Dysmenorrhea Flashcards
What is dysmenorrhea?
painful menstruation
-before and/or during the beginning of menstruation
What is the most common gynecological symptom reported by those who menstruate?
dysmenorrhea
When is dysmenorrhea most commonly seen?
late adolescence and early 20s
What is the significance of dysmenorrhea in terms of daily life?
can be incapacitating
-leading cause of absenteeism from school/work for young women
Describe primary dysmenorrhea.
painful menstruation with normal pelvic anatomy
associated with normal ovulatory cycles
typically begins in adolescence once ovulatory cycles established
-with first few years after menarche; avg 6-12 mo later
Describe secondary dysmenorrhea.
painful menstruation associated with underlying anatomic or pathologic pelvic anatomies
more likely to experience symptoms like:
-irregular uterine bleeding
-chronic pelvic pain
-mid cycle pain
-dyspareunia
Provide an overview of the pathophysiology of primary dysmenorrhea.
although exact cause is unknown, PGs have a large role
people with dysmenorrhea have increased production of endometrial PGs prior to menstruation
PGs result in stronger, more frequent uterine contractions (and vasoconstriction)
increased vasopressin and leukotriene levels
What is the end result of the increased endometrial PG production?
increased myometrial contractions and reduced uterine blood flow = PAIN
What are the risk factors for primary dysmenorrhea?
early menarche ( < 12 yo)
age < 30 yo
family history
heavy menses/longer menstrual periods
smoking
BMI < 20
nulliparity
What are the symptoms of dysmenorrhea?
spasmodic (cramping) pain in lower abdominal region
-may radiate to lower back or thighs
may also experience:
-headache
-NVD
-fatigue or trouble sleeping
-dizziness
-bloating
What does the typical symptom timeframe look like for dysmenorrhea?
few hrs before menstruation –> peaks –> lasts 2-3 days
How is primary dysmenorrhea diagnosed?
based upon symptoms & response to therapy and on clinical history and physical exam
What are some important pieces of medical history to gather when suspecting dysmenorrhea?
pain: onset, severity, type, location, duration
associated symptoms
family history of endometriosis
sexual activity
menstrual history: age at menarche, cycle regularity, menstrual flow
When should secondary dysmenorrhea be considered?
menstrual pain after several years of painless periods
sudden occurrence when normally have mild to no pain
complaints of heavy bleeding
dyspareunia
rectal pain
pain at times other than during menstruation
pain persists beyond first couple days of menstruation
little to no response to drug therapy
What are the goals of therapy for dysmenorrhea?
relieve symptoms
minimize time lost from work, school, etc
identify pts with possible secondary dysmenorrhea for further reassessment
If history does not suggest a secondary cause of dysmenorrhea, what can be done next?
diagnosis of primary dysmenorrhea may be made and confirmed with a 3 month trial of pharmacotherapy
What kind of dysmenorrhea history requires referral to a physician?
history suggestive of secondary dysmenorrhea
What are some non-pharm options for dysmenorrhea?
exercise
TENS
acupuncture
spinal manipulation
topical heat
others - vitamins, minerals, supplements
What kind of exercise is recommended for dysmenorrhea?
regular, low intensity exercise
What is the evidence for exercise with dysmenorrhea?
no strong evidence from RCTs but may help and is reasonable to suggest
What is the evidence for TENS with dysmenorrhea?
high frequency TENS found to be more effective than placebo
-alternative for those wanting non-drug
What is the evidence for spinal manipulation in dysmenorrhea?
Cochrane review: no evidence to support
What is the evidence for topical heat in dysmenorrhea?
some evidence to show its comparable to ibuprofen and combination may be beneficial
What are some OTC agents that might be used for dysmenorrhea?
acetaminophen
pamabrom
pyrilamine
NSAIDs
What is the role of acetaminophen in dysmenorrhea?
analgesic effect may be effective for mild cramping pain
-no PG action = no anti-inflammatory component
What is pamabrom?
mild, short-acting diuretic
What is the role of pamabrom in dysmenorrhea?
might help with bloating
-not a blanket recommendation
What is the role of pyrilamine in dysmenorrhea?
has not been proven to be effective for menstrual sx’s
What is the role of NSAIDs in dysmenorrhea?
1st line for pain relief & improved daily activity
What is the MOA of NSAIDs?
inhibit COX leading to a reduction in PG synthesis
Describe the efficacy of NSAIDs in dysmenorrhea.
efficacious in ~ 80% of patients (if taken early enough)
-more effective the earlier they are taken
in addition to pain relief, they:
-help relieve cramps, headache, and muscle aches
are all equally efficacious
When should NSAIDs be started for dysmenorrhea?
initiate with onset of symptoms OR with onset of bleeding
-dose continuously
How long are NSAIDs used for in dysmenorrhea?
continue using for ~ 3 days
How can NSAIDs be started if fast relief is needed?
may begin with a loading dose
How many cycles is a reasonable treatment trial for NSAIDs in dysmenorrhea?
~ 3 cycles
What are the side effects of NSAIDs?
mild: GI irritation, HA, dizziness, drowsiness
severe: PUD and bronchospasms in hypersensitive pts; caution in renal disease
short-term use: typically not an issue
What is the MOA of CHC in dysmenorrhea?
suppresses endometrial proliferation and ovulation; this prevents PG and LT production in the late luteal phase and decreases the volume of menstrual fluid
Describe the efficacy of CHC in dysmenorrhea.
50-90% achieve pain control within 3-6 months
as a group, all CHCs are similarly effective
continuous-use/extended cycle CHCs and cyclical are all effective
What is the place in therapy for CHC in dysmenorrhea?
1st or 2nd line, depending on the situation
can combine with NSAIDs
What are the advantages of using CHC for dysmenorrhea?
contraceptive and non-contraceptive benefits
-addresses many factors relevant to adolescents
What is the MOA of progestin only products?
inhibit ovulation and decrease menstrual flow
What is the role for progestin only products in dysmenorrhea?
considered when estrogen CI
What is the evidence for progestin only products in dysmenorrhea?
not as well studied, no head-to-head studies but have also been proven efficacious
What is done with treatment resistance?
requires an extensive work-up
treatment is generally guided by laparoscopic findings
-use is reserved due to risks
