Dysmenorrhea

Question 1

Dysmenorrhea

Answer 1

Painful periods”.
Crampy, spasmodic pain in lower abdomen.

Usually begins on 1st day of flow, may continue for as long as 3rd day, abruptly ceases when flow ceases.

Most women experience sx when cycle is ovulatory.

May have associated sx → nausea, vomiting, headache, dizziness, fatigue, bloating, diarrhea.

Question 2

dysmenorrhea

2 types

Answer 2

primary

secondary

Question 3

Secondary Dysmenorrhea

Answer 3

Caused by another pathological entity.

Treatment focused on eliminating or modifying the underlying cause.

Question 4

Secondary Dysmenorrhea

Answer 4

Any condition producing cyclic pain of pelvic viscera can induce dysmenorrhea:
Genital obstruction (imperforate hymen, obstructing malformations of vaginal or cervical canals.)
Endometriosis.
PID.
Adhesions.
Tumors.
Myomas.

Question 5

Primary Dysmenorrhea

Answer 5

Painful menses in women with normal pelvic anatomy.

Prevalence highest in adolescent females:
Studies → estimates range from 20-90%
15% with severe dysmenorrhea.
Leading cause of recurrent short-term school absenteeism in adolescent girls in US.

Question 6

Primary Dysmenorrhea

Answer 6

Risk Factors
Age < 20 years.
Attempts to lose weight.
Depression/anxiety.
Disruption of social networks.
Heavy menses.
Nulliparity.
Smoking.

Question 7

Primary Dysmenorrhea

Etiology

Answer 7

Elevated levels of prostaglandin F2a found in endometrium of women with primary dysmenorrhea.
Prostaglandin rises during luteal phase → increases smooth muscle contractility of uterus.

Prostaglandins released in menstrual fluid → cause uterine contractions & pain.

Question 8

Primary Dysmenorrhea

Etiology

Answer 8

Vasopressin → may also play a role by  uterine contractility & causing ischemic pain due to vasoconstriction.
 vasopressin levels found in women with primary dysmenorrhea

Question 9

Treatments

Answer 9

NSAIDs
Best-established initial therapy for dysmenorrhea.
Direct analgesic effect through inhibition of prostaglandin synthesis &  volume of menstrual flow.
All NSAIDs effective.
May be most effective when therapy started before onset of menstrual pain & flow; does not need to be continued after end of flow.

Question 10

Treatment

Answer 10

Oral contraceptive pills
Well-accepted off-label use for ocs.

Proposed mechanism of action → reduced prostaglandin release during menses.

Question 11

Treatment

Answer 11

Other contraceptive methods:
Depo-Provera → most women amenorrheic within 1st year of use.
Extended-cycle pills → less frequent periods.
Mirena IUS →  prevalence of dysmenorrhea from 60% to 29% after 3 months of use.
Patch → not as effective as ocs.

Question 12

Other pharmacologic treatments:

Answer 12

Danazol (Danocrine); leuprolide acetate (Lupron)
Suppress menstrual cycle.
Rarely used for primary dysmenorrhea.
Expensive.
Unfavorable side effects:
Induce a pseudo-menopause.

Question 13

Nondrug treatments: (No evidence to demonstrate any of these methods to be effective.)

Answer 13

Heat application – shower, heating pad.
Deep breathing & muscle-relaxing exercises.
Elevating knees while lying down or tucking knees into chest.
Massage.
Mild to moderate exercise.
Low fat vegetarian diet.

Question 14

Complementary & alternative medicines:

Answer 14

Supplements: (in small studies found to be more effective than placebo)
Thiamine 100mg daily.
Vitamin E 2,500 IU taken daily for 5 days starting 2 days before menses.
Omega-3 fats from fish oil supplements 2g daily.

Question 15

Herbal remedies:

Answer 15

Japanese herbal preparation – toki-shakuyakusan (TSS).
Shown to be more effective than placebo in controlled studies.
Product is not regulated → ingredients & effectiveness may vary among formulations.

Insufficient data to evaluate other herbal products.

Question 16

Physical treatments:

Answer 16

Acupuncture & acupressure → limited evidence suggests they are effective.

Transcutaneous electric nerve stimulation (TENS) → insufficient evidence to determine effectiveness.

Spinal manipulation → no evidence to suggest effectiveness.

Question 17

Surgical therapies:

Answer 17

In rare instances, surgical intervention may be considered for tx severe dysmenorrhea.

Refractory dysmenorrhea → accepted indication for hysterectomy.

Laparoscopic uterine nerve ablation & presacral neurectomy have been used.

Evidence insufficient to recommend these procedures regardless of cause of dysmenorrhea.

Question 18

Methods under investigation:

Answer 18

Vasopressin-receptor antagonist being tested.

Frameless levonorgestrel IUD being used in Europe for management of primary & secondary dysmenorrhea.