Gynae: Dysmenorrhea

Question 1

How would you explore the presenting complaint of a patient with dysmenorrhea?

Answer 1

• How long has this been going on for? New onset?
• Where does she experience the pain? What does it feel like?
• When exactly does it happen? (primary dysmenorrhoea often coincides with the start of menstruation; secondary dysmenorrhoea may precede and be relieved by the start.)
• Anything make it better?
• Anything make it worse?

Question 2

What other gynae symptoms are important to ask about when discussing dysmenorrhea?

Answer 2

• Are periods regular? How long do they last?
• Are they heavy?
• Dyspareunia?
• Discharge? Abnormal bleeding? (e.g. PCB)
• Urine/bowel symptoms?
• Bloating, lethargy, weight loss?
• Symptoms of anaemia (especially if menorrhagia)

Question 3

What background history do we need for a patient with dysmenorrhea?

Answer 3

• Gynae history – previous infections, operations, smears
• Obstetric history – and has she ever been trying to get pregnant and not
• PMHx – any other medical problems (e.g. IBS, renal problems)
• FHx, DHx, contraception, smoking, alcohol

Question 4

What is dysmenorrhea?

Answer 4

Painful menstruation, associated with high prostaglandin levels, due to contraction and uterine ischaemia

Question 5

What is the differential diagnosis for dysmenorrhea?

Answer 5

• Simple (primary) dysmenorrhoea is the most common cause of painful periods- no organic cause found. Occurs in 50%, responds to NSAIDS or CCP.
• Secondary dysmenorrhea: fibroids, adenomyosis, endometriosis, PID or ovarian tumours. Pain precedes and is relieved by onset of period.

Question 6

What examinations should you do for dysmenorrhea?

Answer 6

• Speculum examination – for any obvious lesions, discharge, ulceration, smeel, tenderness, visualisation of cervix.
• Bimanual pelvic examination – for fixed retro-verted uterus (endometriosis, PID), nodular “string of beads” uterosarcal ligaments, adnexal tenderness
• Abdominal examination
• Observations: full set – how is the patient systemically

Question 7

What investigations should you do for dysmenorrhea?

Answer 7

• Triple swab assessment: check for infective cause
• Bloods: CA125 (may be somewhat raised in endometriosis), FBC
• Transvaginal USS – may show ovarian endometriomas/fibroids/other lesions
• Standard for endometriosis is laparoscopy +/- biopsy

Question 8

What is endometriosis?

Answer 8

• Ectopic endometrial tissue outside the uterine cavity.
• It may arise from retrograde menstruation, haematogenous spread, or coelomic metaplasia (less popular theory).
• Under hormonal control so may bleed cyclically, causing pain.
• Regresses after menopause and during pregnancy.
• Occurs throughout pelvis, can reach lungs. If severe, pelvis can be’ frozen’ due to adesions
• Complications include: adhesions (which may impact fertility), menstrual disturbance (may occur if there is extensive ovarian involvement

Question 9

Describe a typical history and examination findings for a patient with endometriosis

Answer 9

• Hx: Sx often absent, can be cyclic chronic pelvic pain. May present c/o dysmenorrhoea before period, deep dysparenuria, subfertility, pain on passing stool. Rupture of endometrioma cause pain
• O/E: tenderness/ thickening behind uterus or in adnexa. Retroverted+immobile uterus if severe. May be able to visualise it with speculum. If mild, pelvis will feel normal.

Question 10

What are the medical and surgical options for endometriosis?

Answer 10

Medical:
•Combined OCP (negative feedback on gonadotropin release – inhibits ovulation + thickens cervical mucus + thins endometrium)
•cyclical or continuous progestogens (S/E – weight gain, fluid retention, erratic bleeding)
•Gonadotrophin releasing hormone analogues (limited to 6 months due to menopausal-type side effects including on bone mineral density)
•Progesterone IUS (prevents implantation and inhibits penetration of sperm into uterus by causing changes in cervical mucus)

Surgical:
•laparoscopic laser ablation/diathermy – symptomatic improvement in 70%
•TAH+Bilateral Ssalpingo-oophrectomy – “last resort”

Question 11

What is chronic pelvic pain syndrome? What is the management?

Answer 11

-Intermittent or chronic pelvic pain of >6 months, with no known organic cause.
-Non-gynaecological problems may be the cause; IBS is common and psychological factors may be important (including significantly increased levels of childhood sexual or physical abuse).
-Management options include counselling and reassurance, gastroenterology referral, laser uterosacral nerve ablation, TAH + BSO.