6. Dysmenorrhoea

Question 1

What is dysmenorrhoea?

Answer 1

Dysmenorrhoea is defined as cyclical pelvic pain that occurs with menstruation. It affects 50% of menstruating women and is the most common gynaecological condition, regardless of age or nationality.

Question 2

What are the impacts of dysmenorrhoea?

Answer 2

Dysmenorrhoea is associated with a restriction in daily activities and absence from school and work.

Question 3

What are the two main types of dysmenorrhoea?

Answer 3

Dysmenorrhoea is divided into two main categories: Primary and Secondary.

Question 4

What is primary dysmenorrhoea?

Answer 4

Primary dysmenorrhoea is menstrual pain that occurs in the absence of identifiable pelvic pathology. It typically starts in adolescence, 6–12 months after menarche, with the onset of ovulatory cycles.

Question 5

Characteristics of Primary Dysmenorrhoea

Answer 5

The pain is cramping in nature, starting a few hours before menstruation. It may persist for 8-72 hours and is often accompanied by constitutional symptoms like headache, fatigue, diarrhoea, nausea, and vomiting.

Question 6

What is the etiology of primary dysmenorrhoea?

Answer 6

Prostaglandins and leukotrienes play a key role in generating dysmenorrhoea symptoms. Uterine contractions and vasospasm, leading to ischaemia and pain, are modulated by prostaglandins and leukotrienes following progesterone withdrawal in ovulatory cycles.

Question 7

What is the process of prostaglandin synthesis following ovulation?

Answer 7

After ovulation, progesterone withdrawal during the late luteal phase triggers the release of phospholipids. These phospholipids undergo enzymatic conversion through lipoxygenase to produce leukotrienes and through cyclo-oxygenase to produce prostaglandins and thromboxane.

Question 8

What is the role of phospholipids in prostaglandin synthesis?

Answer 8

Phospholipids are released after ovulation during progesterone withdrawal in the late luteal phase. They are converted by lipoxygenase to arachidonic acid, which then leads to the production of leukotrienes and prostaglandins through further enzymatic processes.

Question 9

What enzymes are involved in prostaglandin synthesis after ovulation?

Answer 9

The enzymes involved are lipoxygenase and cyclo-oxygenase. Lipoxygenase converts phospholipids to leukotrienes, while cyclo-oxygenase converts phospholipids to prostaglandins and thromboxane.

Question 10

What are the risk factors for severe primary dysmenorrhoea?

Answer 10

Several risk factors include earlier age at menarche, increased duration of menstruation, smoking, obesity, and alcohol consumption.

Question 11

How is primary dysmenorrhoea diagnosed?

Answer 11

Diagnosis is based on a typical history that distinguishes primary from secondary dysmenorrhoea. Examination should exclude gynaecological pathology, and special investigations are usually not required.

Question 12

Do adolescents with primary dysmenorrhoea require a pelvic examination?

Answer 12

Adolescents who are not sexually active and present with mild to moderate pain and a history suggestive of primary dysmenorrhoea typically do not require a pelvic examination.

Question 13

Is ultrasound routinely used in diagnosing primary dysmenorrhoea?

Question 14

What is the first-line treatment for primary dysmenorrhoea?

Answer 14

Non-steroidal anti-inflammatory drugs (NSAIDs) or prostaglandin synthase inhibitors should be considered as first-line treatment. These are effective in relieving symptoms in 80% of women when started at the onset of symptoms and continued 6-8 hourly.

Question 15

How long should NSAID treatment be continued for primary dysmenorrhoea?

Answer 15

NSAID treatment should be continued for 4 to 6 cycles before considering it to have failed.

Question 16

How effective are oral contraceptives in treating primary dysmenorrhoea?

Answer 16

Oral contraceptives provide relief in 90% of women with primary dysmenorrhoea, and they are recommended as an alternative treatment, especially in women requiring contraception.

Question 17

What other medical treatments are effective for dysmenorrhoea?

Answer 17

Depo-medroxyprogesterone acetate and levonorgestrel intrauterine systems have also been shown to be effective in treating dysmenorrhoea.

Question 18

What surgical treatments can be considered for dysmenorrhoea

Answer 18

Laparoscopic uterosacral nerve ablation and presacral neurectomy can be considered, but they are seldom indicated and have limited supporting evidence.

Question 19

What non-medical treatments can be used for dysmenorrhoea?

Answer 19

Transcutaneous electrical nerve stimulation (high frequency) and acupuncture may improve symptoms in 30-60% of cases. Topical heat therapy may also help, though evidence is limited.

Question 20

Are alternative medicines helpful in treating dysmenorrhoea?

Answer 20

Vitamins B1, B6, E, fish oil, and magnesium may be useful, but there is limited supporting evidence for their effectiveness.

Question 21

When should a patient be referred for laparoscopy in cases of dysmenorrhoea?

Answer 21

Referral for laparoscopy should be considered if there is no improvement with NSAIDs or oral contraceptives, or if secondary dysmenorrhoea is suspected.

Question 22

What is secondary dysmenorrhoea?

Answer 22

Secondary dysmenorrhoea is menstrual pain associated with underlying pelvic pathology. It typically starts 1 to 2 weeks before menstruation and persists until after bleeding stops. Symptoms may also include dyspareunia, menorrhagia, intermenstrual bleeding, and postcoital bleeding, depending on the underlying condition.

Question 23

When do symptoms of secondary dysmenorrhoea typically start?

Answer 23

Symptoms of secondary dysmenorrhoea usually begin several years after menarche and are secondary to anatomical or functional abnormalities.

Question 24

What is the most common cause of secondary dysmenorrhoea?

Answer 24

The most frequent cause of secondary dysmenorrhoea is endometriosis.

Adenomyosis and intra-uterine contraceptive devices are also commonly identified problems.

Question 25

What are other common causes of secondary dysmenorrhoea?

Answer 25

• Endometriosis
• Pelvic Inflammatory Disease
• Intrauterine Devices
• Ovarian Cysts
• Adenomyosis
• Uterine fibroids
• Uterine polyps
• Intra-uterine adhesions
• Cervical stenosis

Question 26

How is secondary dysmenorrhoea diagnosed?

Answer 26

The diagnosis is made through a detailed history and careful gynaecological examination, which includes assessing the size, shape, and mobility of the uterus, the size and tenderness of the adnexae, and checking for nodularity or fibrosis in the uterosacral ligaments and rectovaginal septum.

Question 27

What investigations are often indicated in the diagnosis of secondary dysmenorrhoea?

Answer 27

Investigations may include:

• Full blood count and ESR
• Cultures for pelvic infections (if there is a high clinical suspicion)
• Pelvic ultrasound
• Laparoscopy and/or hysteroscopy

Question 28

What is the key to successful treatment of secondary dysmenorrhoea?

Answer 28

Successful treatment involves identifying and appropriately managing the underlying pathology along with pharmacological management of pelvic pain.

Question 29

How is endometriosis treated in secondary dysmenorrhoea?

Answer 29

Endometriosis, the most common underlying pathology, can be treated by cauterizing or resecting lesions during laparoscopy, followed by medical suppressive treatment.