Dysmenorreah Flashcards
Incidence of dymenorreah
It affects between 50% and 90% of menstruating women.
The most common gynaecological symptom reported by women.
When does 1ry dysmenorrhea start
-Usually begins in adolescence after the establishment of ovulatory cycles, therefore starts 6–12 months after the menarche, once cycles are regular.
In 1ry dysmenorrhea, when does the pain starts?
Pain often starts shortly before the onset of menstruation, and lasts for up to 72 hours, improving as the menses progresses.
What is 2ry dysmenorrhea
Menstrual pain associated with underlying pelvic pathology.
When does 2ry dysmenorrhea start
Pain appears after several years of painless periods.
How 2ry dysmenorrhea progress through the cycle
Pain may persist after menstruation finishes, or may be present throughout the menstrual cycle, but exacerbated by menstruation.
Other gynecological symptoms are present with 2ry dysmenorrhea?
Yes
Pelvic examination in 1ry dysmenorrhea
Normal
Pelvic examination in 2ry dysmenorrhea
Abnormal but if normal doesn’t exclude 2ry dysmenorrhea
DD of 2ry dysmenorrhea
- endometriosis
- adenomysosis
- uterine myomas
- endometrial polyps
- cx stenosis
- Obstructive malformations of the genital tract
Pictures of Dysmenorrhea in case of endometriosis
- cyclical or chronic pelvic pain
that frequently occurs prior to menstruation and may be accompanied by: - HMB
- deep dyspareunia.
Picture of Dysmenorrhea in case of adenomyosis
painful menstruation that may be accompanied by HMB.
Picture of dysmenorrhea in case of myoma
lower abdominal pain, accompanied by HMB; a pelvic mass on examination.
Pictures of dysmenorrhea in case of endometrial polyp
Pedunculated submucosal fibroids and endometrial polyps may cause:
* painful menstrual cramps
* abnormal vaginal bleeding
Picture of dysmenorrhea in case of obstructive abnormality in the genital tract
adolescents experiencing dysmenorrhoea in the first 6 months from the start of menarche, or in pubertal age in the case of concealed menstruation.
3ry cause of dysmenorrhea
- Chronic PID.
- Pelvic adhesions.
- Irritable bowel syndrome.
- Inflammatory bowel disease.
- Interstitial cystitis.
- IUD.
Cause of sudden dysmenorrhea
Acute PID
Pain in PID
- lower abdominal pain and tenderness
- dyspareunia
- abnormal vaginal bleeding
- abnormal vaginal discharge.
In acute infection, fever may be present.
Do IUD may cause dysmenorrhea
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.
1st line ttt of dysmenorrhea
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.
If NSAIDS are contraindicated, what is the 2nd line ttt in dysmenorrhea
Acetaminophens
or in addition to an NSAID if the response is insufficient
Role of Codein in ttt of dysmenorrhea
Codeine may be added to acetaminophen or an NSAID if the response is insufficient.
2nd line medical ttt in dysmenorreah
Hormonal ttt
- COC
- Progesterone regimen
Action of COC in ttt of dysmenorrhea
- 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.
Progesterone regimen used in ttt of dysmenorrhea
- DMPA
- POP
- LNG-IUD (ovulation is n’t suppressed)
Action of progesterone regimens in ttt of dysmenorrhea
Induce endometrial atrophy that decrease menstrual flow and cramping
Surgical options in ttt dysmenorrhea
- presacral neurectomy PSN (limited evidence)
- laparoscopic uterosacral nerve ablation LUNA (no evidence)
- hysterectomy
What is presacral neurectomy
PSN involves total transaction of the presacral nerves lying within the boundaries of the interiliac triangle.
Complications of presacral neurectomy
Constipation
Urinary urgency (doesn’t respond to ttt) 5%
Laparoscopy findings in a case of dysmenorrhea
endometriosis is present at laparoscopy in 12–32% of women, but it may be found in up to 50% of teenagers.
What not to do when treating dysmenorrhea
- spinal manipulation
- uterosacral ligament resection
Mechanism of action of NSAID (mefenemic acid)
inhibit the COX enzymes and production of prostaglandins.
Indication of use of mefenemic acid
- Dysmenorrhoea (first-line drug).
- HMB.
Indication of use of mefenemic acid
- Dysmenorrhoea (first-line drug).
- HMB.
Typical dose of mefenemic acid
500 mg tds
SE of mefenemic acid
indigestion, diarrhoea, headache, and drowsiness. Rare: worsening of asthma, peptic ulcers.
CI of mefenemic acid
Peptic ulcer
Asthma
