2. Dysmenorrhea

Question 1

Describe: Dysmenorrhea (5)

Answer 1

• painful menstruation of uterine origin.
• Affects over 50% of menstruating women to some degree
• Can incapacitate approximately 10% of women affected for 1 to 3 d/mo
• Most commonly occurs from age 20 to 25
• Single greatest cause of lost working hours and school days among young women

Question 2

Name: Dysmenorrhea Aggravating Factors (6)

Answer 2

• Presentation at age < 30
• Menarche before age 12
• Longer cycles/duration of bleeding
• Irregular or heavy menstrual flow
• Heavy smoking
• Nulliparity

Question 3

Define 1°dysmenorrhea (4)

Answer 3

• Menstrual pain not caused by an organic disease
• No identifiable pelvic pathology
• Occurs in ovulatory cycles
• Improves in the third decade of reproductive life and after childbirth

Question 4

Describe onset: 1°dysmenorrhea (1)

Answer 4

Begins within 6 mo to 2 yr after menarche

Question 5

Describe etiology: 1°dysmenorrhea (2)

Answer 5

• Pain due to prolonged myometrial uterine contractions and ↓ blood flow to myometrium
• These are induced by ↑ prostaglandins (PG) (PGF2a , PGE2) production in the secretory endometrium during ovulatory cycles

Question 6

Describe pain: 1°dysmenorrhea (5)

Answer 6

• Cramp/colicky
• Located in lower abdo, radiates to lower back, labia, and inner thighs
• Starts within 1–4 h of onset of menses; lasts 8–72 h
• Is present with every menses
• Other associated Sx (due to PG excess): nausea, vomiting, diarrhea, low backache, headache, dizziness, fatigue

Question 7

Describe physical exam: 1° dysmenorrhea (4)

Answer 7

• Normal external genitalia
• Normal pelvic exam (no adnexal tenderness, masses, or nodules)
• No evidence of vaginal anomalies
• May have lower abdo pain

Question 8

Describe rx: 1° dysmenorrhea (3)

Answer 8

• NSAIDs
• Hormonal suppression (OCPs, Depo-Provera, Mirena)
• Nonpharmacologic (i.e., physical exercise, topical heat, high- frequency transcutaneous electrical nerve stimulation (TENS))

Question 9

Describe 2° dysmenorrhea (2)

Answer 9

• Menstrual pain caused by an organic disease
• Associated with pelvic pathology

Question 10

Describe onset 2° dysmenorrhea (2)

Answer 10

• At menarche (obstructive etiologies) or after age 25 (with pelvic pathology)
• Worsens with age (often occurs after years of painless menses)

Question 11

Describe etiologies 2° dysmenorrhea (8)

Answer 11

• Endometriosis
• Adenomyosis (commonly age 30–45)
• Uterine leiomyomas (degenerating/ pedunculated)
• Non hormonal IUDs
• PID
• Ovarian cysts (e.g., endometriomas)
• Obstructed out flow tract (i.e., cervical stenosis)
• Congenital malformations (i.e., bicornuate, septate uterus)

Question 12

Describe hx 2° dysmenorrhea (2)

Answer 12

• Pain onset before menses
• Other associated Sx: abdo bloating, pelvic heaviness, back pain
  
  • ± Infertility
  • ± Dyspareunia
  • ± Dyschezia

Question 13

Describe physical exam 2° dysmenorrhea (3)

Answer 13

Findings vary based on etiology:

• 1. Endometriosis: cul-de-sac nodularity or tenderness, adnexal tenderness
• 2. Adenomyosis: bulky, tender uterus
• 3. Leiomyoma: enlarged uterus

Question 14

Describe RX 2° dysmenorrhea (3)

Answer 14

• As per primary dysmenorrhea
• Rx of underlying pathology

Question 15

U/S investigation of pelvic pathology causing dysmenorrhea (2° dysmenorrhea) should be considered if one or more of the following is present… (3)

Answer 15

• Suspicious Hx
• Abnormal physical exam
• Failure of NSAID and/or OCP Rx

Question 16

Does normal abdo and pelvi exam necessarily R/O pelvic pathology?

Answer 16

No

Question 17

Describe: Approach to dysmenorrhea (Figure)

Answer 17