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*Module 6 - ppt 5 Dr. Maysoon Al-Amoud

Module 6 - ppt 5 Dr. Maysoon Al-Amoud

Dysmenorrhea

PO Box 27121 Riyadh 11417Tel: 4912326 Fax: 4970847Introduction to Primary Carea course of the Center of Post Graduate Studies in FM


ObjectivesGeneral considerations.Classification of dysmenorrheaCauses of dysmenorrhea Clinical picture of dysmenorrheaManagement of dysmenorrhea

*Module 6 - ppt 5 Dr. Maysoon Al-Amoud


Introduction*Module 6 - ppt 5 Dr. Maysoon Al-AmoudDysmenorrhoea - painful menstruation- is one of the most common gynaecologic problems seen by the family physician. It affects 50% of all women and between 20% & 90% of all adolescent women. ~ 1% of all adult & 15% of adolescent women describe their dysmenorrhoea as severe. It is the leading cause of morbidity in female high school students, resulting in absence from school and nonparticipation in sports.


Classification *Module 6 - ppt 5 Dr. Maysoon Al-AmoudPrimary : The presence of painful menses in the absence of disease Secondary : The occurrence of painful menstruation caused by pelvic disease.


Risk factors of dysmenorrheaAge < 20 yearsAttempts to lose weightDepression/AnxietyHeavy mensesNulliparitySmokingDisruption of social network


*Module 6 - ppt 5 Dr. Maysoon Al-Amoud No underlying pelvic pathology. Caused by release of prostaglandin F2 from tendometrium at time of ovulatory menstruation uterine hypercontactility .Ischemia of uterine wall during a contraction causes pain.Causes of dysmenorrhoea Primary dysmenorrhea


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudProstaglandins induce smooth muscle contraction in the uterus, as well as in intestine, bronchi, & vasculature, Account for the systemic symptoms of diarrhea, asthma exacerbation, hypertension, & headache experienced by women with 1o dysmenorrhea. As contractions cause the pressure within uterus to exceed that of the systemic circulation, ischemia ensues, causing an anginal epuivalent in uterus. Primary dysmenorrhea ... continueCauses of dysmenorrhoea


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudUnderlying pelvic pathology with variable severity : Adenomyosis, myomas, polyps, Infections chronic pelvic, endometriosis, Tumors, dhesions, leiomyomas, Intrauterine devices, Anatomic causes, Bladder pathology & GI pathologyPsychosexual problemsBlind uterine horn(rare). Secondary dysmenorrhea Causes of dysmenorrhoea


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudClinical findings Symptoms: History of : Pain at menses onset for 12-72 hrsPain is : crampy & intermittent in naturePain most intense in lower abdomen, to back or upper thighs.Headache, nausea, vomiting, diarrhea & fatigueWorst on 1st day of menses then gradually resolveOnset: gradual with 1st yr then worsen as menses become regular.If 2ry: onset >20 yrs old, for 5-7 ds & worsen progressively. pelvic pain not with menses.


Painful MenstruationDysmenorrheaSpasmodicCyclic Radiate to back, inner aspect of thighs


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudClinical findings Physical examination: Pelvic examination + cervical smear pain not with menses & culture should be for all married pts presenting with a chief complaint of dysmenorrheaIf find cul-de-sac induration & uterosacal ligament nodularity on pelvic examination endometriosis.Uterine abnormalities or tenderness raise index of suspicion for underlying pathology as a cause.


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudManagementMedical therapyPhysical modalitiesAlternative & complementary therapyBehavioral modificationSurgical intervention


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudMedical therapy Drug groups:NSAIDs diclofenac, ibuprofen,Danzol LeuprolideDepo-methroxyprogesteron-terone acetateCC :oral & intravaginalCOX-2 inhibitorsLevonorgestrel IUDNifedipineTransdermal CC patchAim: endometrial prostaglandin production; CC


Inhibition of ovulationDesire contraceptionNo relief or cannot tolerate NSAIDsNo contraindication

Oral Contraceptive PillsOCsMinipillDMPAGnRHa


Agents used in the treatment of dysmenorrhea


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudPhysical modalities Utilize :Heat Acupuncture or acupressureSpinal manipulationA heated abdominal patch was demonstrated to have efficacy similar to ibuprofen (400 mg) quicker - not greater relief of heat + ibuprofen Acupuncture : in91% relief as compared 36% of control.


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudAlternative & complementary therapy Numerous supplements & herbal formulations. Few are backed by solid evidence.Example:Vitamin E 200mg units bd daily, beginning 2 days before menses & continuing through 1st 3 days of bleeding shorter duration & lower intensity of pain than in placebo.


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudBehavioral modification Life-style: strenuous Ex. & caffeine intake can modulate prostaglandin-induced uterine contractions. Strenuous Ex. : uterine tone uterine angina periods + prostaglandins ...... strenuous Ex. In 1st few days of menses dysmenorrhea.Caffeine : controversial effect, it uterine tone by uterine cyclic adenosine monophosphote level.


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudSurgical intervention Continues to have significant dysmenorrhea + preceding treatment testing for secondary dysmenorrhea .Chronic pelvic pain not responding to supportive therapy adhesions, endometriosis or chronic PID discovered on diagnostic laparoscopy.Hysterectomy is an option for refractory 1o amenorrhea.


*Module 6 - ppt 5 Dr. Maysoon Al-AmoudTreatment at PHC centres primary dysmenorrhea: try previously mentioned methods.

Secondary dysmenorrhea: refer to investigate (e.g. laparoscopy) & treat underlying causeHave patience and empathy.


Tips for general practitioners

Adolescents are unlikely to have underlying disease and so do not usually require a pelvic examination First line treatment for dysmenorrhoea should be oral contraceptives and/or non-steroidal anti-inflammatory drugs Specialist referral is indicated if oral contraceptives and non-steroidal anti-inflammatory drugs fail The levonorgestrel intrauterine system is useful in managing secondary dysmenorrhoea


When to referReferral for laparoscopy is indicated if initial measures, such as oral contraceptives and NSAIDs, have not improved symptoms. Referral is also indicated if secondary dysmenorrhoea is suspected (for example, associated menstrual symptoms Menorrhagia, Intermenstrual or postcoital bleeding DyspareuniaAbnormal pelvic examinationIf the patient has pain management problems with disruption to daily living.


Summary

Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreatedSimple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of womenOral contraceptives can be considered for women who wish to avoid pregnancyFor women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective


Thank youDr. Maysoon Al-Amoud*Module 6 - ppt 5 Dr. Maysoon Al-Amoud


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