Dysmenorrhea Flashcards
Dysmenorrhea is defined as…
Painful menstruation, occurring before and/or during the beginning of menstruation
Primary dysmenorrhea is different from secondary dysmenorrhea in these ways…
Painful menstruation with normal pelvic anatomy - associated with normal ovulatory cycles + typically begins in adolescence
Secondary dysmenorrhea is different from primary dysmenorrhea in these ways…
Painful menstruation associated with underlying anatomic/pathologic pelvic abnormalities
Ex: endometriosis
Individuals with secondary dysmenorrhea are more likely to experience additional symptoms such as…
Irregular uterine bleeding
Chronic pelvic pain
Mid-cycle pain
Dyspareunia (painful intercourse)
Pathophysiology of primary dysmenorrhea involves…
Prostaglandins
People with dysmenorrhea have ____ production of ____ prior to…
Increased production of endometrial prostaglandins, prior to menstruation
Prostaglandins result in…
Stronger, more frequent uterine contractions + vasoconstriction; increased vasopressin and leukotriene levels
Resulting in increased myometrial contractions, reduced uterine blood flow, leading to pain
Risk factors for primary dysmenorrhea
Early menarche (<12 yo)
Under 30 years old
Family hx of dysmenorrhea
Heavy menses, longer menstrual periods
Smoking
BMI under 20
Nulliparity
Symptoms of dysmenorrhea include…
Cramping pain in lower abdominal region
Headache, N/V/D, fatigue, dizziness, bloating
Often comes and goes in cycles
Symptom timeframe for dysmenorrhea is usually…
Few hours before menstruation - peaks, lasts 2-3 days
Diagnosis of primary dysmenorrhea is based upon…
Symptoms + response to therapy, as well as clinical history and physical exam
A thorough medical history to diagnosis primary dysmenorrhea involves…
History of…
Pain (onset, severity, type, location, duration)
Associated symptoms
Family hx of endometriosis
Sexual activity
Menstrual history
Secondary dysmenorrhea should be considered if…
Menstrual pain after years of painless periods that lasts beyond first couple days, or pain at times other than during menstruation
Little to no response to drug therapy
Complaints of heavy bleeding, pain during intercourse, rectal pain
Symptoms often overlap with other conditions, so thorough history necessary
Goals of therapy for dysmenorrhea include…
Relieve symptoms
Minimize time lost from work, school, etc.
Identify patients with possible secondary dysmenorrhea for further assessment
If history does not suggest a secondary cause of dysmenorrhea, we can…
Make a presumptive diagnosis of primary dysmenorrhea, and confirm with 3 month trial of pharmacotherapy
Initiate empiric therapy
A history suggestive of secondary dysmenorrhea requires…
Referral to a physician
Exercise for dysmenorrhea…
Has no strong evidence, but may help + is reasonable to suggest
Regular, low intensity exercise; NOT during dysmenorrhea episode
TENS for dysmenorrhea…
Is found to be more effective than placebo, but has low quality evidence
Alternative for those wanting non-drug options
AE’s for TENS include…
Headache, muscle tightness, redness, burning
Acupuncture and spinal manipulation for dysmenorrhea…
May be beneficial, but likely no evidence to support
Topical heat for dysmenorrhea…
Some evidence to show its comparable to ibuprofen. Combination may be beneficial
Acetaminophen for dysmenorrhea…
May be effective for mild cramping pain (but is inferior to NSAID’s, does not decrease inflammation)
Pamabrom for dysmenorrhea…
May help with bloating (is a mild, short-acting diuretic) - found in Midol
Pyrilamine for dysmenorrhea…
Has not been proven to be effective for menstrual symptoms - often found in combination products
1st line therapy for dysmenorrhea is…
NSAID’s
MOA of NSAID’s is to…
Inhibit cyclooxygenase leading to a reduction in PG synthesis
Efficacy of NSAID’s for dysmenorrhea…
Are effective for pain relief - cramps, headache, and muscle aches
More effective if taken early enough to prevent buildup of prostaglandins
Is there a class difference with NSAID’s?
All are equally efficacious, but can vary by individual.
NSAID’s for dysmenorrhea therapy should be dosed…
Duration? Not looking for specific dose
Upon onset of symptoms, or onset of bleeding - dosed continuously
Loading dose may be appropriate
NSAID’s should be continued for…
3 days
Remember that PG synthesis peaks in about 3 days
A reasonable treatment trial for NSAID’s is…
3 cycles (~3 months)
Common NSAID’s that may be used include…
Ibuprofen
Naproxen
Mefenamic acid
Diclofenac
Flurbiprofen
Mild and typical AE’s of NSAID’s include…
GI irritation
Headache
Dizziness
Drowsiness
Potential severe AE’s of NSAID’s include…
Peptic ulcer
Bronchospasm in hypersensitive patients
Caution in renal dysfunction
Long-term AE’s are typically not an issue
Combined hormonal contraceptives MOA for dysmenorrhea is…
To suppress endometrial proliferation + ovulation - prevents PG + LT production in late luteal phase + decreases volume of menstrual fluid
50-90% of patients achieve pain control within 3-6 months
Is there a class difference between CHC’s?
No - all CHC’s are all similar effective, regardless of route of administration. Continuous use + extended cycle are also effective
CHC’s can be combined with…
NSAID’s
Advantages to using CHC’s for dysmenorrhea include…
Contraceptive + non-contraceptive benefits (regulate cycle, lighter periods, acne…)
Progestin products work by…
Inhibiting ovulation and decreasing menstrual flow
Progestin-only products have less ____ for efficacy, but have been proven…
Evidence for efficacy, have been proven efficacious.
Good option if estrogen is contraindicated
Treatment resistance of dysmenorrhea requires…
Extensive workup, usually guided by laparoscopic findings
