1. بسم الله الرحمن الرحيم 1Module 6 - ppt 5 Dr. Maysoon Al-Amoud

2. Dysmenorrhea PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 Introduction to Primary Care a course of the Center of Post Graduate Studies in FM

3. Objectives General considerations. Classification of dysmenorrhea Causes of dysmenorrhea Clinical picture of dysmenorrhea Management of dysmenorrhea 3Module 6 - ppt 5 Dr. Maysoon Al-Amoud

4. Introduction 4Module 6 - ppt 5 Dr. Maysoon Al-Amoud  Dysmenorrhoea - 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.

5. Classification 5Module 6 - ppt 5 Dr. Maysoon Al-Amoud 1.Primary : The presence of painful menses in the absence of disease 2.Secondary : The occurrence of painful menstruation caused by pelvic disease.

6. Risk factors of dysmenorrhea Age < 20 years Attempts to lose weight Depression/Anxiety Heavy menses Nulliparity Smoking Disruption of social network

7. 7Module 6 - ppt 5 Dr. Maysoon Al-Amoud  No underlying pelvic pathology.  Caused by release of prostaglandin F 2  from tendometrium at time of ovulatory menstruation  uterine hypercontactility. Ischemia of uterine wall during a contraction causes pain. Causes of dysmenorrhoea Primary dysmenorrhea

8. 8Module 6 - ppt 5 Dr. Maysoon Al-Amoud  Prostaglandins 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 1 o 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... continue Causes of dysmenorrhoea

9. 9Module 6 - ppt 5 Dr. Maysoon Al-Amoud Underlying pelvic pathology with variable severity : Adenomyosis, myomas, polyps, Infections – chronic pelvic, endometriosis, Tumors, dhesions, leiomyomas, Intrauterine devices, Anatomic causes, Bladder pathology & GI pathology Psychosexual problems Blind uterine horn(rare). Secondary dysmenorrhea Causes of dysmenorrhoea

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

14. Painful Menstruation Dysmenorrhea SpasmodicCyclic Radiate to back, inner aspect of thighs

15. 15Module 6 - ppt 5 Dr. Maysoon Al-Amoud Clinical findings Physical examination: Pelvic examination + cervical smear pain not with menses & culture should be for all married pts presenting with a chief complaint of dysmenorrhea If 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.

17. 17Module 6 - ppt 5 Dr. Maysoon Al-Amoud Management Medical therapy Physical modalities Alternative & complementary therapy Behavioral modification Surgical intervention

19. 19Module 6 - ppt 5 Dr. Maysoon Al-Amoud Medical therapy Drug groups: NSAIDs – diclofenac, ibuprofen, Danzol Leuprolide Depo-methroxyprogesteron-terone acetate CC :oral & intravaginal COX-2 inhibitors Levonorgestrel IUD Nifedipine Transdermal CC patch Aim:  endometrial prostaglandin production; ± CC

20. Inhibition of ovulation Desire contraception No relief or cannot tolerate NSAIDs No contraindication Oral Contraceptive Pills OCsMinipillDMPAGnRHa

22. Agents used in the treatment of dysmenorrhea

23. 23Module 6 - ppt 5 Dr. Maysoon Al-Amoud Physical modalities Utilize : 1.Heat 2.Acupuncture or acupressure 3.Spinal manipulation A 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.

24. 24Module 6 - ppt 5 Dr. Maysoon Al-Amoud Alternative & 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 1 st 3 days of bleeding  shorter duration & lower intensity of pain than in placebo.

25. 25Module 6 - ppt 5 Dr. Maysoon Al-Amoud Behavioral modification Life-style: strenuous Ex. & caffeine intake can modulate prostaglandin-induced uterine contractions. Strenuous Ex. :  uterine tone   uterine “angina” periods +  prostaglandins......  strenuous Ex. In 1 st few days of menses  ±  dysmenorrhea. Caffeine : controversial effect, it  uterine tone by  uterine cyclic adenosine monophosphote level.

26. 26Module 6 - ppt 5 Dr. Maysoon Al-Amoud Surgical 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 1 o amenorrhea.

27. 27Module 6 - ppt 5 Dr. Maysoon Al-Amoud Treatment at PHC centres primary dysmenorrhea: try previously mentioned methods. Secondary dysmenorrhea: refer to investigate (e.g. laparoscopy) & treat underlying cause Have patience and empathy.

28. 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

29. When to refer Referral 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 Dyspareunia Abnormal pelvic examination If the patient has pain management problems with disruption to daily living.

30. Summary Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated Simple analgesics and non-steroidal anti- inflammatories are effective in up to 70% of women Oral contraceptives can be considered for women who wish to avoid pregnancy For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective

31. تم بحمد الله Thank you Dr. Maysoon Al-Amoud 31Module 6 - ppt 5 Dr. Maysoon Al-Amoud