dysmenorrhea and pre-menstrual syndrome ( pms )

Dysmenorrhea and Dysmenorrhea and Pre-menstrual Pre-menstrual

syndromesyndrome(PMS)(PMS)

Primary Spasmodic Primary Spasmodic DysmenorrheaDysmenorrhea

• Painful menstruation Painful menstruation without without underlying pathologyunderlying pathology

• Commonest in teens/early twentiesCommonest in teens/early twenties• Onset 1 or more years after Onset 1 or more years after

menarchemenarche• Associated vomiting and faintnessAssociated vomiting and faintness

Secondary DysmenorrheaSecondary Dysmenorrhea• Painful menses Painful menses secondary to secondary to

pathologypathology• Pain may begin before bleeding and Pain may begin before bleeding and

may last for entire durationmay last for entire duration• Commoner 30s and 40sCommoner 30s and 40s

Secondary DysmenorrheaSecondary Dysmenorrhea• EndometriosisEndometriosis• FibroidsFibroids• AdenomyosisAdenomyosis• Pelvic Inflammatory DiseasePelvic Inflammatory Disease• Uterine anomaliesUterine anomalies

Nerves around Uterus, Cervix and Nerves around Uterus, Cervix and OvariesOvaries

Nerve around Nerve around EndometriosisEndometriosis

(in peritoneum, not in (in peritoneum, not in endometrioma)endometrioma)

Peritoneal endometriosis innervated by sensory Aδ & C, cholinergic & adrenergic nerve fibers (IHC study) (Tokushige et al, Hum Reprod, 2006)

Nerve fibers not found in ovarian endometrioma (IHC study) (Al-Fozan et al, Fertil Steril, 2004)

Deep Infiltrating Deep Infiltrating Rectovaginal EndometriosisRectovaginal Endometriosis

Bicornuate uterus

Hematosalpinx

HematocolposCervical orificesVaginal Stenosis

Vagina

History TakingHistory Taking• TimingTiming• SeveritySeverity• Disruption in life-styleDisruption in life-style• Previous gyn historyPrevious gyn history• Contraceptive needsContraceptive needs• Wish for fertilityWish for fertility

ExaminationExamination• Vaginal exam not essential in young Vaginal exam not essential in young

female with Primary dysmenorrheafemale with Primary dysmenorrhea• Vagina -septum/ tenderness Vagina -septum/ tenderness • Uterus- size / mobility/ Uterus- size / mobility/

position/tendernessposition/tenderness• Adnexa –tenderness/ enlargementAdnexa –tenderness/ enlargement

InvestigationsInvestigations• Transabdominal ultrasound with full Transabdominal ultrasound with full

bladderbladder• Transvaginal ultrasound –increased Transvaginal ultrasound –increased

sensitivitysensitivity• Laparoscopy –gold standard for Laparoscopy –gold standard for

endometriosisendometriosis• Risks versus benefitsRisks versus benefits

Management Primary Management Primary Spasmodic Spasmodic

DysmenorrheaDysmenorrhea• EducationEducation• Prostaglandin synthetase inhibitorsProstaglandin synthetase inhibitors• Combined oral contraceptive pill-Combined oral contraceptive pill-

choose a progestagen dominant pillchoose a progestagen dominant pill• ““Bicycle” or “Tricycle” pillBicycle” or “Tricycle” pill• Failure to respond to Pill increases Failure to respond to Pill increases

likelihood of underlying pathologylikelihood of underlying pathology

Adolescent Adolescent EndometriosisEndometriosis

• 症狀症狀 : Dysmenorrhea, acyclic : Dysmenorrhea, acyclic pain (or both), dyspareunia, pain (or both), dyspareunia, G-I painG-I pain

• 診斷：超音波 診斷：超音波 (( 不必然要內不必然要內診，測診，測 serum CA-125?)serum CA-125?)• 藥物治療藥物治療 : OCP, NSAID: OCP, NSAID 。。無效則腹腔鏡手術無效則腹腔鏡手術• 病灶病灶 : (1): (1) 外觀外觀 : clear, red : clear, red

and whiteand white 。。 (2) (2) 80% 80% 屬屬minimal to mild stageminimal to mild stage

• 術後術後 : GnRH-a (!), add-back: GnRH-a (!), add-back• 長期追蹤長期追蹤 (ACOG, committee opinion, (ACOG, committee opinion,

2005)2005)

Premenstrual SyndromePremenstrual Syndrome• Physiological premenstrual changePhysiological premenstrual change• All but 3-5% of ovulating females All but 3-5% of ovulating females

experience one or more symptomexperience one or more symptom• Remitting completely inn the Remitting completely inn the

postmenstrual week postmenstrual week (Berek & Novak’s Gynecology)(Berek & Novak’s Gynecology)

SymptomsSymptoms• Physical –bloating/breast Physical –bloating/breast

tenderness/headachetenderness/headache• Psychological-aggression/agitation/crying Psychological-aggression/agitation/crying

bouts/depression/irritabilitybouts/depression/irritability• Depressed mood, hopelessness, self-deprecation• Anxiety, tension• Affective liability• Anger, irritability, interpersonal conflict• Decreased interest in usual activities• Difficulty concentrating• Decreased energy• Appetite changes or cravings• Changes in sleep• Feeling overwhelmed or out of control• Physical symptoms such as breast tenderness, headache, bloating

Measurement and Measurement and DiagnosisDiagnosis

• Cyclical symptoms –character, Cyclical symptoms –character, timing, severitytiming, severity

• Degree of underlying psychological Degree of underlying psychological dysfunctiondysfunction

• Degree of disruption of lifestyleDegree of disruption of lifestyle• Usually self documented using Usually self documented using

diary/calendardiary/calendar

AetiologyAetiology• No measurable abnormality in No measurable abnormality in

female sex hormones or prolactinfemale sex hormones or prolactin• Oophorectomy abolishes symptomsOophorectomy abolishes symptoms• Cyclical HRT reproduces symptoms Cyclical HRT reproduces symptoms • ? Abnormal endorphins? Abnormal endorphins• ? Change in serotonin metabolism? Change in serotonin metabolism

TreatmentTreatment• 15 RCTs SSRIs vs placebo 15 RCTs SSRIs vs placebo • SSRIs improve physical and psychological symptomsSSRIs improve physical and psychological symptoms• Both intermittent and continuous therapy beneficialBoth intermittent and continuous therapy beneficial ((Dimmock et al Lancet

2000)• Lifestyle modification: (some benefits for some women)Lifestyle modification: (some benefits for some women) Elimination of caffeine from the dietElimination of caffeine from the diet Smoking cessationSmoking cessation Regular exerciseRegular exercise Regular meals and a nutritious dietRegular meals and a nutritious diet Adequate sleepAdequate sleep Stress reductionStress reduction

TreatmentTreatment• Temporary or permanent abolition of Temporary or permanent abolition of

hormonal cyclehormonal cycle• GnRH analogueGnRH analogue• Hysterectomy and OophorectomyHysterectomy and Oophorectomy• Progesterone/progestagens shown to Progesterone/progestagens shown to

be ineffectivebe ineffective

Non-contraceptive Benefits Non-contraceptive Benefits of Oral Contraceptive Pillsof Oral Contraceptive Pills

• Dysmenorrhea Dysmenorrhea Mittelschmerz Mittelschmerz Metrorrhagia Metrorrhagia Premenstrual syndrome Premenstrual syndrome Hirsutism Hirsutism Ovarian and endometrial cancer Ovarian and endometrial cancer Functional ovarian cysts Functional ovarian cysts Benign breast cysts Benign breast cysts Ectopic pregnancy Ectopic pregnancy Acne Acne Endometriosis Endometriosis

• AmenorrheaAmenorrhea• Dual suppression in IVF programDual suppression in IVF program

成份：成份：Estrogen & ProgestinEstrogen & Progestin

Low-dose : ＜ 30~35μg EEHigher dose: 50 μg EE

World Health Organization World Health Organization Precautions for the Use of OCsPrecautions for the Use of OCs(( 世界衛生組織對使用避孕藥的提醒世界衛生組織對使用避孕藥的提醒 ))

• Category 4 (refrain from useCategory 4 (refrain from use))Venous thromboembolism*Venous thromboembolism*Cerebrovascular or coronary artery disease*Cerebrovascular or coronary artery disease*Structural heart diseaseStructural heart diseaseDiabetes with complicationsDiabetes with complicationsBreast cancer*Breast cancer*Pregnancy*Pregnancy*Lactation (<6 weeks postpartum)Lactation (<6 weeks postpartum)Liver diseaseLiver diseaseHeadaches with focal neurologic symptomsHeadaches with focal neurologic symptomsMajor surgery with prolonged immobilizationMajor surgery with prolonged immobilizationAge >35 years and smoke 20 cigarettes or more per dayAge >35 years and smoke 20 cigarettes or more per dayHypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease)Hypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease)

• Category 3 (exercise caution)Category 3 (exercise caution)Postpartum <21 daysPostpartum <21 daysLactation (6 weeks to 6 months)Lactation (6 weeks to 6 months)Undiagnosed vaginal or uterine bleeding*Undiagnosed vaginal or uterine bleeding*Age >35 years and smoke fewer than 20 cigarettes per dayAge >35 years and smoke fewer than 20 cigarettes per dayHistory of breast cancer but no recurrence in past 5 yearsHistory of breast cancer but no recurrence in past 5 yearsInteracting drugsInteracting drugsGallbladder diseaseGallbladder disease

• Category 2 (advantages outweigh risks)Category 2 (advantages outweigh risks)• Category 1 (no restrictions)Category 1 (no restrictions)

謝謝謝謝

高雄長庚醫院婦產部 , 2008