Dysmenorrhea Flashcards
Definition of dysmenorrhea
Painful menstruation that interferes with daily activities with absence of pain b/w menstrual period
Cause of menstrual cramping
Release of prostaglandin during shedding of uterine lining (in the absence of pregnancy, progesterone level drops and shedding begins)
- causes uterine contractions, cervical dilatation
Primary dysmenorrhea
Painful menstruation that interferes with daily activities with absence of pain b/w menstrual period with NO underlying pathology
Clinical features of primary dysmenorrhea
- Onset of pain within 2 years of menarche
- Cramping begins few hours before onset of menses and persist for hours/days
General sx of dysmenorrhea:
- Lower abdominal pain related to menstrual cycle
- Radiates to back
- A/w nausea, headache
Normal PE
Treatment of primary dysmenorrhea
Analgesia
- Paracetamol
- NSAIDs
Contraceptives
- COCPs
- POPs
- Depo-provera (injectables)
- Implanon
- Mirena
Psychotherapy, hypnotherapy, heat therapy
Secondary dysmenorrhea
Painful menstruation that interferes with daily activities with absence of pain b/w menstrual period WITH underlying pathology
Clinical features of secondary dysmenorrhea
Not limited to duration of menses
Up to 2 weeks before start of menses
A/w other symptoms: Dyspareunia, infertility, AUB
Do U/S pelvis to look for secondary cause
Causes of secondary dysmenorrhea
Structural
- Endometriosis
- Adenomyosis
- Fibroids
- IUCD
- Cervical stenosis (post-instrumentation)
Inflammation
- PID (Acute/ Chronic)
- Pelvic Adhesions (Post-surgical/ post infectious)
Endometriosis
Ectopic endometrial tissue found outside the uterine cavity
- Estrogen dependent, driven by cyclical hormone changes
- A/w inflammatory response of peritoneum
Common sites of endometriosis
Most common: Ovaries
Pouch of Douglas
Uterovesical fold
Posterior pelvic wall and uterosacral ligaments
Uterus, tubes, bowel, ureters, bladder, diaphragm, lung, previous scars (never spleen)
Risk factors of endometriosis
- Nulliparity
- Early menarche
- Low BMI
- High caffeine intake
- Short menstrual cycle
- Prolonged and heavy menstrual bleeding
Protective features for endometriosis
Regular exercise
Prolonged periods of amenorrhea
Smoking
Main symptoms of endometriosis
Dysmenorrhea + Dyspareunia + Dyschezia
- Severe dysmenorrhea 1-2 days before onset of menses
Chronic pelvic pain
- deep, diffuse, dull pain in pelvis
- radiates to back
Infertility
- Adhesions + scarring ->Anatomic distortion of fallopian tubes and ovaries
- Excessive release of prostaglandins, cytokines and chemokines -> chronic inflammatory environment affects ovarian function and endometrial receptivity
Pre-menstrual + post-menstrual spotting
Dyschezia: straining while passing motion
Dyspareunia
- Scarred tissue fix pelvic organs
- Pain when organs move during sex
Local organ involvement symptoms of endometriosis
Bowel symptoms
- Tenesmus
- Diarrhoea, constipation
- PR bleed
- Recurring diarrhea (Deep infiltrating endometriosis)
Bladder = Dysuria
Lung = Hemoptysis (Very rare)
Mood: unexplained fatigue, weariness, depression, anxiety
Physical examination for endometriosis
Abdominal PE
- large endometriotic cyst
Bimanual examination
- Posterior vaginal fornix nodules
- Uterosacral ligament nodules ( pathognomonic sign)
- Adnexal mass, non-mobile and tenderness (enlarged ovaries - endometrioma)
- Fixed retroverted uterus
DRE
- Rectovaginal nodules
- POD nodules
Endometriosis can present with normal PE
