32: 33-year-old woman with painful periods Flashcards
Primary dysmenorrhea
defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea is then defined as painful menses secondary to some pelvic pathology.
Primary dysmenorrhea is associated with increasing amounts of prostaglandins. The actual prevalence is unknown but ranges from 20-90%. Ten to fifteen percent of women feel their symptoms are severe and have to miss school or work. Dysmenorrhea usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours.
Risk Factors for Primary Dysmenorrhea
Mood disorders such as depression or anxiety have been associated with dysmenorrhea, especially in adolescents. This may be a complex association as other factors may be comorbid with the mood disorder diagnosis.
There is also an association between tobacco use and dysmenorrhea.
Women who have more children are noted to have a decreased incidence of primary dysmenorrhea.
Additionally, women who report overall lower state of health or other social stressors have a tendency for dysmenorrhea. It is not associated with lower socioeconomic class.
Primary dysmenorrhea most commonly occurs in women in the teens and twenties. It is notably associated with ovulatory cycles. Classically, an adolescent will start experiencing dysmenorrhea one or two years after menarche. This is the time it takes naturally for an adolescent to develop regular ovulatory cycles. The earlier the onset of menarche the more likely dysmenorrhea may occur.
Normal Pelvic Exam Findings
Unless a woman is pregnant, a normal uterus in not larger than eight weeks in size, approximately the size of a clenched fist. A normal uterus may be mildly tender on exam just prior to or during menses. A normal uterus can be tilted anteriorly (anteverted or anteflexed), midline, or tilted posteriorly (retroverted or retroflexed). An anteflexed or retroflexed uterus may be difficult to assess for size because of its position. The uterus should be smooth in contour around the entire surface area. Serosal fibroids or large mucosal fibroids may cause a “knobby” feel to the uterus.
The uterus should be mobile. The uterus is held in the pelvis by a series of ligaments on each side. With endometriosis the uterus may become nonmobile because of implants along these ligaments.
Ovaries are normally 2 x 3 centimeters in size-roughly the size of an oyster. In an obese woman the ovaries may be nonpalpable. During ovulation the ovaries may be slightly larger secondary to physiologic cysts. Caution should be taken while palpating the ovaries since the patient may have a mild sickening feeling. Mild tenderness on palpation of the ovaries is normal.
Nabothian cysts are physiologically normal on the cervix. These are formed during the process of metaplasia where normal columnar glands are covered by squamous epithelium. They are merely inclusion cysts that may come and go and are of no clinical significance. While looking at the cervix white discharge can also normally be seen coming from the os or in the vagina. If there are endometrial growths on the cervix or vagina these may be blueish.
Vaginal discharge can be normal or abnormal. Normal vaginal discharge is termed physiologic leukorrhea. This patient has no symptoms like itching, burning, or foul smelling discharge. It is normal for women to have physiologic clear to white vaginal discharge. The volume of discharge may get so heavy a woman will wear a pad for comfort; the volume may change during the course of a menstrual cycle.
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Anything longer than seven days is most likely menorrhagia.
Metrorrhagia is irregular frequent bleeding but it doesn’t have to be heavy. Menometrorrhagia that is irregular frequent and heavy bleeding.
Premenstrual Syndrome Diagnostic Criteria
Premenstrual dysphoric disorder is a complex disorder that occurs at a specific time in a woman’s cycle during multiple menstrual cycles in a year.
A minimum of five symptoms need to begin the week prior to menses, start to improve during menses and then become minimal the week after menses.
The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess.
The patient must also have one of the following: food cravings, changes in sleep, being “out of control”, decreased energy, anhedonia, and some physical symptoms.
The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms for the woman. It may be helpful to get the perspective of other close contacts of the patient.
Preconception Counseling
- Vitamin supplementation Daily supplementation with 400-800 micrograms of folic acid, as many pregnancies are unplanned. This lowers the risk for neural tube defects by over 70%.
- Substance abuse Substances like alcohol, tobacco, illicit drugs, and caffeine should be discontinued (or, in the case of caffeine, at least cut back).
- Immunizations Check for immunizations that must be given prior to pregnancy because they are live, such as MMR and chickenpox. New guidelines suggest Tdap as well.
- Chronic conditions Get any chronic medical problems-like diabetes, depression, or thyroid disorders-under control prior to pregnancy.
Primary Dysmenorrhea - Presentation & Treatment
In a family physician’s office, primary dysmenorrhea in an adolescent is a common diagnosis.
In a woman under 20 who is not sexually active with the classic history of suprapubic pain the first two days of menses, non-steroidal anti-inflammatory medications can be started without a pelvic exam.
Ibuprofen is the gold-standard anti-inflammatory, but many other anti-inflammatories have also been proven equally efficacious when taken cyclically starting a day or two prior to the onset of menses and continuing into the first days of menses.
Choice of the specific anti-inflammatory to use should be based on cost and side effects the patient experiences. If anti-inflammatories are not effective, combination birth control pills (monophasic or triphasic) with medium-dose estrogen are effective.
A pregnancy test should be performed in an adolescent who is sexually active. Other testing should be added if the patient has any type of dysfunctional uterine bleeding or pelvic pain outside of the typical pattern.
Treatment for Leiomyomas and Associated Symptoms
- Progesterone-releasing intrauterine device (IUD) (Mirena)
- acupuncture
- Combined hormonal contraceptives
- Depo-Provera
- ParaGard IUD
- uterine artery embolization
Progesterone-releasing intrauterine device (IUD) (Mirena)
an effective option for reducing menstrual blood flow in women with menorrhagia secondary to fibroids. Another appeal is that it can be left in for five years.
In studies the progesterone-releasing IUD (levonorgestrel-releasing intrauterine system) has clearly demonstrated decreased menstrual flow in women with fibroids. In one smaller study, the device decreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Through decreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In women who hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with fewest side effects.
Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potential side effects are lower abdominal pain and breast tenderness. The risk of uterine perforation is more likely at the time of insertion. The risk of infection is within the first 20 days of insertion.
Combined hormonal contraceptives
Oral contraceptives have been proven effective when used for dysmenorrhea related to anovulation only without a structural problem, especially in a woman who needs birth control.
In women with isolated dysmenorrhea, small trials have demonstrated benefit. However, a meta-analyses of these found insufficient evidence that oral combined hormonal pills are effective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause both menorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and work loss, and felt to decrease dysmenorrhea with a smaller endometrial lining.
OCPs are commonly known to patients and providers making them often the initial step in management. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, such as the Nuva-ring and the Ortho-Evra patch, are worth considering. These may not cause nausea and vomiting as they bypass the gastrointestinal system altogether. All types of combined hormonal contraceptives have slightly increased risk of venous thromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35 years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The Nuva-ring has risks of leukorrhea and vaginitis in approximately 5% of patients; the other types do not.
Depo-Provera
another potential tx for leiomyomas and the symptoms associated with them. However, recent literature does demonstrate that there is bone density loss after several years of use. In addition, Depo- Provera significantly affects fertility. It may take nine to 18 months for a woman to regain regular menses after her last injection. Other side effects would include weight gain, irregular menses for weeks to several months, and potential mood changes. However, there is no risk of venous thromboembolism and this can be used in a smoker older than 35.
Hysterectomy is the definitive surgical option for women with secondary dysmenorrhea and those with menorrhagia. It is reserved for women who no longer desire to bear children.
Some surgeons will offer hysterectomy to woman with a uterus 14 to 16 weeks in size or greater whether or not the patient has symptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication for hysterectomy. For a patient who has failed other management, hysterectomy may be an option.
Myomectomy, in which the surgeon removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient’s future reproductive plans are important in distinguishing these two options. Other surgical options for dysmenorrhea unrelated to uterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy. These two treatments have insufficient evidence at this time to recommend to most women.
ParaGard IUD
another effective form of bc. This device may stay inside the uterus for up to 10 years. For a woman who is not planning any more children, this may be a viable option for birth control. An advantage of the ParaGard IUD is that it has no hormones; it is made of copper. However, in women using ParaGard there is an increased risk of dysmenorrhea and menorrhagia just from the IUD. It is not a treatment for leiomyomas at all. In this case it could potentially make the symptoms worse.
uterine artery embolization
must understand the potential for urgent hysterectomy, consideration of future fertility is imperative. Some consider this a relative contraindication. Post procedure the patient usually has pelvic pain for at least 24 hours, sometimes lasting up to 14 days. “Post-embolization syndrome” is a group of complaints that include pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure to consider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis of fibroids, and vaginal discharge and bleeding for up to two weeks. This treatment is usually reserved for women who cannot tolerate other hormonal treatments or who do not want those treatments for other reasons. This procedure is performed by an interventional radiologist. It is not an option for dysmenorrhea alone or for menorrhagia without uterine fibroids.
Hormonal Birth Control Therapies
Progesterone-Only Intrauterine Device (IUD)
The progesterone-only IUD can stay in place for three to seven years, depending on which brand you use. You may have some irregular bleeding at the beginning for up to six months. Some women will stop bleeding altogether, and others continue having periods with less bleeding. The IUD is just taken out if you decide to try to get pregnant again. If, after five years, you decide you do not want to get pregnant, you just take it out and replace it at the same visit for another five years.
Progestin Implants
These are put under the skin and last for three years.
Ortho-Evra Patch
The patch is left in place for one week. You place a new patch weekly for three weeks, then during the fourth week you do not place any patch and have your period.
Depo-Provera Shot
The Depo-Provera shot is given every 12 weeks. If a woman on this decides to get pregnant, it may take a little longer to get pregnant after stopping the shots than if she used the IUD. It also has a higher rate of irregular bleeding at the beginning.
Vaginal Ring
The vaginal ring is placed inside the vagina and left for three weeks. Then the fourth week you remove it and have your period.
Premenstrual Syndrome Treatment
Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular.
Oral contraceptives are effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. It would be appropriate to try this in a woman also needing birth control. The most favorable pill is the formulation containing ethinyl estradiol and drospirenone.
SSRI during menses are an effective treatment of premenstrual syndrome, especially if severe or mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as daily treatment for decreasing both psychologic and physical symptoms. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a woman has symptoms and continue until the start of menses or three days later. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost.
Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in women. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in women done with childbearing.
Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies the effectiveness is inconsistent. If this were to be tried on a patient, the dosing would be during luteal phase. You must be cautious about causing potential electrolyte abnormalities with this drug.
Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity.
Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been studied and shown some efficacy. These are all worth discussing with patients, although true efficacy is not proven.
