1. Dysmenorrhea
Abdullah Baghaffar

2. Definition: Dysmenorrhea is defined as Painful menstruation
The term dysmenorrhea is derived from the Greek words:
dys, meaning difficult/painful/abnormal
meno, meaning month
rrhea, meaning flow

3. Classification
1- Primary  painful menstruation not associated with pelvic pathology
2- Secondary  painful menstruation caused by pelvic pathology

4. Epidemiology 50-75 % of women report dysmenorrhea
Typical age range for primary dysmenorrhea is between 17 and 22 years
Secondary dysmenorrhea is more common in older women

5. Primary Dysmenorrhea

6. Etiology
During menstruation, Prostaglandin F2α is released from endometrial cells  uterine smooth muscle contraction,  some degree of uterine ischemia.
This is associated with painful and sometimes debilitating cramps.
PG production  during the 1st 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

8. Features of Primary Dysmenorrhea
Starts with ovulatory cycles M after menarche
Begins few hrs before or with the onset of menstruation and usually lasts hrs
The pain is crampy/ colicky , usually strongest in the lower abdomen and may radiate to the back or inner thighs

9. Features of Primary Dysmenorrhea
Associated symptoms
-Back pain & pain in the upper thighs 60%
-Nausea /vomiting 89%
-Diarrhea 60%
-Fatigue / malaise 85%
-Headache 45%
-Dizziness, nervousness, fainting in severe cases

10. Risk factors
The following risk factors have been associated with more severe episodes of dysmenorrhea:
Earlier age at menarche
Long menstrual periods
Heavy menstrual flow
Smoking
Positive family history

11. Management 1. NSAID  1st line 80% effective
Ibuprofen (400 mg q 6 hrs)
Naproxen(250 mg q 6 hrs)
Mefenamic acid (500 mg q 8 hrs)
2. ORAL CONTRACEPTIVES  90% effective If NSAID are not effective or contraindicated
Some Pt may require combining both drugs Consider 2ry Dysmenorrhea if no improvement with therapy.

12. Management 3. Tocolytics: 4. Progestogens
Resistant cases may respond to tocolytic agents eg. salbutamol, nifedipine
4. Progestogens
Especially medroxyprogestrone acetate or dydrogesterone in daily high doses may also be beneficial in resistant cases
5. Nonpharmacologic pain management:
Acupuncture
Transcutaneous electrical stimulation
Psychotherapy, hypnotherapy and heat patches
6. Surgical procedures
Presacral neurectomy
Uterosacral nerve ablation
Have been largely abandoned

13. Management Mechanism of Action 1- NSAID 2- Oral Contraceptives
Inhibits prostaglandin production
Antagonistic action at the receptor
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)

14. Secondary Dysmenorrhea

15. Secondary Dysmenorrhea
Features which may indicate secondary dysmenorrhea:
Dysmenorrhea occurring during the first or second cycles after menarche, which may indicate congenital outflow obstruction
Dysmenorrhea beginning after the age of 25 years
Pelvic abnormality with physical examination

16. Secondary Dysmenorrhea
Dysmenorrhea not limited to the menses
Less related to the first day of flow
Little or no response to therapy with NSAIDs, OCs, or both.
Usually associated with other symptoms such as dyspareunia , infertility or abnormal vaginal bleeding

17. Causes Of Secondary Dysmenorrhea
Endometriosis
Chronic PID
Adhesions
Mullerian duct anomalies
Adenomyosis
Endometrial polyp
Fibroids
Ovarian cysts
Pelvic congestion
Imperforate hymen, transverse vaginal septum
Cervical stenosis
IUCD - copper

18. Causes of secondary dysmenorrhea:
Endometriosis:
Pain extends to premenstrual or post menstrual phase or may be continuous, may also have deep dysparueunia, premenstrual spotting and tender pelvic nodules (especially on the uterosacral ligaments); onset is usually in the 20s and 30s but may start in teens

19. Pelvic inflammation
Initially pain may be menstrual, but often with each cycle it extends into the premenstrual phase; may have intermenstrual bleeding, dyspareunia and pelvic tenderness.

20. Adenomyosis, Fibroid Tumors
Uterus is generally clinically and symmetrically enlarged and may be mildly tender; dysmenorrhea is associated with a dull pelvic dragging sensation.

21. Pelvic Congestion
A dull, ill-defined pelvic ache, usually worse premenstrually, aggravated by standing, relieved by menses; often a history of sexual problems.

22. Evaluation Pain analysis Associated symptoms Menstrual history
Gravidity and parity status
Infertility
Previous pelvic infections
Dyspareunia
Pelvic surgeries, injuries or procedures
Sexual history

23. Evaluation 2. Examination
A pelvic exam is indicated at the initial evaluation which should be performed to exclude uterine irregularities, cul du sac tenderness or nodularity that may suggest endometriosis, PID or pelvic mass. It should be completely normal in a Pt with 1ry dysmenorrhea, however if evaluated during the pain uterus & cx will be mildly tender.

24. Evaluation 3. Investigation
Not required if History & physical examination are consistent with 1ry dysmenorrhea
The following can performed to exclude organic causes of dysmenorrhea:
Cervical culture to exclude STDs
WBC count to exclude infection, ESR
HCG level to exclude ectopic pregnancy
Abdominal or transvaginal ultrasound
Hysterosalpingograms
Other more invasive procedures such as laparoscopy , hysteroscopy, D&C

25. Management Treating the underlying disease
The treatments used for primary dysmenorrhea are often helpful

26. PREMENSTRUAL SYNDROME

27. Definition
PMS is a group of physical, emotional & behavioral symptoms that occur in the 2nd half (luteal phase) of the menstrual cycle often interferes with work & personal relationships followed by a period entirely free of symptoms starting with menstruation.
Premenstrual syndrome
T1- A group of physical, emotional & behavioral symptoms that occur in the second half of the menstrual cycle
F2-It starts before the menses & continues untill ovulation
T 3-40% of women are significantly affected at one time or another
T % of women will have sever symptoms that will affect their work & lifestyle

28. Epidemiology
the incidence of PMS in the United States range from 30 to 50% of women of childbearing age
It is estimated that 75 to 80 percent of all women experience some PMS symptoms during their lifetime.

29. ETIOLOGY Incompletely understood Multifactorial
Genetics likely play a role
CNS-mediated neurotransmitter interactions with sex steroids (progestrone, estrogen and testosterone)
Serotonergic dysregulation- currently most plausible theory
F 5- PMS is a psychiatric disorder & it is not related to the hormonal changes of the menstrual cycle

30. Diagnosis
At least one of the following affective and somatic symptoms during the five days before menses in each of the three prior menstrual cycles:
Affective
Depression
Angry outbursts
Irritability
Anxiety
Confusion
Social withdrawal
F 5-

31. Diagnosis Symptoms relieved within four days of onset of menses
Somatic
Fatigue
Breast tenderness
Abdominal bloating
Headache
Swelling of the extremities
Symptoms relieved within four days of onset of menses
Symptoms present in the absence of any pharmacologic therapy, drug or alcohol use

32. Diagnosis
Symptoms occur reproducibly during two cycles of prospective recording
Patient suffers from identifiable dysfunction in social or economic performance

33. Management
A thorough history and physical examination should be performed to rule out any other medical causes
Goal: symptom relief
No proven beneficial treatment, suggestions include:
Psychological support
Diet/supplements
Avoid sodium, simple sugars and caffeine
Calcium mg/d
magnesium mg/d
Vit E 400 IU/d
Vit B6
Regular aerobic exercise
Treatment of PMS
T 1-The selection of medications should be tailored to the patients main symptoms

34. Management Medications Herbal remedies NSAIDs for discomfort and pain
Spironolactone for fluid retention
SSRI antidepressants
Progesterone suppositories
OCP for somatic symptoms
Danazol
GnRH agonists if severe PMS unresponsive to other treatments
Herbal remedies

35. Premenstrual Dysphoric Disorder
PMDD is described as a more severe form of PMS with specific diagnostic criteria
Treatment with SSRIs (first line) highly effective

36. Thank you for listening..