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