DYSMENORRHEADYSMENORRHEA SALWA NEYAZI COSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

DYSMENORRHEA WHAT IS DYSMENORRHEA? Painful menstruation WHAT IS ITS INCIDENCE? % WHAT ARE THE TWO MAIN CATEGORIES? 1- Primary  painful menstruation without associated pelvic disease 2-Secndary  painful menstruation caused by pelvic pathology

DYSMENORRHEA HOW 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 DYSMENORRHEA

PRIMARY DYSMENORRHEA Usually begins few hrs before or with the onset of menstruation then gradually decrease +ve family Hx The pain is crampy/ colicky, in the lower abdomen most intense in the midline lasts for hr Started with ovulatory cycles 6-12 M after menarche Associated 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 1 st 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  1 st 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 irritation Nausea GIT ulceration ↑ Bleeding time Nephrotoxicity Fenamates  blurred vision, headache & dizziness Bronchospasm 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 dysmenorrhea If results are normal - Codeine may be helpful under close supervision to avoid addiction -Acupuncture

SECONDARY DYSMENORRHEA

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 Endometriosis Endometritis Adhesions Mullerian anomalies Adenomyosis Endometrial polyp Submucous fibroid Cx stenosis Pelvic congestion Conditioned behavior Stress & tension

2RY DYSMENORRHEA HOW TO EVALUATE PT WITH 2RY DYSMEN ? CBC ESR Cultures for std U/S HSG  if intruterine scarring or fibroid is suspected Laparoscopy Hysteroscopy D&C TREATMENT OF 2RY DYSMENORRHEA Treat the cause

2RY DYSMENORRHEA CX STENOSIS Cx stenosis  ↑ Intrauterine pressure during menses  Retrograde menstruation  endometriosis Cx 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

ENDOMETRIOSIS Endometriosis  Ectopic endometrial tissue Adenomyosis  Endometrial tissue in the myometrium Hx  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 pain Hx  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 response Pain 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 vasculature Pain  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 SYNDROME

PMS WHAT IS PMS ? A group of physical, emotional & behavioral symptoms that occur in the 2 nd 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 another 2-3%  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 Irritability Aggression Tension Anxiety Depression /  interest in the usual activities Lethargy Insomnia or hypersomnia Change in appetite  overeating or food craving Crying Change in lipido Thirst Loss of concentration Poor coordination, Clumsiness, accidents

ETIOLOGY DO WE KNOW WHAT CAUSES PMS ? No, many theories have been postulated, most of them have to-do with various hormonal alterations Vit B6 deficiency Multifactorial psychoendocrine disoreder Alterations 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 symptoms Antiprogestrone RU486  No relief

ETIOLOGY Abnormal 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

DX DIAGNOSTIC 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

TREATMENT 1- 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 & sleep Aerobic exercise  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 THERAPY SUPPRESSION OF OVULATION 1-Danazol 200 mg QID D Oral Contraceptives 3-Medroxyprogestrone acetate 10 mg BID/TID contiuously MISCILANEOUS Rx 1-Micronized progestrone 100mg AM 200mg PM D Multiple Vitamines 3- Pyridoxine B6  50 mg/ day or B-complex 4-Ca Carbonate 1200mg/D 5-Prime rose oil  γ linolenic acid