Dysmenorrhea Flashcards
Define dysmenorrhea
Painful menstruation
- Occurs before and/or during the beginning of menstruation
What is primary dysmenorrhea? (3)
- Painful menstruation with normal pelvic anatomy
- Associated with normal ovulatory cycles
- Typically begins in adolescence once ovulatory cycles established (within first few years after menarche; on average 6-12 months later)
What is secondary dysmenorrhea? (2)
- Painful menstruation associated with underlying anatomic or pathologic pelvic abnormalities
- More likely to experience other symptoms like:
- Irregular uterine bleeding
- Chronic pelvic pain
- Mid-cycle pain
- Dyspareunia
What is the pathophysiology of primary dysmenorrhea? (5)
- Although the exact cause is unknown, prostaglandins are known to have a significant 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
- End result = increased myometrial contractions, reduced uterine blood flow, which leads to PAIN
What are some risk factors for primary dysmenorrhea? (7)
- Early menarche (<12yo)
- Age <30
- Family history of dysmenorrhea
- Heavy menses/longer menstrual periods
- Smoking
- Weight (BMI <20)
- Nulliparity
What is the main symptom of dysmenorrhea?
Spasmodic (cramping) pain in lower abdominal region
- May radiate to lower back or thighs
With dysmenorrhea, other symptoms may include: (5)
- Headache
- NVD
- Fatigue or trouble sleeping
- Dizziness
- Bloating
What is the symptom timeframe of dysmenorrhea?
Few hours before menstruation –> peaks –> lasts 2-3 days
How is primary dysmenorrhea diagnosed?
Based upon symptoms and response to therapy and on clinical history and physical exam
Diagnosis of either type of dysmenorrhea requires a thorough medical history, which would include assessing what things? (5)
- Pain: onset, severity, type, location, duration
- Associated symptoms
- Family history of endometriosis
- Sexual activity
- Menstrual history: age at menarche, cycle regularity, time since menarche, estimated menstrual flow
When diagnosing dysmenorrhea, we would consider secondary if the person has any one or multiple of the following: (8)
- 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
(Symptoms overlap with other conditions so a thorough history is necessary)
What are the goals of therapy for dysmenorrhea treatment? (3)
- 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, a presumptive diagnosis of primary dysmenorrhea may be made and confirmed with a _ month trial of pharmacotherapy (empiric therapy is initiated)
3
A history suggestive of secondary dysmenorrhea requires:
referral to a physician
What are 6 potential non-pharm treatment options for dysmenorrhea?
- Exercise
- TENS (transcutaneous electrical nerve stimulation)
- Acupuncture/accupressure
- Spinal manipulation
- Topical heat
- Others
- Vitamins, minerals, supplements
Exercise for dysmenorrhea treatment. Yay or nay? (2)
- Regular, low intensity exercise
- No strong evidence from RCTs, but may help and is reasonable to suggest.
Yay
What to know about TENS for dysmenorrhea treatment? (3)
- High frequency TENS found to be more effective than placebo
- Alternative for those wanting non-drug
- AEs: headache, muscle tightness, redness, burning
Topical heat for dysmenorrhea. What to know?
Some evidence to show its comparable to ibuprofen and combination may be beneficial
What are some potential OTC agents to use for dysmenorrhea? (4)
- Acetaminophen
- May be effective for mild cramping pain - Pamabrom
- Mild, short-acting diuretic - Pyrilamine
- Not been proven to be effective for menstrual symptoms - NSAIDs
What is the MOA of NSAIDs in dysmenorrhea?
Inhibit COX, meaning prevents synthesis of prostaglandins which is what is thought to be the main cause of the pain
What is THE first line option for dysmenorrhea?
NSAIDs (for pain relief and improved daily activity)
Are any of the NSAIDs more or less efficacious when it comes to dysmenorrhea?
No, they are all equally efficacious (as a class) for symptoms, so trial and error might be needed to find best one for pt
A reasonable treatment trial for NSAIDs in dysmenorrhea is?
~3 cycles
How might NSAIDs be dosed for dysmenorrhea? (No numbers) (3)
- Initiate with onset of symptoms OR with onset of bleeding - dose continuously
- Continue for ~3 days
- May begin with a loading dose
In terms of minor ailment prescribing, what NSAIDs can we give for dysmenorrhea and how much supply?
Sufficient quantity for 3 consecutive cycles
- Can give quantity for 5 days of treatment and up to 6 cycles
I. Ibuprofen
II. Mefenamic Acid
III. Naproxen base
IV. Naproxen sodium
V. Diclofenac potassium
VI. Flurbiprofen
What is the MOA of combined hormonal contraceptives for dysmenorrhea?
Suppresses endometrial proliferation and ovulation; this prevents PG and LT production in the late luteal phase and decreases the volume of menstrual fluid
What place in therapy do CHCs have for dysmenorrhea?
- 1st or 2nd line, depending on the situation
- Can combine with NSAIDs
What is an advantage to CHCs for dysmenorrhea?
Contraceptive and non-contraceptive benefits
- Address many factors relevant to adolescents
Progestin only products for dysmenorrhea. Yay or nay?
- Not as well studied, and no head-to-head studies, but have also been proven efficacious
- Provide progestin only and inhibit ovulation and decrease menstrual flow = no pain
- Yay
