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

1RY DYSMENORRHEA1RY DYSMENORRHEA1RY DYSMENORRHEA1RY DYSMENORRHEA

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

SECONDARY SECONDARY DYSMENORRHEADYSMENORRHEA

SECONDARY SECONDARY DYSMENORRHEADYSMENORRHEA

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

PREMENSTRUAL SYNDROMEPREMENSTRUAL SYNDROMEPREMENSTRUAL SYNDROMEPREMENSTRUAL SYNDROME

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