Dysmenorrhea and PMS

Patricia Crowley TCD Department of Obstetrics and Gynaecology

Primary Spasmodic Dysmenorrhea

• Painful menstruation without underlying pathology

• Commonest in teens/early twenties

• Onset 1 or more years after menarche

• Associated vomiting and faintness

Secondary Dysmenorrhea

• Painful menses secondary to pathology

• Pain may begin before bleeding and may last for entire duration

• Commoner 30s and 40s

Secondary Dysmenorrhea

• Endometriosis

• Fibroids

• Adenomyosis

• Pelvic Inflammatory Disease

• Uterine anomalies

History Taking

• Timing

• Severity

• Disruption in life-style

• Previous gynae history

• Contraceptive needs

• Wish for fertility

Examination

• Vaginal exam not essential in young female with ? Primary dysmenorrhea

• Vagina -?septum/ tenderness in POD

• Uterus- size / mobility/ position/tenderness

• Adnexa –tenderness/ enlargement

Investigations

• Transabdominal ultrasound with full bladder

• Transvaginal ultrasound –increased sensitivity

• Laparoscopy –gold standard for endometriosis

• Risks versus benefits

Management Primary Spasmodic Dysmenorrhea

• Education

• Prostaglandin synthetase inhibitors

• Combined oral contraceptive pill-choose a progestagen dominant pill

• “Bicycle” or “Tricycle” pill

• Failure to respond to Pill increases likelihood of underlying pathology

Premenstrual Syndrome

• Physiological premenstrual change

• All but 5% of females experience one or more symptom

Symptoms

• Physical –bloating/breast tenderness/headache

• Psychological-agression/agitation/crying bouts/depression/irritability

Measurement and Diagnosis

• Cyclical symptoms –character, timing, severity

• Degree of underlying psychological dysfunction

• Degree of disruption of lifestyle

• Usually self documented using diary/calendar

Aetiology

• No measurable abnormality in female sex hormones or prolactin

• Oophorectomy abolishes symptoms

• Cyclical HRT reproduces symptoms

• ? Abnormal endorphins

• ? Change in serotonin metabolism

Dimmock et al Lancet 2000

Treatment

• 15 RCTs SSRIs vs placebo

• SSRIs improve physical and psychological symptoms

• Both intermittent and continuous therapy beneficial

Treatment

• Temporary or permanent abolition of hormonal cycle

• GnRH analogue

• Hysterectomy and Oophorectomy

• Progesterone/progestagens shown to be ineffective