Dysmenorrhoea

Question 1

Dysmenorrhoea - def

Answer 1

Primary dysmenorrhea = no obvious organic cause

Secondary dysmenorrhoea = pain due to an underlying condition

Question 2

Dysmenorrhoea - ax

Answer 2

Hx

1. Timing of pain
2. Severity of pain (+ degree of functional loss)
3. Pelvic pain, deep dyspareunia
4. Previous hx PID or STIs
5. Previous abdominal or genital tract surgery (may cause adhesions)

Question 3

Dysmenorrhoea - ex + ix

Answer 3

Ex

1. Abdo exam - to exclude pelvic masses
2. Pelvic exam - cervical excitation, adnexal tenderness, mobility, masses

Ix

3. STI screen (including Chlamydia swab)
4. U/S - endometriomata, PID sequelae, fibroids, congenital anomalies
5. Laparoscopy - for U/S abnormalities, medical tx failures or concomitant subfertility

Question 4

Primary dysmenorrhoea - overview

Answer 4

1. Diagnosis of exclusion. Definition = menstrual pain without pelvic pathology
2. Caused by vasoactive eicosanoids producing abnormal uterine contractions and decreasing uterine flow, with subsequent ischaemia (similar to what may be seen in angina). Intensity of menstrual cramps and associated symptoms (e.g. nausea, fatigue, bloating) are directly proportional to the amount of eicosanoid produced
3. The most common chronic pelvic pain for women of reproductive age - occurs in 60% of women and 70% of adolescents
4. Colicky, cramping pain occurring during menses. May last for 1-5d, resolving with or before the end of menstruation. Pain may be localised to the pelvis or radiate to the lower back and particularly to the upper and inner thighs
5. Tx = NSAIDs, COCP. COCP acts via ovulation suppression and endometrial thinning, which reduces production of eicosanoid prostaglandin

Question 5

Secondary dysmenorrhoea - causes

Answer 5

1. Endometriosis, adenomyosis
2. PID
3. Pelvic adhesions
4. Fibroids (although not always causal)
5. Cervical stenosis, Asherman’s syndrome, congenital abnormalities causing genital tract obstruction (e.g. non-communicating cornua)

Question 6

Dysmenorrhoea - mx

Answer 6

1. Appropriate reassurance, analgesia
2. Symptom control (5):
   i. Mefenamic acid 500mg tds with each period is effective
   ii. COCP to abolish ovulation
   iii. Data on Mirena IUD demonstrate benefit
   iv. Paracetamol, hot-water bottles, etc., may be helpful for some
   v. TENS, vitamin B1, and magnesium may be of benefit to some women.
3. Tx any underlying causes (3):
   i. Endometriosis—COCP, progestagens, GnRH analogues
   ii. Antibiotics for PID
   iii. Relief of obstruction (usually surgical).
4. Therapeutic laparoscopy—for above indications: gold standard for diagnosis + management of endometriosis, adhesions, or complicated PID.
5. Hysterectomy is now rare for this indication alone.