Dysmenorrhoea Flashcards
What is meant by dysmenorrhoea?
Painful periods
What is the nature of the pain of dysmenorrhoea?
crampy lower abdominal pain, which starts at the onset of menstruation
What are the 2 categories that dysmenorrhoea can be classed into?
- Primary dysmenorrhoea
- Secondary dysmenorrhoea
What is the difference between primary and secondary dysmenorrhoea?
Primary dysmenorrhoea occurs with no underlying pelvic patholoy, whereas secondary is associated with pelvic pathology
What is the physiology that results in menses?
- in the absence of fertilisation of the egg, the corpus luteum regresses and there is subsequent decline in oestrogen and progesterone production
- endoetrial cells respond to decline in progesterone with prostaglandin release
- prostaglandin release causes:
- spinal artery vasospasm - leading to ischaemic necrosis and shedding superficial layer of endometrium
- increased myometrial contractions
What is thought to cause primary dysmenorrhoea?
Thought to occur secondary to excessive release of prostaglandins (PGF2α and PGE2) by endometrial cells
may also relate to neuropathic dysregulation, venous pelvic congestion, psychological causes
What are 8 underlying causes for secondary dysmenorrhoea?
- Endometriosis
- Adenomyosis
- PID
- Pelvic adhesions
- Fibroids (not always)
- Cervical stenosis (iatrogenic post-LLETZ or instrumentation)
- Asherman’s syndrome
- Congenital abnormalities e.g. non-communicating cornua
What are 5 risk factors for primary dysmenorrhoea?
- Early menarche
- Long menstrual phase
- Heavy periods
- Smoking
- Nulliparity
What is the typical description of dysmenorrhoea?
- lower abdominal or pelvic pain, which can radiate to the lower back or anterior thigh
- Crampy pain
- Lasts for 48-72 hours around the menstrual period
- Characteristically worst at onset of menses
What are 2 places where primary dysmenorrhoea pain can radiate to?
Lower back or anterior thigh
How long does primary dysmenorrhoea pain usually last for each time is occurs?
48-72 hours
What are 5 symptoms that dysmenorrhoea pain may be associated with?
- Malaise
- Nausea
- Vomiting
- Diarrhoea
- Dizziness
What may be present on examination in primary dysmenorrhoea?
usually unremarkable, uterine tenderness may be present
Following what may primary dysmenorrhoea resolve?
Pregnancy
What are the 4 main causes of secondary dysmenorrhoea to exclude before a diagnosis of primary dysmenorrhoea is made?
- Endometriosis
- Adenomyosis
- Pelvic inflammatory disease
- Adhesions
What are 2 non-gynaecological differentials for primary dysmenorrhoea?
inflammatory bowel disease and irritable bowel syndrome
What are the investigations in primary dysmenorrhoea based upon and what are 2 examples?
No specific investigations, based on ruling out underlying pathology
- If risk of STI, high vaginal swab and endocervical swabs
- Tranvaginal ultrasound (TVS) if pelvic mass on examination
What is the aim of management of primary dysmenorrhoea?
symptomatic improvement
What are 3 groups of ways to manage primary dysmenorrhoea?
- Lifestyle changes
- Pharmacological
- Non-pharmacological
What key lifestyle change is recommended as treatment for primary dysmenorrhoea?
stop smoking -clear relationship with primary dysmenorrhoea
What are the first and second line treatments for primary dysmenorrhoea?
- First line: analgesia (NSAIDs±paracetamol)
- Second line: 3-6 months trial of hormonal contraception
What are the 2 key options for analgesia for primary dysmenorrhoea?
- NSAIDs: ibuprofen, naproxen, mefenamic acid
- Used ± paracetamol
How do NSAIDs work to treat dysmenorrhoea?
inhibit production of prostaglandins, which are implicated in the pathogenesis of primary dysmenorrhoea
What are 2 types of hormonal contraception that can be used in a 3-6 months trial to treat primary dysmenorrhoea?
- Monophasic combined oral contraceptive pill - first line
- Intrauterine system (e.g. Mirena coil)
What are 2 non-pharmacololgical options to treat primary dysmenorrhoea?
- Local application of heat (water bottles or heat patch)
- Transcutaneous electrical nerve stimulation (TENS)
What is pelvic inflammatory disease?
Infective inflammation of the upper genital tract in females, which affects the endometrium uterus, fallopian tubes, ovaries and peritoneum
In which group of patients is the prevalence of PID highest?
sexually active women aged 15 to 24
What are 5 anatomical structures that can be affected by PID?
- Endometrium
- Uteris
- Fallopian tubes (salpingitis)
- Ovaries
- Peritoneum
What causes pelvic inflammatory disease?
spread of bacterial infection from the vagina or cervix to the upper genital tract
What 2 types of STI are responsible for 25% of cases of PID?
- Chlamydia trachomatis
- Neisseria gonorrhoea
What are 5 types of bacteria which can cause PID?
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Streptococcus
- Bacteriodes
- Anaerobes
What are 7 risk factors for pelvic inflammatory disease?
- Sexually active
- Aged 15-24
- Recent partner change
- Intercourse without barrier contraceptive protection
- History of STIs
- Person history of PID
- Instrumentation of the cervix
How can instrumentation of the cervix lead to PID? What are 3 examples of instrumentation of the cervix?
Inadvertently introducing bacteria into female reproductive tract
- Gynaecological surgery
- Termination of pregnancy
- Insertion of intrauterine contraceptive device
What are 6 possible symptoms of PID? What are 3 further symptoms in advanced cases?
- Lower abdominal pain
- Deep dyspareunia
- Menstrual abnormalities e.g. menorhagia, dysmenorrhoea, IMB
- Post-coital bleeding
- Dysuria
- Abnormal vaginal discharge (especially if purulent or with unpleasant odour)
If advanced:
- Severe lower abdominal pain
- Fever >38oC
- Nausea and vomiting
What are 4 possible features on vaginal examination in PID?
- Tenderness of uterus/ adnexae
- Cervical excitation (on bimanual palpation)
- Palpable mass in lower abdomen
- Abnormal vaginal discharge
What are 4 possible differentials for pelvic inflammatory disease?
- Ectopic pregnancy
- Ruptured ovarian cyst
- Endometriosis
- UTI
What are 7 possible investigations for suspected PID?
- Endocervical swabs: for gonorrhoea and chlamydia
- High vaginal swab: trichomonas vaginalis and bacterial vaginosis
- Full STI screen - HIV, syphilis, gonorrhoea, chlamydia = minimum
- Urine dispstick ± MSU (UTI)
- Pregnancy test
- Transvaginal ultrasound scan - if diagnostic uncertainty or severe
- Laparoscopy - severe/uncertainty
How is testing from endocervical and high vaginal swabs performed in the UK and what should be remembered about this technique?
Testing is via nucleic acid amplification (NAAT)
negative swabs do not exclude the diagnosis
What 4 STIs should be screened for when investigating suspected PID as a minimum?
- Chlamydia
- Gonorrhoea
- HIV
- Syphilis
When might you consider performing transvaginal ultrasound scan for suspected PID?
If there is severe disease or diagnostic uncertainty
What is the difference between double and triple swabs?
- Double swabs: endocervcial NAAT swab and high vaginal charcoal media swab
- Triple swabs: endocervical NAAT swab, high vaginal charcoal media swab, endocervical charcoal media swab
What 2 infections can the endocervical NAAT be used to detect?
chlamydia and gonorrhoea
What can the endocervical charcoal media swab be used to detect?
gonorrhoea
What 4 infections can the high vaginal charcoal media swab be used to detect?
- Trichomonas vaginalis
- Bacterial vaginosis
- Group B streptoccocus
- Candida
What is laparoscopy used for in suspected PID and when should it be used?
- used to observe gross inflammatory changes and to obtain peritoneal biopsy
- indicated only in severe cases where there is diagnostic uncertainty
What is the mainstay in the management of pelvic inflammatory disease?
Antibiotic therapy - 14 day course broad spectrum with good anaerobic coverage
What kind of antibiotics are used to treat PID?
- broad spectrum antibiotics with good anaerobic coverage for 14 days
- Options include:
- doxycycline, ceftriaxone and metronidazole
- Ofloxacin and metronidazole
When should antibiotics be started for PID?
Commence immediately, before result of swabs available
In addition to antibiotic management, what are 4 other aspects of management of PID?
- Anagesics e.g. paracetmol
- Rest and avoid sexual intercourse until abx course completed and partner(s) treated
- All sexual partners from past 6 months should be tested and treated to prevent recurrence and spread
- Sometimes admitted to hospital
What are 5 situations when someone with PID should be admitted to hospital?
- Pregnant and especially if risk of ectopic
- Severe symptoms: nausea, vomiting, high fever
- Signs of pelvic peritonitis
- Unresponsive to oral antibiotics, need for IV therapy
- Need for emergency surgery or suspicion of alternative diagnosis
What 2 things increase the risk of complications of PID?
- Repeated episodes of pelvic inflammatory disease (recurrent PID)
- Delaying treatment
What are 5 possible complications of PID?
- Ectopic pregnancy
- Infertility
- Tubo-ovarian abscess
- Chronic pelvic pain
- Fitz-Hugh Curtis syndrome
Why can ectopic pregnancy occur as a complication of PID?
due to narrowing and scarring of Fallopian tubes
What proportion of women with PID suffer from infertility?
1 in 10
What is Fitz-Hugh Curtis syndrome?
complication of PID; perihepatitis that typically causes right upper quadrant pain
What are 3 aspects of counselling to consider for a patient being treated for PID?
- Offer advice regarding practice of safer sex and consistent use of condoms
- Regular STI screening should be encouraged
- Inform about potential long-term sequelae of PID
What is endometriosis?
chronic condition in which endometrial tissue is located at sites other than the uterine cavity
What are 7 examples of places where endometrial tissue can be located in endometriosis?
- Ovaries
- Pouch of Douglas
- Uterosacral ligaments
- Pelvic peritoneum
- Bladder
- Umbilicus
- Lungs
In which age group of women is a diagnosis of endometriosis most common?
between ages 25 to 40
What location of endometrial tissue outside of the endometrium gives it a different name, other than endometriosis?
Endometrial tissue in uterine muscle (myometrium) - adenomyosis
What is thought to be a potential cause of endometriosis in pathophysiological terms?
Retrograde menstruation: endometrial cells travel backwards from uterine cavity, through fallopian tubes, and deposit on pelvic organs where they can seed and grow
these cells may be able to travel to disant sites through lymphatic system and vasculature
What is the symptomatology of endometriosis dependent on and why?
Dependent on individual’s menstrual cycle - because endometrial tissue is sensitive to oestrogen
Will have bleeding from ectopic tissue during menstruation, resulting in pain and bloating/ distension at ectopic sites
What can bleeding from endometriosis sites lead to in the long term?
Repeated inflammation and scarring can occur, leading to adhesions
What are 2 situations when symptoms of endometriosis will be reduced?
- Pregnancy
- Menopause
What are 6 risk factors for endometriosis?
- Early menarche
- Family history of endometriosis
- Short menstrual cycles
- Long duration of menstrual bleeding
- Heavy menstrual bleeding
- Defects in the uterus or fallopian tubes
What are 8 symptoms of endometriosis?
- Cyclical pelvic pain - occurs at time of menstruation/ immediately before
- Constant pelvic pain - if adhesions have formed
- Dysmenorrhoea
- Dyspareunia
- Dysuria
- Dyschezia (difficult, painful defecating)
- Subfertility
- Focal symptoms of bleeding if endometriosis at distant sites
What is 1 example of a feature of endometrial tissue at a distant site?
haemothorax - if ectopic tissue in lungs
What are 3 possible findings on bimanual examination of endometriosis?
- Fixed, retroverted uterus
- Uterosacral ligament nodules
- General tenderness
What are 4 differentials to rule out when diagnosing endometriosis?
- Pelvic inflammatory disease
- Ectopic pregnancy
- Fibroids
- Irritable bowel syndrome
What is the gold standard investigation of endometriosis?
Laparoscopy
Why is laparoscopy particularly useful in suspected endometriosis and what are 3 possible findings?
Useful at differentiating between endometriosis and pelvic inflammatory disease
- Chocolate cysts
- Adhesions
- Peritoneal deposits
What is chocolate cyst?
- Dark brown ovarian cyst - fluid filled, have their colour due to bleeding into them
- (aka endometriomas)
In addition to laparoscopy, what is another investigation that can be performed in suspected endometriosis?
Pelvic ultrasound scan
What is the purpose of performing a pelvic ultrasound scan in endometriosis?
Can determine severity of endometriosis and should be performed before any surgery
What are 2 things that a skilled operator may be able to demonstrate on pelvic ultrasound in endometriosis?
- Kissing ovaries: bilateral endometrioma adherent together
- Pelvic mobility can be demonstrated, including any bowel involvement
What is the treatment in endometriosis based upon?
individual requirements of each patient; if asymptomatic, no treatment neeed
What are 3 aspects of management of endometriosis?
- Pain treatment
- Ovulation suppression
- Surgery
What type of pain management may be used for endometriosis?
Analgesia or NSAIDs; follow analgesic ladder
Why might you aim to achieve ovulation suppression in endometriosis?
can cause atrophy of endometriosis lesions and therefore reduction in symptoms
How long is ovulation suppressed in endometriosis?
6-12 months
What are 4 types of hormone thearpy that can be used to achieve ovulation suppression in endometriosis?
- COCP - low dose
- Norethisterone - synthetic progesterone
- Injected hormones
- Intrauterine devices e.g. Mirena
What are 4 types of surgery which can be used to manage endometriosis?
- Excision
- Fulgaration - diathermy
- Laser ablation
- Hysterectomy and removal of ovaries with hormone replacement until menopausal
What is a limitation of surgical management of endometriosis such as ablation, fulgaration, excision?
relapses will almost certainly occur, surgery may have to be repeated
What may end up being the ultimate management of endometriosis?
hysterectomy with removal of ovaries and hormone replacement until menopausal age
