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DYSMENORRHEADYSMENORRHEADYSMENORRHEADYSMENORRHEA
SALWA NEYAZISALWA NEYAZICOSULTANT OBSTETRICIAN GYNECOLOGISTCOSULTANT OBSTETRICIAN GYNECOLOGIST
PEDIATRIC & ADOLESCENT GYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGIST
DYSMENORRHEA
WHAT IS DYSMENORRHEA? Painful menstruation
WHAT IS ITS INCIDENCE? 50-75 %
WHAT ARE THE TWO MAIN CATEGORIES? 1- Primary painful menstruation without
associated pelvic disease 2-Secndary painful menstruation caused by pelvic pathology
DYSMENORRHEAHOW TO EVALUATE A PATIENT WITH
DYSMENORRHEA? 1-History 2-Physical examination should be completely
Normal in Pt with 1ry dysmen, however if evaluated during the pain uterus & cx will be mildly tender 3-Investigations not required if Hx & physical examination are consistent with 1ry dysm
*U/S Allow the physician to *HSG confirm presence or *Laparoscopy absence of pelvic disease *Hystroscopy *D&c
PRIMARY DYSMENORRHEA
Usually begins few hrs before or with the onset of menstruation then gradually decrease
+ve family HxThe pain is crampy/ colicky , in the lower abdomen
most intense in the midline lasts for 12-72 hrStarted with ovulatory cycles 6-12 M after menarcheAssociated symptoms
-Back pain & pain in the upper thighs 60% -Nausea /vomitting 90% -Diarrhea 60% -Fatigue / malaise 85% -Headache (tension or migraine) 45% -Dizziness, nervousness, fainting in sever cases
1ry DYSMENORRHEA
WHAT IS THE CAUSE OF 1RY DYSMEN ?
-Prostaglandin (PG F2α) release from endometrial cells uterine smooth muscle contraction, increased intra
uterine pressure & some degree of uterine ischemia
-PG production ↑ during the 1st 48-72 hrs of menses
-PG may also cause hypersensitization of pain terminals
to physical & chemical stimuli
-Behavioral,cultural & psychological factors influence
the Pt reaction to pain
1ry DYSMENORRHEA
WHAT IS THE TREATMENT OF 1RY DYSMEN?
1-NSAID 1st line 80% effective *Propionic a derivatives Ibuprofen Naproxen *Fenamates Mefenamic acid “Ponstan”
2-ORAL CONTRACEPTIVES 90% effective If NSAID are not effective or contraindicated
3-FOLLOW UP Some Pt may require combining both drugs Consider 2ry Dysm if no improvement with therapy
1ry DYSMENORRHEA
WHAT IS THE MECHANISM OF ACTION OF THESE DRUGS? 1- NSAID Inhibits prostaglandin production Antagonistic action at the receptor “Ponstan” Should be used with the start of pain regularly for 2- 3 days 2- ORAL CONTRACEPTIVES endometrial thickness PG through inhibition of ovulation & change the hormonal status to that of the early proliferative phase (which has the lowest level of PG)
1ry DYSMENORRHEA
WHAT ARE THE SIDE EFFECTS OF NSAID?Gastric irritationNauseaGIT ulceration↑ Bleeding timeNephrotoxicityFenamates blurred vision, headache &
dizzinessBronchospasm in Pt with bronchial asthma Hypersensitivity reaction Autoimmune hemolytic anemia
TREATMENT OF 1RY DYSMENORRHEA
WHAT CAN BE DONE TO IMPROVE THE EFFECTIVNESS OF NSAID?
-Changing the type of inhibitor -Starting the medication 24 hrs before the onset of cramps & continued for 2-3 days after the flow has started
WHAT ELSE MAY BE HELPFUL TO IMPROVE 1RY DYSMENORRHEA ? -To continue normal activities -Gentle abdominal massage -Local heat - Regular exercise -Avoid stress, lack of sleep & caffeine
1ry DYSMENORRHEA
HOW TO MANAGE A PT WHO CONTINUES TO HAVE PROBLEM ?Investigations to R/O 2ry dysmenorrheaIf results are normal
- Codeine may be helpful under close supervision to avoid
addiction -Acupuncture
2RY DYSMENORRHEA
Hx -Older patients with onset of symptoms several years after menarche -Recurrent pelvic infections -IUCD -Recent pelvic surgery -Heavy periods -Irregular cycles
Physical examination May help in Dx by finding abnormalities that point to a pelvic disease
CAUSES OF 2RY DYSMENORRHEA
EndometriosisEndometritisAdhesionsMullerian anomaliesAdenomyosisEndometrial polypSubmucous fibroidCx stenosisPelvic congestionConditioned behavior
Stress & tension
2RY DYSMENORRHEA
HOW TO EVALUATE PT WITH 2RY DYSMEN ?CBC ESRCultures for stdU/SHSG if intruterine scarring or fibroid is
suspectedLaparoscopyHysteroscopyD&C
TREATMENT OF 2RY DYSMENORRHEA Treat the cause
2RY DYSMENORRHEACX STENOSIS
Cx stenosis ↑ Intrauterine pressure during menses Retrograde menstruation
endometriosisCx stenosis
-Congenital -2ry to cervical injury *electrocautery *cryocautery *conization *infection
Scanty menstrual flow & sever cramping through out the menstrual cycle
CX STENOSIS
Dx Internal os scarred & impossible to pass uterine sound or even very thin probe
Rx -D&C -The problem frequently recurs repeat procedure -Vaginal delivery afford morelasting cure
Pt with large endocervical polyp will have the same
presentation
ENDOMETRIOSISEndometriosis Ectopic endometrial tissueAdenomyosis Endometrial tissue in the myometriumHx Sever dysmenorrhea
Infertility Dysparunea
Pelvic examination Evidence of endometriosis in vagina
or cx Tenderness Thickening / nodules of rectovaginal septum or uterosacral ligament Ovarian (chocolate) cyst
ENDOMETRIOSIS
Dx -Laparoscopy or laparotomy -Direct biopsy of vaginal or cx lesion
Rx To supress menstruation by medication Cauterization of endometriotic spots Analgesics
PELVIC INFECTION & ADHESIONS
PID & Pelvic abscess adhesions pelvic painHx Acute episodes of pain begins with menses
& continues Pain may involve the entire abdomen
Examination -Sever tenderness on palpation of the uterus & cx motion (cx excitation) -Purulent cx discharge
Associated findings -Fever -↑↑ WBC & ESR
PELVIC INFECTION & ADHESIONS
Infections due to other conditions such as Appendicitis & IUCD Create similar responsePain due congestion, edema & adhesions due to the inflammatory process Rx Appropriate antibiotics
Surgical release of adhesions TAH BSO
PELVIC CONGESTION SYNDROME
Engorgement of the pelvic vasculaturePain Burning or throbbing
Worse at night Worse after standing for a long time
Examination Vasocongestion of the vagina & cx Uterine enlargement & tenderness
Dx Laparoscopy Congestion of the uterus Varicosities of broad ligament & pelvic
side wall veins
Rx Medroxyprogestrone acetate TAH BSO
PMS
WHAT IS PMS ?A group of physical, emotional & behavioral symptoms that occur in the 2nd half (luteal phase) of the menstrual cycle often interfere with work & personal relationships followed by a period entirely free of symptoms starting with menstruation
WHAT THE INCIDENCE OF PMS ?40% Significantly affected at one time or another2-3% Sever symptoms with impact on their work & lifestyle
5% by the American psychiatric association definition
PMS
WHAT SYMPTOMS ARE ASSOCIATED WITH PMS?PHYSICAL SYMPTOMS
-Bloated feeling -Wt gain -Breast pain & tenderness -Skin disorders “acne” -Hot flushes -Headache -Pelvic pain -Changes in bowel habits -Joint or muscle pain -edema
EMOTIONAL / PSYCHOLOGIC SYMPTOMS OF PMS
IrritabilityAggressionTensionAnxietyDepression / interest in the usual activitiesLethargyInsomnia or hypersomniaChange in appetite overeating or food cravingCryingChange in lipidoThirst
Loss of concentrationPoor coordination, Clumsiness, accidents
ETIOLOGYDO WE KNOW WHAT CAUSES PMS ?
No, many theories have been postulated, most of them have to-do with various hormonal alterationsVit B6 deficiency Multifactorial psychoendocrine disorederAlterations in the serotoninergic neuronal mechanism in the CNS (serotonin deficiency)Ovulation / progestrone production are important in this syndrome Drugs that inhibit ovulation
relief of PMS symptomsAntiprogestrone RU486 No relief
ETIOLOGYAbnormal response of the CNS to the normal
fluctuations of estrogen & progestrone during the menstrual cycle
Administration of estrogen & progestrone to women with PMS whose ovaries were suppressed
with GnRH agonist analogues development of
PMS symptoms
BIOPYCHOSOCIAL MODEL
Hormonal changes of the luteal phase of the menstrual cycle, that is the ↑↑ estradiol & progestrone act as a trigger to stimulate the development of PMS symptoms in women who are biologically, socially & psychologically predisposed
to develop PMS Biological explanation abnormal response of the CNS to the hormonal changes could be related to serotonin or γ-aminobutyric acid Social explanation mimicking the behavior of other important females in her life, social expectations or pressure from others
Psychological explanation rejection of the female role or that PMS could be a
variation of other common affective disorder
EVALUATION Pt should keep a diary of her symptoms through-
out 2-3 menstrual cycles then the physician should review these symptoms with the Pt to determine what seems to be causing her the most difficulty
Complete Hx & physical examination to R/O any medical problem
DXDIAGNOSTIC CRITERIA FOR THE PMDD
(PreMenstrual Dysphoric Disorder) in the Diagnostic Statistical Manual for Mental Disorders Requires 5 of the following
-Depressed mode -Anexiety -Labile mode -Irritability -Change in appetite - Lethargy -Sleep disturbance -Out of control -Lack of interest -Physical sympt *Occur in the week before menses in most menstrual cycles *Disappear few days after the onset of menses *Impair social, occupational function or the ability to interact with others
TREATMENT1- SUPPORTIVE Counseling & education the physician
should reassure the Pt that her symptoms are real & can be treated The goal is to provide the Pt with greater control over her life Life style changes such as exercise & dietary modifications 2-MEDICATIONS The selection of medications should be tailored to the Pt main symptoms
LIFE STYLE CHANGES
Adequate rest & sleepAerobic exercise 20-30 min 3-7 times/wk
-↑ β-endorphins in the brain
-Distract the women from her emotional feelings
Healthy diet Avoid fasting
Frequent small meals
↑ Complex carbohydrates
Simple sugars, Salt & Caffeine
Avoid fat free diet
High protein diet
MEDICAL THERAPY
SYMPTOMATIC Rx 1- Bloating & feeling of fluid retention
Diuretics (spironolactone) 2-Cramping, back pain, heat intolerance
Antiprostaglandines 3-Breast tenderness Bromocriptine 4-Depression, anxiety, irritability Alprazolam
0.25 mg bd SSRI Fluoxetine (Prozac) 5-20 mg/D (D20-28)
MEDICAL THERAPYSUPPRESSION OF OVULATION
1-Danazol 200 mg QID D 20-28 2-Oral Contraceptives 3-Medroxyprogestrone acetate 10 mg
BID/TID contiuously
MISCILANEOUS Rx 1-Micronized progestrone 100mg AM 200mg PM D 20-28 2-Multiple Vitamines 3-Pyridoxine B6 50 mg/ day or B-complex 4-Ca Carbonate 1200mg/D 5-Prime rose oil γ linolenic acid