Dysmenorreah

Question 1

Incidence of dymenorreah

Answer 1

It affects between 50% and 90% of menstruating women.

The most common gynaecological symptom reported by women.

Question 2

When does 1ry dysmenorrhea start

Answer 2

-Usually begins in adolescence after the establishment of ovulatory cycles, therefore starts 6–12 months after the menarche, once cycles are regular.

Question 3

In 1ry dysmenorrhea, when does the pain starts?

Answer 3

Pain often starts shortly before the onset of menstruation, and lasts for up to 72 hours, improving as the menses progresses.

Question 4

What is 2ry dysmenorrhea

Answer 4

Menstrual pain associated with underlying pelvic pathology.

Question 5

When does 2ry dysmenorrhea start

Answer 5

Pain appears after several years of painless periods.

Question 6

How 2ry dysmenorrhea progress through the cycle

Answer 6

Pain may persist after menstruation finishes, or may be present throughout the menstrual cycle, but exacerbated by menstruation.

Question 7

Other gynecological symptoms are present with 2ry dysmenorrhea?

Answer 7

Yes

Question 8

Pelvic examination in 1ry dysmenorrhea

Answer 8

Normal

Question 9

Pelvic examination in 2ry dysmenorrhea

Answer 9

Abnormal but if normal doesn’t exclude 2ry dysmenorrhea

Question 10

DD of 2ry dysmenorrhea

Answer 10

• endometriosis
• adenomysosis
• uterine myomas
• endometrial polyps
• cx stenosis
• Obstructive malformations of the genital tract

Question 11

Pictures of Dysmenorrhea in case of endometriosis

Answer 11

1. cyclical or chronic pelvic pain
   that frequently occurs prior to menstruation and may be accompanied by:
2. HMB
3. deep dyspareunia.

Question 12

Picture of Dysmenorrhea in case of adenomyosis

Answer 12

painful menstruation that may be accompanied by HMB.

Question 13

Picture of dysmenorrhea in case of myoma

Answer 13

lower abdominal pain, accompanied by HMB; a pelvic mass on examination.

Question 14

Pictures of dysmenorrhea in case of endometrial polyp

Answer 14

Pedunculated submucosal fibroids and endometrial polyps may cause:
* painful menstrual cramps
* abnormal vaginal bleeding

Question 15

Picture of dysmenorrhea in case of obstructive abnormality in the genital tract

Answer 15

adolescents experiencing dysmenorrhoea in the first 6 months from the start of menarche, or in pubertal age in the case of concealed menstruation.

Question 16

3ry cause of dysmenorrhea

Answer 16

• Chronic PID.
• Pelvic adhesions.
• Irritable bowel syndrome.
• Inflammatory bowel disease.
• Interstitial cystitis.
• IUD.

Question 17

Cause of sudden dysmenorrhea

Answer 17

Acute PID

Question 18

Pain in PID

Answer 18

1. lower abdominal pain and tenderness
2. dyspareunia
3. abnormal vaginal bleeding
4. abnormal vaginal discharge.

In acute infection, fever may be present.

Question 19

Do IUD may cause dysmenorrhea

Answer 19

history of IUD insertion, usually 3–6 months previously.
Pain may be accompanied by longer and heavier periods, often with bleeding or spotting between periods.

Question 20

1st line ttt of dysmenorrhea

Answer 20

NSAIDs unless contraindicated

Treatment is initiated with the onset of bleeding and/or symptoms and need not be necessary for more than 2–3 days.

Question 21

If NSAIDS are contraindicated, what is the 2nd line ttt in dysmenorrhea

Answer 21

Acetaminophens

or in addition to an NSAID if the response is insufficient

Question 22

Role of Codein in ttt of dysmenorrhea

Answer 22

Codeine may be added to acetaminophen or an NSAID if the response is insufficient.

Question 23

2nd line medical ttt in dysmenorreah

Answer 23

Hormonal ttt
- COC
- Progesterone regimen

Question 24

Action of COC in ttt of dysmenorrhea

Answer 24

• Can be a first-line therapy for some women
• A significant reduction in painful menstrual cramping with COC containing both low and medium dose of ethinyl oestradiol compared with placebo
• Continuous COC may be used.

Question 25

Progesterone regimen used in ttt of dysmenorrhea

Answer 25

• DMPA
• POP
• LNG-IUD (ovulation is n’t suppressed)

Question 26

Action of progesterone regimens in ttt of dysmenorrhea

Answer 26

Induce endometrial atrophy that decrease menstrual flow and cramping

Question 27

Surgical options in ttt dysmenorrhea

Answer 27

• presacral neurectomy PSN (limited evidence)
• laparoscopic uterosacral nerve ablation LUNA (no evidence)
• hysterectomy

Question 28

What is presacral neurectomy

Answer 28

PSN involves total transaction of the presacral nerves lying within the boundaries of the interiliac triangle.

Question 29

Complications of presacral neurectomy

Answer 29

Constipation
Urinary urgency (doesn’t respond to ttt) 5%

Question 30

Laparoscopy findings in a case of dysmenorrhea

Answer 30

endometriosis is present at laparoscopy in 12–32% of women, but it may be found in up to 50% of teenagers.

Question 31

What not to do when treating dysmenorrhea

Answer 31

• spinal manipulation
• uterosacral ligament resection

Question 32

Mechanism of action of NSAID (mefenemic acid)

Answer 32

inhibit the COX enzymes and production of prostaglandins.

Question 33

Indication of use of mefenemic acid

Answer 33

• Dysmenorrhoea (first-line drug).
• HMB.

Question 34

Indication of use of mefenemic acid

Answer 34

• Dysmenorrhoea (first-line drug).
• HMB.

Question 35

Typical dose of mefenemic acid

Answer 35

500 mg tds

Question 36

SE of mefenemic acid

Answer 36

indigestion, diarrhoea, headache, and drowsiness. Rare: worsening of asthma, peptic ulcers.

Question 37

CI of mefenemic acid

Answer 37

Peptic ulcer
Asthma