Menstrual Irregularities

Question 1

Define primary dysmenorrhea.

Answer 1

Painful menses in the absence of other pelvic pathology, usually occurs in the first few years after menarche
(Rare for secondary dysmenorrhea to present at menarche, since it is usually due to acquired pelvic pathology)

Question 2

Why does primary dysmenorrhea not typically manifest until 1-2 years after menarche?

Answer 2

Primary dysmenorrhea occurs with ovulatory menses, and menses are typically anovulatory for the first few years after menarche

Question 3

List five risk factors for primary dysmenorrhea.

Answer 3

Smoking
Low BMI
Nulliparity
Abuse
Social disruption
Depression
Visceral pain syndromes incl. irritable bowel, painful bladder

Question 4

What is the pathophysiology of primary dysmenorrhea?

Answer 4

Prostaglandin production stimulates myometrial tone & contractions (prostaglandin F2 alpha also sensitizes nerve fibres to pain)
Compression/ctxn of myometrial blood vessels leads to myometrial ischemia, causing pain

(Women with dysmenorrhea have abnormally high levels of prostaglandins, higher basal uterine tone & higher amplitude ctxns)

Question 5

What tests should be done to work up primary dysmenorrhea?

Answer 5

None are required if history is not suggestive of pathology, exam is normal, and patient responds to therapy (may defer exam in adolescents who respond to therapy)

Question 6

List five possible causes of secondary dysmenorrhea.

Answer 6

STIs
Endometriosis
Congenital genital tract malformations (outflow obstruction)
Adenomyosis
Fibroids
Copper IUD

Question 7

List three medical treatments for dysmenorrhea.

Answer 7

NSAIDs - no evidence that any particular NSAID is superior
CHC
Progestins - DMPA, continuous POP, dienogest, LNG-IUS 52 mg

Question 8

List four surgical treatments for dysmenorrhea.

Answer 8

Excision/ablation endometriosis
LUNA (laparoscopic uterosacral nerve ablation)
PSN (presacral neurectomy)
Endometrial ablation
Hysterectomy

Question 9

Why should you try and avoid/delay laparoscopy for diagnosis of endometriosis?

Answer 9

Try to minimize total number of procedures - repeat procedures may worsen pain due to adhesions, neuropathic pain syndrome

First surgery may improve fertility for women with endometriosis, subsequent surgeries do not seem to have the same effect