Primary Dysmenorrhoea Max Brinsmead MB BS PhD May 2015
Primary Dysmenorrhoea – Definition Pain with menstruation in the absence of any pelvic pathology Secondary dysmenorrhoea is associated/secondary to pelvic pathology Primary dysmenorrhoea is associated only with ovulatory cycles Correlates with luteal Progesterone and intrauterine generation of Prostaglandins
Dysmenorrhoea – Differential Diagnosis Endometriosis Adenomyosis PID Fibroids Uterine obstruction problems Clot colic Irritable bowel syndrome Musculoskeletal problems
Clinical Clues Pain that begins with or before menstruation and eases as the flow reduces is often PRIMARY Pain that begins after the onset of menses or gets worse as the flow reduces is often SECONDARY Endometriosis PID Primary dysmenorrhoea may get better after 1st pregnancy and childbirth But not always Ask about pre menstrual spotting (PMS) “Do you go straight into a full flow or do your periods muck about for a few days” PMS has a high likelihood of endometriosis And luteal phase defects
Dysmenorrhoea – The Psychogenic Component The Problem is worse for: Emotional/Vulnerable Work dissatisfaction School problems Sexual dysfunction Smokers Drug dependent
10 Dysmenorrhoea - Treatment Rest, Relaxation, Local heat Psychotherapy Diet – weight reduction Smoking cessation NSAIDs – in the correct dose/mode Combined Oral Contraceptive Cyclical Continuous Depo Provera Mirena BUT there is still a 20 – 25% rate of incomplete control of symptoms using these treatments
NSAIDs – First-line Treatment 73 RCTs unanimous. NSAID more effective than placebo (RR 4.50, OR CI 3.85-5.27) And more effective than Paracetamol But have more side effects Mostly gastrointestinal Studies thus far have not identified any particular NSAID to have either greater effectiveness or safety
Surgical Treatments Laparoscopic uterine nerve ablation (LUNA) Laparoscopic presacral neyrectomy (LPSN) Both shown to be effective compared to no treatment or controls in RCT LPSN more effective than LUNA in the longer term Constipation is a side effect of LPSN Hysterectomy is the ultimate cure for dysmenorrhoea
Cochrane on Diet & Herbal Remedies Magnesium: 3 trials - some benefit Vitamin B6: 1 trial showed benefit but Mg + B6 was no better than Mg alone Vitamin B1: 1 large trial (100mg daily) showed benefit Vitamin E: Does not appear to boost the analgesic effects of NSAID Omega-3 fatty acids more effective than placebo in 1 small trial Japanese Herbal Remedy more effective than placebo in 1 small trial 14 RCTs of Chinese Herbal Medicine show benefit (RR=1.99, CI 1.52 -2.60)
Cochrane on Other Interventions High frequency TENS more effective than placebo (7 RCTs, OR 7.2, CI 3.1-16.5) Auricular acupuncture of some benefit in pain associated with pelvic endometriosis No benefit from spinal manipulation 4 trials of exercise but only one of high quality Exercise reduces menstrual distress scores and has a residual effect for next 3 cycles 5 trials of behaviour modification provides some support for relaxation training, or “pain management training”
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