Chapter 32: Dysmenorrhea and Chronic Pelvic Pain Flashcards
What is Dysmenorrhea?
Painful periods
How do we define chronic pelvic pain?
Chronic pelvic pain: Non-cyclic pelvic pain for 6 months or more not related to menstruation
Discuss the two types of dysmenorrhea
Primary Dysmenorrhea = excess prostaglandins leading to painful uterine contractions, specifically PGF2a (F2A).
Secondary = caused by something else clinically identifiable. Leiomyomas, polyps, adhesions, inflammation, endometriosis, tumors, etc.
Discuss prostaglandin release that is linked to dysmenorrhea
When menstruation starts, preformed PGs are released from shedding uterine lining, causing stimulation for contraction of smooth muscle cells. Causes contractions in other places too, leading to N/V/D (your gut and colon and esophagus). Furthermore, necrotic endometrial cells
being shed dump arachidonic acid from cell walls, which can be used to make more PGs.
PGE2 also made, and is a potent vasodilator and inhibitor of platelet aggregation. Possible cause of menorrhagia.
In primary/secondary dysmenorrhea, we can sometimes see dyspareunia. What else do we see symptom wise that may help us distinguish primary and secondary, and which one do we typically see this pain during intercourse with?
Dyspareunia is typically seen in secondary, not primary, which typically presents as recurrent month-after-month spasmodic lower abdominal pain occurring on the first 1 to 3 days of menstruation
Primary sounds a lot like labor pains, lower abdominal pain, cyclical, N/V/D, need heating pad/hot water bottle
Secondary can be superimposed on menstruation, lasts longer, may precede, becomes worse during menstruation, and often occurs later in life.
3 most common physical exam findings that could indicate a secondary dysmenorrhea vs. a primary one
i) Irregular enlargements of the uterus: Leiomyomata
ii) Boggy, tender, symmetrical enlargement: Adenomyosis
iii) Painful posterior cul-de-sac and restricted uterus movement = Endometriosis or pelvic scarring/adhesions
iv) Primary? Normal physical exam.
Would we ever get labs for dysmenorrhea?
Labs: Cxs for Gonorrhea/Chlamydia if infection suspected
We have a few medical ways to treat dysmenorrhea. How?
Primary:
- NSAIDs (PG synthetase inhibitors). Usually so effective that if this doesn’t work, you may need to re-think your diagnosis.
- If incapacitating pain, consider presacral neurectomy (interrupting superior hypogastric plexus from the fourth lumbar vetebra to the sacrum). Can damage local vasculature, cause chronic constipation, etc.
- Can also use OCPs (DepoProvera (Depot medroxyprogesterone), Nexplanon (long acting implantable progesterone contraceptive), Mirena (progesterone intrauterine delivery systems)
How do we treat secondary dysmenorrhea?
Treat the underlying condition
Discuss Rome III criteria for IBS
Rome III criteria - Symptoms of recurrent abdominal pain and discomfort and a marked change in bowel habits for at least 6 months with symptoms experienced on at least 3 days of at least 3 months.
Two or more of the following must apply: Pain with a bowel movement, onset of pain is related to a change in frequency of stool, onset of pain is related to a change in stool appearence.
What causes IBS?
Not sure what causes it, but linked to bowel motility issues, visceral hypersensitivity, psychosocial factors like stress, imbalance of neurotransmitters, and infection.
Symptoms heightened/more frequent in those with physical or sexual abuse as children.
What is interstitial cystitis and what causes it?
Interstitial cystitis - Chronic inflammatory condition of the bladder that is often characterized by pelvic pain, urinary frequency and urgency, dyspareunia.
Proposed mechanism is a breakdown in the glycosaminoglycan layer that normally coats the mucosa of the bladder.
How do we diagnose interstitial cystitis?
There is a specific index we use to see if cytoscopy is needed. You can also do potassium sensitivity testing and bladder distention with water.
Primary treatment option for chronic pelvic pain
You can suppress ovulation to rule out any other ovarian or menstrual causes of the cramping.
GnRH agonists which can help with this also tend to have helpful effects against other hormonally affected things like in IBS, interstitial cystitis, and pelvic congestion syndrome where engorged pelvic vessels are purported to cause pelvic aching and pain).
What do we do if we expect IBS
IBS: Referral to GI for extensive workup of possible food allergies, indicated radiology, etc.
