Dysmenorrhoea

Question 1

Definition and pathogenesis

Answer 1

Excessive pain during menstrual period
Can be primary or secondary
Thought to be due to prostaglandins and leukotrienes in menstrual fluid causing vasoconstriction in uterine vessels leading to uterine contractions

Question 2

Primary dysmenorrhoea

Answer 2

No pelvic pathology
Effects up to 50% of women
Appears within 1-2 years of menarche
Pain starts just before or within 1-2 hours of onset of period and lasts 1-3 days
Pain is suprapubic cramping
NSAIDs are effective - stop prostaglandin production
COCP is second line

Question 3

Secondary dysmenorrhoea

Answer 3

Typically starts several years after menarche
Pelvic pathology
Pain tends to start 3-4 days before onset of period
Refer to gynaecology for assessment

Question 4

Causes of secondary dysmenorrhoea

Answer 4

Endometriosis
Adenomyosis
PID
IUDs
Fibroids

Question 5

Risk factors

Answer 5

Very common!
Longer periods
Early menarche
Smoking
Alcohol
Obesity
Mental health problems
Note: childbirth and increasing age reduce

Question 6

Elicit in history

Answer 6

Age at menarche
Cycle length and regularity and duration of bleeding
Timing of pain related to period
Location of pain (suprapubic, back of legs/lower back)
Smoking history
Sexual history
Obstetric and contraceptive history
Sx of underlying pathology - discharge, IMB, PCB, dyspareunia
Dyschezia, rectal pain/bleeding (endometriosis)

Question 7

Possible signs on examination

Answer 7

Adenomyosis - uterus enlarged, tender, “boggy”
Endometriosis - generalised pelvic tenderness. May be fixed and retroverted due to adhesions and may be nodules in uterine ligament

Question 8

Investigations

Answer 8

Speculum
Swabs (high vaginal, chlamydia)
Smear if due
Pelvic US: if uterine enlarged or adenexal mass present
TVUS
In specialist care: MRI, laparoscopy/laparotomy with biopsy

Question 9

Conservative management

Answer 9

Education/reassurance
Smoking cessation
TENS
Tea (normal, camomile, mint)
Abdominal/back massage/lying supine
Heat

Question 10

Medical management

Answer 10

NSAIDs - effective
Hormonal contraceptives (COCP, POP, IUS)

Question 11

Surgery

Answer 11

Well, not really
Laparascopic uterine nerve ablation has been used but NOT RECOMMENDED
Hysterectomy if particularly bad
Thermal or laser ablation for endometriosis