Dysmenorrhoea_Flashcards

Question 1

What is dysmenorrhoea?

Answer 1

Dysmenorrhoea is characterized by excessive pain during the menstrual period.

Question 2

What are the two types of dysmenorrhoea?

Answer 2

The two types of dysmenorrhoea are primary and secondary dysmenorrhoea.

Question 3

What characterizes primary dysmenorrhoea?

Answer 3

Primary dysmenorrhoea is characterized by the absence of underlying pelvic pathology.

Question 4

How common is primary dysmenorrhoea among menstruating women?

Answer 4

Primary dysmenorrhoea affects up to 50% of menstruating women.

Question 5

When does primary dysmenorrhoea usually appear?

Answer 5

Primary dysmenorrhoea usually appears within 1-2 years of the menarche.

Question 6

What is thought to be partially responsible for primary dysmenorrhoea?

Answer 6

Excessive endometrial prostaglandin production is thought to be partially responsible for primary dysmenorrhoea.

Question 7

What are the features of primary dysmenorrhoea?

Answer 7

Features of primary dysmenorrhoea include pain that typically starts just before or within a few hours of the period starting, and suprapubic cramping pains which may radiate to the back or down the thigh.

Question 8

What are the management options for primary dysmenorrhoea?

Answer 8

Management options for primary dysmenorrhoea include NSAIDs such as mefenamic acid and ibuprofen, which are effective in up to 80% of women, and combined oral contraceptive pills as second line.

Question 9

What characterizes secondary dysmenorrhoea?

Answer 9

Secondary dysmenorrhoea is characterized by the presence of an underlying pathology.

Question 10

When does secondary dysmenorrhoea typically develop?

Answer 10

Secondary dysmenorrhoea typically develops many years after the menarche.

Question 11

What are some causes of secondary dysmenorrhoea?

Answer 11

Causes of secondary dysmenorrhoea include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices (normal copper coils), and fibroids.

Question 12

What is the Clinical Knowledge Summaries’ recommendation for patients with secondary dysmenorrhoea?

Answer 12

The Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.

Question 13

What is the effect of the intrauterine system (Mirena) on dysmenorrhoea?

Answer 13

The intrauterine system (Mirena) may help with dysmenorrhoea.

Question 14

Summarise dysmenorrhoea

Answer 14

Dysmenorrhoea

Dysmenorrhoea is characterised by excessive pain during the menstrual period. It is traditionally divided into primary and secondary dysmenorrhoea.

Primary dysmenorrhoea

In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.

Features
pain typically starts just before or within a few hours of the period starting
suprapubic cramping pains which may radiate to the back or down the thigh

Management
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line

Secondary dysmenorrhoea

Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids

Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.

*this refers to normal copper coils. Note that the intrauterine system (Mirena) may help dysmenorrhoea

Textbooks

Links
Clinical Knowledge Summaries22
Dysmenorrhoea guidelines

Question 15

Sabrina is a 16-year-old woman presenting with abdominal pains. The abdominal pain was around her lower abdomen and is crampy in nature and occasionally radiates to her back. Her pain normally comes on approximately 4-12 hours before the onset of her menstruation and lasts throughout the menstruation period. She also feels increasingly fatigues during this period. No abdominal pains were noted outwith her menstruation period.

Sabrina has just started menstruation 1 year ago. Her menstrual flow was normal and she only experienced minor pains during her previous menstrual cycles. She is not currently sexually active with no previous sexual partners. She denies any vaginal discharge or bleeding in between cycles. She remains unsure if she wants children in the near future.

Given the likely diagnosis, what is the likely 1st line treatment?

Combined oral contraceptive pill
Intrauterine copper coil
Intravenous ceftriaxone and oral doxycycline
Mefenamic acid
Tranexamic acid

Answer 15

Mefenamic acid

NSAIDs such as mefenamic acid are the first line treatment for primary dysmenorrhoea

This patient likely has primary dysmenorrhoea as her abdominal pains occur close to the period of her menstruation and there are no accompanying symptoms with the abdominal pains. As she is also not sexually active, this makes secondary dysmenorrhoea less likely. Given the lack of risk factors, a pelvic ultrasound is not always necessary and a clinical diagnosis of primary dysmenorrhoea can be made.

The 1st line treatment for primary dysmenorrhoea is a non-steroidal anti-inflammatory medication (NSAID). This can include ibuprofen, naproxen and mefenamic acid. They reduce the severity of the pain by reducing the amount of prostaglandins in the body.

Tranexamic acid, although similar in name to mefenamic acid, is not an NSAID and does not provide any form of analgesia property. This is commonly used as an antifibrinolytic and is commonly used in haemorrhages.

The combined oral contraceptive pill is often helpful in the management of primary dysmenorrhoea but is used when NSAIDs are not tolerated or ineffective at controlling the symptoms.

Intrauterine copper coil should not be used as this can occasionally worsen dysmenorrhoea and can induce menorrhagia as well.

Question 16

A 39-year-old woman presents to her general practitioner with what she describes as ‘Pre-menstrual syndrome’. She describes severe pain that occurs 3-4 days before the start of her period each month which stops her from being able to go to work. She has a regular 29-day cycle which has only started being painful in the past year. She is nulliparous and uses the progesterone-only pill for contraception.

What is the most appropriate management of this patient?

Refer to gynaecology
Trial of combined oral contraceptive pill
Trial of fluoxetine
Trial of intra-uterine device
Trial of tranexamic acid

Answer 16

Refer to gynaecology

All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation

This patient has secondary dysmenorrhoea as her pain precedes the first day of her menstrual cycle. Secondary dysmenorrhoea is associated with pathologies such as pelvic inflammatory disease, endometriosis, adenomyosis, and fibroids. As it is pathological, it must be investigated further with a referral to gynaecology.

The combined oral contraceptive pill may improve her symptoms, depending on the cause, however, it is important that she is investigated first.

Fluoxetine is a selective-serotonin inhibitor that can be prescribed in premenstrual dysphoric disorder (a combination of affective, somatic, and behavioural symptoms which affects women during the luteal phase of their menstrual cycle). It is not appropriate in the management of secondary dysmenorrhoea.

Intra-uterine devices can cause secondary dysmenorrhoea and would not be appropriate.

Tranexamic acid is used in the management of menorrhagia, not secondary dysmenorrhoea.

Question 17

A 37-year-old woman presents to the GP with a 5-month history of painful menstruation. Her menarche was at 13 years old and she had regular 30-day painless cycles but recently, they have been intensely painful, with pain starting 4 days before menstruation. She has no intermenstrual bleeding, dyspareunia, or changes in vaginal discharge, however, she sometimes has postcoital bleeding.

A pelvic and speculum examination shows an enlarged, boggy uterus, but no other abnormalities. She is not planning on having children in the near future and has never been pregnant.

What is the best next step for the GP to take?

Offer mefenamic acid
Offer the combined oral contraceptive pill
Offer the intrauterine system
Refer to a sexual health clinic for further investigations
Refer to gynaecology for further investigations

Answer 17

Refer to gynaecology for further investigations

All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation

The emergence of painful periods or worsening period pain after many years of painless or less painful periods suggests secondary dysmenorrhoea, which is often caused by an underlying pelvic problem (e.g. endometriosis, adenomyosis, fibroids etc.).

Refer to gynaecology for further investigations is correct as although the presence of an enlarged boggy uterus suggests adenomyosis, which can cause secondary dysmenorrhoea, its diagnosis would need confirming in secondary care and is not appropriate in a GP setting. All patients with secondary dysmenorrhoea need a referral to gynaecology for investigations, especially in this case where the patient has post-coital bleeding without associated features of pelvic inflammatory disease (e.g. fever, changes in vaginal discharge, cervical excitation), which is a red flag and may suggest malignancy.

Offer mefenamic acid is incorrect. Although this would be appropriate to relieve pain, and it may be used in the management of adenomyosis, a referral to gynaecology is more important to confirm its diagnosis and refute other possible causes, including malignancy, which can have post-coital bleeding as a feature. Prescribing this may mask the symptoms of an underlying cause, which risks it worsening over time.

Offer the combined oral contraceptive pill (COCP) and offer the intrauterine system are incorrect options as a referral to gynaecology is more important in secondary dysmenorrhoea to confirm an underlying diagnosis and screen for potential malignancy, especially considering post-coital bleeding can suggest its presence. If this patient were to be diagnosed with adenomyosis, the COCP or intrauterine system may be considered, but this can only be done after further investigations in secondary care as this may mask symptoms of a potentially sinister underlying cause.

Refer to a sexual health clinic for further investigations is incorrect as this would be more appropriate if pelvic inflammatory disease were likely, characterised by pelvic pain, dyspareunia, abnormal vaginal discharge, fever, and cervical excitation, which are not seen here.