1. Dysmenorrhea and PMS Nazila Karamy-MD Obstetric and Gynecology Specialist www.doctorkaramy.ir

2. Primary Dysmenorrhea Painful menstruation without underlying pathology Commonest in teens(13-19),early twenties Onset 1 or Max 2 years after menarche(cos of it occurs only in ovulation cycle tht it happens 1 year after menarche) If it occurs 2 y after menarch almost always it’s not primary dysmenorhea

3. Clinical characteristics pain:happaens with mense onset it takes long Max 2-3 days The kind:colic or cramp Location:usually :Midline in suprapubic, sth in back,flunk,thigh Associated: vomiting and faintness,loss of appetite,diarhea,headache Reduce with increasing age @after NVD

4. Etiology (primary dysmenorhea) Decrease of progestrone in the end of luteal phase(near to next mense)=>lysosome rupture => phospholipase A2 + => Increase PG E2,PF2@=>Contraction of uterus,vasoconstrictor

5. Secondary Dysmenorrhea Painful menses secondary to pathology Onset =>always after 20 y Pain may begin before bleeding and may last for entire duration Commoner 30s and 40s

6. Secondary Dysmenorrhea Endometriosis Polyp(source=>endometer) Fibroidce (source=>myometer) Pelvic Inflammatory Disease(PID) Uterine anomalies(Bicorn uterus,...) Ovarian cysts @tumors

10. History Taking so according tht treat Timing Severity Disruption in life-style Previous gynae history Contraceptive needs Wish for fertility

11. Examination Vaginal exam not essential in young female with ? Primary dysmenorrhea Vagina ?septum/ tenderness in BME Uterus? size / mobility/ position/tenderness Adnexa ?tenderness/ enlargement

12. Investigations Transabdominal ultrasound with full bladder Transvaginal ultrasound –increased sensitivity Laparoscopy –gold standard for endometriosis Risks versus benefits @U CAN’T FIND ANY PATHOLOGY

13. Management Primary Spasmodic Dysmenorrhea Education esp husband Nutrition:decrease taking sweet,fatty,alchohol,coffeine,choclate,salt,red meat Increase sea food,vegetable,fruit Exercise:aerobic(Min 30 minutes, 4times/weeks Calcium supplement=>decrease mood disorders

14. MEDICAL THERAPY Prostaglandin synthetase inhibitors(NSAIDS)=>Mefenamic acid or Ibuprofen(Advil) taking regular from first day till 3 days(No need taking before mestural cycle)

15. Combined oral contraceptive pill-choose a progestagen dominant pill Such as Tricycle” pill IN RESISTANT CASES: Presacral neurectomy hystrectomy

16. In Failure to respond to Pill=>> Regard secondary dysmenorhea increases likelihood of underlying pathology tht treatment is due to the patology

17. PMS (Premenstrual Syndrome) Physiological premenstrual change About 95% of females experience one or more symptom

18. Symptoms Physical :bloating/breast tenderness/headache/flushing Psychological:agression/agitation/crying bouts/depression/irritability

19. Etiology PMS exists only in ovulation cycle SO it’s not in menapause,oophorectomy,non ovulatory cycles It happens in luteal phase not in follicular phase

20. Etiology SO Endocrine changes =>decrease endocrine,serotonin in PG metabolism, IN LUTEAL PHASE,change

21. Treatment Control nutrition @exercise as dysmenorhea Psychologic treatment by relaxation or medical therapy if needed SSRI inhibitors:Floxetin( both continuous,intermittant are effective) Nortriptilin in severe deppression)(25 mg /day through the cycle) Alprazolam in severe anxiety

22. Bromocriptin in breast congestion (2.5 mg from the Day 10 to 26 of the cycle) In severe breast congestion =>danazole is OK Spirinolactone in severe weight gain,edema,abdomen bloating

23. If no response to usual Treatment??? Temporary or permanent abolition of ovulation by: GnRH analogue plus Add back regimen OCP,High dose of progestrone (Depo provera 150 mg every 3 months) Hysterectomy and Oophorectomy if not response to other treatment @not want to be pregnant