7.3 - Dysmenorrhoea + Endometriosis Flashcards
Define primary and secondary dysmenorrhoea
Primary: Pain associated with the menstrual cycle and begins with onset of ovulatory cycles typically at menarche +/- 2yrs. (as in was always painful)
Secondary: Pain associated with the menstrual cycle due to pelvic pathology (was not painful and now painful).
How would you manage a patient with primary dysmenorrhoea (notice manage and not just treatment of)!
Conduct abdominal/pelvic/transvaginal US and reassure patient.
First line: NSAIDS (Mefenamic acid)
2nd Line: COCP (suppresses ovulation)
3rd line Depot progestogens (Suppresses ovulation and reduces contractions)
4th line: Mirena Coil (LVN-IUS)
When I say lines here, any would work, it is based on the preference of the patient
Why do you conduct an US with a patient presenting with dysmenorrhea since the age of 12. Note: Menarche was at age 13 and the patient is currently 14 years old.
This is a case of !primary dysmenorrhea. In these cases, the abdominal/pelvic/transvaginal US is used to ensure that there are no pelvic pathologies that may be causing this and reassure the patient
Secondary is defined as pain associated with the menstrual cycle due to pelvic pathology. Give 4 pelvic pathologies
Fibroids
Adenomyosis
Endometriosis
PID
How would you manage a patient with secondary dysmenorrhoea (notice manage and not just treatment of)!
Perform a history and clinical exam including a pelvic exam
If is normal, begin with medications (NSAIDs, COCP, Depot progestogen, Mirena Coil)
If abnormal findings (e.g. Pelvic mass/tenderness) or medications have failed, US/Diagnostic laparoscopy
Why not hysteroscopy? Its not completely wrong, but in the absence of heavy menstrual bleeding, the pelvic pathologies are typically out of the uterus
A patient with dysmenorrhea on the ward asks for pain killers. she says she typically uses codeine for this pain. Why would you not prescribe codeine?
Constipation => increased abdominal pressure => more pain
What is adenomyosis?
Endometrial-like tissue in the myometrium (muscles of the uterus)
10% of women are affected by endometriosis. Define Endometriosis
The presence of !Oestrogen-dependent, endometrial-like tissue outside the uterus !with impact on quality of life.
What are the 2 main culprits of PID (pelvic inflammatory disease)?
Chlamydia, Gonorrhoea
Give 6 sx of Endometriosis
Must include:
Chronic pelvic pain
Dysmenorrhea
Subfertility.
Dyspareunia
Rectovaginal disease
Others: Ovulation pain, Chronic fatigue, may affect bladder.
What is the Retrograde menstruation theory?
It is the theory explaining the ethology of endometriosis.
The retrograde menstrual theory of endometriosis suggests that during menstruation, some of the menstrual blood flows backwards through the fallopian tubes into the pelvic cavity instead of leaving the body. This backward flow can carry endometrial cells (the cells lining the uterus) with it, which then implant and grow on organs within the pelvic area, such as the ovaries and fallopian tubes. This process can lead to the development of endometriosis, causing pain, inflammation, and sometimes infertility.
Based on the theory of retrograde menstruation, pelvic sites are most commonly affected. State 5 pelvic and 2 extrapelvic sites
Pelvic: Broad ligamentm Round ligament, cervix, rectum, sigmoid colon,
Extrapelvic: Umbilicus, Lungs, scars from laparotomy/perineal scars.
You are taking a history from a patient suffering from dysmenorrhea. What questions would you ask?
Relationship of pain to cycle -> !SOCRATES
Offer pain relief
Endometriosis: Dyspareunia, Dyschezia
PID: Fever, previous UTI
Impact on quality of life (part of definition)
Always! Previous investigations and treatment to date.
Always! Desire for future fertility
You are about to perform an examination on a patient presenting with dysmenorrhoea. What examination findings are you looking for?
Fixed, retroverted uterus
Pelvic tenderness (Uterosacral ligaments)
Palpable nodules (in pouch of douglas or uterosacral ligaments)
You have taken a history and a focused examination noting pelvic tenderness. You opt to perform a diagnostic laparoscopy as previous medications have failed. What findings would indicate endometriosis? State 4
“Powder Burn” lesions (1st pic)
“Gunshot lesions” second pic
Red implants (third picture)
Endometriomas/chocolate cysts, Kissing ovaries (4th picture)
Nodules and cysts (broad/uterosacral ligaments)
