03. dysmenorrhoe
TRANSCRIPT
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Dysmenorrhea
Dr. Mashael Shebaili
Asst. Prof. & Consultant
Ob/Gyne Department
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Dysmenorrhoea
(Painful menstruation)
Primary
Secondary
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1. Primary dysmenorrhoea
No pelvic pathology
The pain is associated with bleeding
in the first and second day.
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2. Secondary dysmenorrhoea
Secondary to pelvic pathology as
endometriosis, chronic pelvic infection
or endometrial polyps The pain starts few days before
menstruation, continues for the
duration of menses and may persist for
days after.
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Incidence
80% of patients attend family planning
clinic have dysmenorrhoea and was severe
in 18% of them (Robinson et al., 1992)
Epidemiology
1. Long time smoker six time more than
non-smokers
2. Age is inversely associated with
dysmenorrhoea
3. Less common in parous women.
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Primary dysmenorrhoea
Aetiology
Uterine hyperactivity: abnormal
(increased) uterine hyperactivity
leading to uterine eschemia.
Hyperalgesic substances e.g.
prostaglandin E.
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Causes
1. Increased uterotonic prostaglandins PGF2a
2. Leucotrines produced by endometrium
stimulates myometrial activity
3. Vasopressin is a vasoconstrictor substance
which stimulates uterine contraction.
Circulating vasopressin levels was found tobe higher on the first day of menstruation in
women with dysmenorrhoea.
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Treatment of primary
dysmenorrhoeaA. Medical treatment
Reassurance and simple analgesic
NSAIDs are useful first line treatment with80-90% improvement, particularly the
mefenamic acid derivatives.
If contraception is also required OCCP isappropriate.
Oxytocin antagonist for future.
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Surgical treatment
Used as last resort
Laparoscopic uterosacral nerve ablation
LUNA
Hysterectomy
Cervical dilatation has no beneficial effect
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Secondary dysmenorrhoea
Aetiology
1. Endometriosis
and adenomyosis2. Chronic PID
3. Congenital or
acquired uterine
abnormalities
Investigations
1. USS
2. HSG
3. Hysteroscopy
4. laparoscopy
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Treatment of secondary dysmenorrhoea
(that of the cause), e.g.
Endometriosis
Adenomyosis
Uterine abnormalities
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Premenstrual tension syndrome
Recurring cyclical disorder in the luteal
phase of the menstrual cycle, involving
behavioral, psychological and physicalchanges resulting in loss of work or social
impairment (Ried and Yen 1981)
PMT may occur after hysterectomy with
conservation of functioning ovaries
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Diagnosis
The American psychiatric association(APA) criteria for diagnosis are:
A.Symptoms are temporarily related tomenstruation
B. The diagnosis requires at least 5 of the
following symptoms, and one of thesymptoms must be one of the first 4:
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1. Affective labiality sudden onset of being
sad, tearful, irritable or angry
2. Anxiety or tension
3. Depressed mode, feeling of hopelessness
4. Decreased interest in usual activities
5. Easy fatigability or marked lack of energy
6. Difficulty in concentration
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7. Changes in appetite (food craving or over
eating)
8. Insomnia
9. Feeling of being overwhelmed or out ofcontrol
10. Physical symptoms (bloating, breast
tenderness, headache, edema, joint or
muscular pain and weight gain.
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C. The symptom interfere with work,
usual activities or relationshipD. The symptoms are not an exacerbation
of another psychiatric disorder
Prevalence
Difficult to ascertain; 40% reported mild
symptoms, of them 2-10% the
symptoms interfere with their work or
life style
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EtiologyList of biological theories
1) Estrogen excess
2) Progesterone
deficiency
3) Hyperprolactinemia
4) Hypoglycemia
5) Vit. B deficiency6) Increased
aldosteron activity
7) Increased activity of
renin angiotensin
system
8) Recently, alteration
in neurotransmitters
particularly the
serotoninergic andopioid pathways
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Treatment of PMS
A.Non pharmacological treatment
1) Reassurance and support
2) Relaxation and stress management3) Reflexology therapy that reduce
somatic and psychological PMS
symptoms4) Increase aerobic exercise ? By altering
endorphins
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5) Well balanced diet with low sodium and fat
contents
6) Restriction of alcohol, chocolate, caffeine
and dairy products
7) Supplementation with vitamin B6, E,
magnesium and calcium8) Evening primrose oil
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Women on estrogen
replacement therapy does not
develop symptoms of PMS
unless progesterone is added
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B.Medical treatment
Pharmacological suppression of the
hypothalamopituitary ovarian axis
should offer a logical approach to
therapy (to stop cyclical ovarianactivity)
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1. Ovarian suppression using OCCP is
beneficial in some patients but causeexacerbation of symptoms in others
2. Danazol for breast symptoms
3. GnRH agonist: it improve symptoms in some
women & can be used as a treatment
4. Diuretics in patients complaining of bloating,edema and weight gain
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5. NSAIDs: reduce many of the somatic
symptoms as dysmenorrhoea6. For emotional and psychological
manifestations serotoninergic antidepressent
offer good first line approach. Fluoxetine
(Prozac)
7. Anoxiolytic as alprazola (Xanox) also offersome help.
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C.Surgical treatmentReserved only to patients with severe
symptoms not responding to medical
treatment
Hysterectomy
Bilateral oophorectomy (balance between
symptoms relief and hypoestrogenic stateand complications and the coast of HRT.
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Thank you