Primary dysmenorrhea and premenstrual syndrome (3.6) Flashcards
Define the following terms:
A) Menerache
B) Dysmenorrhoea
C) Amenorrhoea
D) Primary amenorrhoea
E) Secondary amenorrhoea
F) Dyspareunia
A) Menarche: occurrence of first menstrual period
B) Dysmenorrhoea: painful menstruation
C) Amenorrhoea: absence of menstruation
D) Primary amenorrhoea: failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics
E) Cessation of menses for at least 3 months
F) Painful intercourse
Outline the stages in the menstrual cycle?
See attached image
Outline the menstrual cycle starting from the hypothalamus (e.g. what hormones are involved)
- Hypothalamus releases GnRH
- GnRH stimulates anterior pituitary gland to release gonadotrophic hormones (FSH and LH)
- FSH and LH act on the ovaries: to stimulate follicle development in the ovary
GnRH: gonadotrophin-releasing hormone
FSH: follicle-stimulating hormone
LH: luetinising hormone
What happens in the ovary under FSH influence
20 follicles continue to grow
- Each follicle has an ovum
- one follicle develops faster than the others to become dominant follicle which secretes oestrogens
- Oestrogens secreted by the dominant follicle will decrease FSH secretion via negative feeback to stop growth of other follicles
- The rest of the follicles will degenerate
- Dominant follicle becomes the mature graafian follicle (GF)
What does FSH do?
Follicle stimulating hormone –> main hormone stimulating oestrogen release
- oestrogen controls the proliferative phase of endometrium, which causes endometrium to regnerate (thickens + increase vascularity)
> occurs from day 5 or 6 until mid-cycle
- High estrogen level in mid cycle leads to surge of LH secretion
What does LH do?
LH: main hormone controlling subsequent progesterone secretion from the corpus luteum
- stimulates ovulation in mid cycle
- Graafian follicle swells and ruptures –> release of ovum
fertilisation possible
Provide a summary of the 28 day menstrual cycle
What is dysmenorrhoea? What are the types?
Recurrent, cramping pain associated with menstruation
- Primary dysmenorrhoea (no pathology)
- Secondary dysmenorrhoea
Most common gynaecological symptoms reported by women:
- 70% of adolescent or young woman, 40 % of adult women
- decreases with age
What causes secondary dysmenorrhoea? What is the pathophysiology of secondary dysmenorrhoea?
Causes:
- Endometriosis
- Endometrial polyps
- Fibroids
- Uterine myomas
- Cervical stenosis
- PID
- IUD use
- Obstructive malformations of the genital tract
Pathophysiology: see attached image
What are some risk factors for dysmenorrhoea?
- Early menarche
- Heavy and increased duration of menstrual flow
- Family history
- Smoking
- Obesity
- Social environment: fewer social support, stressful close relationships
- Lower socioeconomic status
- Depression
- Nulliparity
- Usually improves symptoms after childbirth and/or 3rd decade of reproductive life
What are some symptoms that a patient would experience?
Cramping, suprapubic pain
- Across the lower abdomen (stomach)
- May extend to lower back, thighs
> Starts several hours or about 1 day before start of menstruation, may persist upto 2-3 days
> peak pain is with maximum blood flow
> pain slowly settles after bleeding starts
other symptoms: diarrhoea, nausea and vomiting, lightheadedness, diziness and fever
other causes of pelvic pain (i.e IBS, IBDM chronic PID etc) may worsen
How to diagnose (patient assessment)?
- Menstrual history
- age of patient
- age at menerache
- start of dysmenorrhoea
- length and regularity of cycles
- dates of law few periods
- duration of periods
- amount of bleeding
- Pain nature:
- type, location, radiation
- timing in relation to menstruation
- severity, duration, progression
- associated symptoms (i.e. diarrhoea etc)
- degree of disability (effect on QOL) –> work/school days missed
- Rule out secondary dysmenorrhoea –> see next slide
How to differentiate primary from secondary dysmenorrhoea?
What’s the 1st line, 2nd line and other agents used for the treatment of dysmenorrhea
See attached image (NSAIDs purposely left out cos its on the table)
What are some therapeutic approaches (non-pharmacological) to dysmenorrhoea?
- High frequency transcutaneous electrical nerve stimulation (TENS) –> good evidence
- Exercise
- Acupuncture
- Topical heat therapy –> as effective as ibrupofen 400mg TID
- Biofeedback, relaxation, hypnotherapy (behavioral interventions)
What is premenstrual syndrome (PMS)
PMS is caused by fluctuations in hormone levels five to ten days before the start of menstruation
- Wide range of symptoms –> both physical and psychological
Cyclic recurrence of symptoms during the luteal phase of menstrual cycle
>often symptoms dissipate with onset of menses
>mixture of mood, physical and cognitive symptoms
- Symptoms usually begin 25-35 years of age
- 85% report one or more symptoms of PMS
- Genetics: family history
- Precise pathology unclear, some suggest complex interaction between ovarian steroids and serotonin and GABA neurotransmitters
- Severe PMS = Pre-menstrual dysphoric disorder (PMDD)
What are some common symptoms of PMS
See attached image
How to diagnose PMS? what do symptoms have to be?
Symptoms must be:
- limited to luteal phase (often worse few days before menses)
- impacting daily life
- symptoms present for at least 2 previous cycles
- Not explained by some other diagnosis
> Ask about previous cycles (Diary over 3 cycles)
Symptoms - patient assessment
Onset of symptoms
- Experienced 7-14 days before menses
- Disappear a few hours after onset of menses
Patient age
- Most common in 30s and 40s
Presenting complaints
- Symptoms suggestive of mental health disorders e.g. low mood, irritability, insomnia
- Cyclical in nature, in conjunction with other symtpoms e.g. breast tenderness, bloating, fluid, retention
What are the affective and somatic symptoms that are in the 5 days before menses in each of the three prior menstrual cycles?
Affective
- Depression
- Angry outbursts
- Irritability
- Anxiety
- Confusion
- Social withdrawal
Somatic
- Breast tenderness
- Abdominal bloating
- Headache
- Swelling of extremities
Symptoms are relieved within 4 days of the onset of menses, without recurrence until at least cycle day 13
What are some non-pharmacological options for PMS?
Patient education
- Biologic basis of PMS –> may help give patient sense of control and relief of symptoms
- Education to establish patient expectations
Daily charting of symptoms –> symptom diary
- Greater awareness of symptoms by patient
Exercise
- Regular, aerobic
- Reduces severity of smyptoms
Adequate rest and relaxation (relaxation courses)
Stress reduction
Dietary
- (sodium restriction –> if fluid retention, bloating, breast swelling)
- (caffeine restriction–> if irritability or insomnia)
What are some pharmacological options for PMS?
NSAIDS
- Most studied for PMS - naproxen, mefenamic acid, however any NSAID could be used
- May help with the physical symptoms of PMS
- Can start a few days before expected menses
What are some complementary medicines for PMS?
What is the therapeutic approach for PMS? When to follow up?
- Individual therapy to target most troublesome symptoms
- Non-pharmacological and symptom diaries should be considered
- Try one agent for 2-4 cycles before switching to the next therapy
What/when to follow up?
- Symptoms - mood, physical symptoms
- How are they in comparison to the start of therapy
- Symptom diary
- Side effects: individualized to the drug therapy
- Additional therapies since the last visit –> consider non-pharmacological, herbals etc
Alarming symptoms –> when to refer?
- If only physiological symptoms are present –> could be mental health condition
- Severe or disabling symptoms –> could indicate more severe form such as PMDD
- Symptoms that worsen or stay the same after onset of menses –> could be secondary causes as PMS symptoms should abate once menstruation starts
