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