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
- Uterine fibroids
- Fam hx
- Low BMI
- 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
- CYCLICAL PAIN
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
Investigations for endometriosis
- TV Ultrasound (1st line)
- Ovarian endometriosis: Low echo cyst
- Ovaries stuck to uterus, non-mobile and tender
- Bowel endometriosis: Sliding sign negative (POD involvement) - Endometriosis Mapping
Ultrasound Scan - MRI
note: laparoscopy is NO longer the gold standard in diagnosing endometriosis
- Surgical risk
- Missed lesions – inability of many gynaes to identify pathology
- Delays in treatment
Classical description of endometriosis with laparoscopy
Chocolate cyst
- Recurrent swelling and bleeding into the cyst forms old blood which is chocolate in colour
Matchstick deposits
Blue-black gunpowder lesion containing hemosiderin deposits from entrapped blood ++
Management of endometriosis
First line: Dienogest (Visanne) - progestin
- can be used as long term tx
- take continuously everyday
COC
GnRH agonist: induce hypogonadrotropic hypogonadism (reduce estrogen levels)
- temporary
- cannot be used long term
Pain management: panadol, NSAIDs
How long does medical treatment of endometriosis last?
Till menopause
Surgical treatment of endometriosis
Surgical adhesiolysis and excision of endometriosis
THBSO/ Hysterectomy to prevent recurrence
*After surgery, continue patient on long term medical therapy
Investigations for dysmenorrhea
Bloods
- FBC (TW)
Swabs:
* Endocervical swabs for chlamydia/gonorrhoea
* High Vaginal swabs for trichomonas/gardnerella
Imaging
* Ultrasound Pelvis
- Pelvic Inflammatory Disease – Tubo-ovarian abscesses = tubulocystic adnexal masses
- Endometriosis- Low echo ovarian cysts
- Adenomyosis- Globularly enlarged uterus,
thickened myometrium
- Cervical Stenosis- Distension of endometrial cavity with low echo fluid
PE for dysmenorrhea
General inspection
Abdomen
1. Pelvic abdominal masses (Size,
mobility, tenderness)
- Pelvic Examination
- External Genitalia inspection
- Speculum
- Vaginal Discharge (Swabs)
- Masses (Biopsy)
- Opportunistic Cervical
Screening (If not done) - Vaginal Examination
- Cervical Excitation: Pelvic Inflammatory
Disease - Uterine Size
-> Retroverted: Endometriosis
-> Irregularly enlarged- fibroids
-> Globularly enlarged- adenomyosis - Uterosacral Nodules- endometriosis
- Adnexal masses
-> Ovarian cysts: Endometriomas
-> Tubo-ovarian abscesses
