but no recurrence in past 5 years Interacting drugs Gallbladder diseaseCategory 3 (exercise caution) Postpartum 35 years and smoke fewer than 20 cigarettes per day History of breast cancer but no recurrence in past 5 years Interacting drugs Gallbladder disease Category 2 (advantages outweigh risks)Category 2 (advantages outweigh risks) Category 1 (no restrictions)Category 1 (no restrictions)

27. 謝謝 高雄長庚醫院婦產部, 2008