Download - Dysmenorrhea
DYSMENORRHEADYSMENORRHEA DYSMENORRHEADYSMENORRHEA
By Dr Faisal Al HadadBy Dr Faisal Al Hadad
Consultant of Family Medicine, PSMMCConsultant of Family Medicine, PSMMC
Dysmenorrhea
Dysmenorrhea is chronic, cyclic pelvic pain associated with
menstruation.
Two main categories
1- Primary: painful menstruation without associated pelvic disease
2- Secondary: painful menstruation caused by pelvic pathology
Evaluating patient with dysmenorrhea
1- History
2- Physical examination: should be completely normal in Pt with 1ry dysmenorrhea, however if evaluated during the pain uterus & cx will be mildly tender
3- Investigations: not required if Hx & physical examination are
consistent with 1ry dysmenorrhea *U/S *HSG *Laparoscopy allow physician to confirm presence *Hystroscopy or absence of pelvic disease *D&c
Primary dysmenorrhea
Primary dysmenorrhea is the most common gynecologic complaint and one of the leading causes of absenteeism in young women
Increased levels of PG stimulates uterine smooth muscle contraction → vasoconstriction of the uterine arteries → uterine hypoxia → pain of dysmenorrhea
Onset: within 6-12 months after menarche
Usually begins few hrs before or with the onset of menstruation
The pain is crampy/ colicky in the lower abdomen and suprapubic area associated with nausea, vomitting, diarrhea, headache and fatigue.
Treatment of 1ry dysmenorrhea
1- NSAIDs are 1st line treatment *Propionic acid derivatives (Ibuprofen, naproxen) *Fenamates (mefenamic acid)
2- Oral contraceptives * If NSAID are not effective or contraindicated * 90% effective within 3-4 months of use
3- Some Pt may require combining both drugs 4- Consider 2ry dysmenorrhea if no improvement with therapy
Causes of 2ry dysmenorrhea
Endometriosis Adenomyosis Endometrial polyp Fibroid Cx stenosis Pelvic inflammatory disease Presence of an IUD Adhesions
Evaluating pt with 2ry dysmenorrhea
1- History - Onset of symptoms : several years after menarche - Recurrent pelvic infections (PID) - Fever and vaginal discharge (PID) - IUCD - Recent pelvic surgery (adhesions) - Heavy periods (adenomyosis, endometrial polyp, fibroid) - Infertility and dysparunea (endometriosis)2- Physical examination: may help in Dx by finding abnormalities
that point to a pelvic disease
Evaluating pt with 2ry dysmenorrhea
3- Investigations
CBC: anaemia related to chronic menorrhagia, infection (PID)
Cervical/vaginal swabs for cultures: PID
Transvaginal ultrasound: pelvic masses, uterine fibroids and polyps, pelvic abscess, adenomyosis.
Laparoscopy: both diagnostic and therapeutic, particularly in the management of endometriosis and where pain is of uncertain origin
Hysteroscopy: defines intrauterine pathology and provides an endometrial tissue sample for histology
CX STENOSIS
Causes:
- Congenital
- 2ry to cervical injury (electrocautery, cryocautery, conization, infection)
Presentation: Scanty menstrual flow & sever cramping through out the menstrual cycle
Diagnosis: Internal os scarred & impossible to pass uterine sound or even very thin probe
Treatment
- D&C
- Vaginal delivery afford more lasting cure
ENDOMETRIOSIS
Endometriosis: an ectopic endometrial tissue in extra-uterine sites (ovaries, fallopian tubes or uterosacral ligaments)
History: Sever dysmenorrhea, infertility and dysparunea
Pelvic examination
- Evidence of endometriosis in vagina or cx
- Rectovaginal examination reveals tenderness and nodularity along the uterosacral ligaments
ENDOMETRIOSIS
Diagnosis
-Laparoscopy or laparotomy
-Direct biopsy of vaginal or cx lesion
Treatment
- Suppress menstruation (OCP, GnRG agonists, danazol)
- Cauterization of endometriotic spots
Pelvic inflammatory disease
PID adhesions pelvic pain
History
- Acute episodes of abdominal pain begins with menses & continues
- Fever
- Vaginal discharge
Examination
- Sever tenderness on palpation of the uterus & cx motion
- Purulent cx discharge
Pelvic inflammatory disease
Investigations: ↑WBC, ↑ESR, ↑CRP
Treatment
- Appropriate antibiotics
- Surgical release of adhesions
Thank you