week 4- Dysmenorrhea Flashcards
dysmenorrhea
pelvic pain (cramping) that occurs with menses
primary vs secondary dysmenorrhea
primary dysmenorrhea - menstrual pain with no identifiable pelvic pathology
secondary dysmenorrhea - menstrual pain associated with an identifiable pelvic pathologic condition (e.g. endometriosis, ovarian cysts)
membranous dysmenorrhea
intense cramping pelvic pain associated with the spontaneous sloughing of the endometrium in one piece that retains the shape of the uterine cavity (i.e. a single cast); rare
dysmenorrhea in what % of women
16-91%
Primary vs secondary dysmenorrhea peak onset
primary is in adolescent and early 20s (decrease with age and parity/births)
secondary is 40-50s
risk factors for dysmenorrhea
heavy menses, age, family hx, nulliparity (never given birth)
modifiable: smoking, weight loss attempts, high waist to hip ratio
mental health, social network disruption, sexual abuse
protective factors for dysmenorrhea
exercise, OCP, early childbirth, fish intake
highest OR for risk factors for dysmenorrhe
heavy menstrual flow (4.7)
PMS (2.4)
< 30 yoa (1.9)
primary dysmenorrhea
menstural pain without pathology, usually begins 6-12 months after menarche
diagnosis of primary dysmenorrhea
clinical
-pelvic exam normal
-urine test to rule out pregnancy (hCG) and infection (STIs)
manage primary dysmenorrhea
nonpharmalogical or NSAIDs
sx of primary dysmenorrhea
recurrent, crampy, suprapubic pain occurring just prior to or during menses (typically lasts 2-3 days), with or without radiation to the back or legs; may be associated with nausea, fatigue, bloating, general malaise
causes of primary dysmenorrhea
biological (not psychological or anatomical)
-abnormal and increased prostanoid secretion causing abnormal uterine contractions which reduce uterine blood flow and lead to uterine hypoxia
-drop in prosesterone –> slough endometrial lining –> prostaglandin F released –> contractions
-leukotriene
-vasopressin
what is increased in primary dysmenorrhea and causes uterine contractions
prostanoid (also possibly eicosanoid)
then prostaglandin F released when progesterone drops
leukotreiene
vasopressin
physical exams finding suggest which type of dysmenorrhea
secondary cause of dysmenorrhea (e.g. pelvic mass, uterine outflow obstruction)
pelvic examination vs abdominal exam and inspect external genitalia
-pelvic: sexual active adolescence (high risk of PID)
-ab+ external: no sex
high risk of PID in
adolescents who are sexually active
do pelvic exam if
suspect endometriosis or secondary causes of dysmenorrhea
endometriosis vs adenomyosis vs PID findings on imaging
- endometriosis: fixed uterus or reduced uterine mobility, adnexal masses, and uterosacral nodularity
- adenomyosis: uterine enlargement or asymmetry
- PID: mucopurulent cervical discharge
diagnosing primary vs secondary dysmenorrhea
primary: cramping pain lasts 3 days max and responds to NSAIDs
secondary: variable history and clinical presentation
physical and pelvic exam
primary: normal
secondary: abnormal (+)
imaging for secondary causes i.e. laparoscopy
primary dysmenorrhea vs endometriosis in adolescent
usually primary but if 3-6 months of therapy and still bad check is secondary dysmenorrhea (most common in adolescent in endometriosis)
secondary dysmenorrhea causes
- endometriosis
- adenomyosis
- uterine leiomyomas (fibroids) or uterine polyps
- pelvic inflammatory disease (PID) or pelvic adhesions
- obstructive vaginal or uterine congenital anomalies
- cervical stenosis
- ovarian cysts
other differentials to consider (including non-gynecologic):
- ectopic pregnancy
- malpositioned intrauterine device (IUD)
- urinary tract infection (UTI)
- interstitial cystitis
- irritable bowel syndrome
- musculoskeletal causes (e.g. abdominal wall, pelvic and hip muscles/joints)
endometriosis
chronic, estrogen-dependent condition characterized by ectopic implantation of functional uterine tissue (endometrial glands and stroma) outside the uterine cavity
endometriosis risks
25-29 yrs, caucasian, menorrhagia, nulliparity, …
symptoms of endometriosis
asymptomatic or
chronic and cyclic pelvic pain, dysmenorrhea, dyspareunia, dysuria, dyschezia, sub-fertility or infertility; possibly hyperalgesia
diagnosis of endometriosis
history, pelvic exam, CA125, TVUS, MRI, laparoscopy, histology
tender vaginal exam, palpable nodules in posterior fornix, adrenal mass, uterine immobility
prognosis of endometriosis
infertility, miscarriage, endometrial cancer
3 subtypes of endometriosis
endometrioma,
deep infiltrating endometriosis,
superficial peritoneal endometriosis
findings with high LR+ for endometriosis
palpable abnormality in rectovaginal septum
palpable abnormality in pouch of Douglas
history of pain that increases during menses + infertility
imaging and labs with high LR+ for endometriosis
TVUS- SonoPODogrpahy
MRI
endometriosis classification
superficial vs deep
stage1-4
ovary and peritoneum…
slide 19- 21?????
adenomyosis
ectopic endometrial tissue within the uterine myometrium
risks for adenomyosis
increased estrogen exposure (parity, early menarche, short cycles, high BMI, OCP use..), prior uterine surgery
sx of adenomyosis
dysmenorrhea, menorrhagia, chronic pelvic pain, dyspareunia; asymptomatic
diagnosis test for adenomyosis
TVUS**
pelvic exam: boggy enlarged uterus
blood: CBC, ferritin (anemia)
cure for adenomyosis
hysterectomy
prognosis of adenomyosis
commonly coexists (leiomyoma 50%, endometriosis 11%, endometrial polyps 7%)
transvaginal ultrasound (TVUS) signs of adenomyosis
hyperechoic islands
linear striations
myometrial cysts
s-shaped endometrium
asymmetrical myometrial thickening
uterine leiomyomas (fibroids)
a group of benign smooth muscle tumours
how many female has uterine leiomyomas (fibroids)
70-80% females by age 50
risks for uterine leiomyomas (fibroids)
early menarche, use of OCP before age 16yrs, increased BMI, African-descent
sx of uterine leiomyomas (fibroids)
asymptomatic or pelvic pain, pressure, abnormal vaginal bleeding (AUB)
diagnosis of uterine leiomyomas (fibroids)
TVUS and physical: enlarged irregular uterus
CBC, ferritin (anemia)
uterine (endometrial) polyp
overgrowths of endometrial glands and stroma within the uterine cavity
risks for uterine (endometrial) polyp
abnormal uterine bleeding, unopposed estrogen, chronic tamoxifen use, 40-49 yoa
diansogis of uterine (endometrial) polyp
TVUS, tissue sample, pelvic exam (speculum) see pedunculate endometrial polyp from external os
hCG, CBC, coagulation panel (INR, aPTT, fribrinogen) for anemia and coagulopathy
uterine (endometrial) polyp prognosis
mostly benign
risk of malignancy increase with age and polyp size and postmenopausal, PCOS
pelvic inflammatory disease (PID)
inflammation of the upper genital tract (uterus, fallopian tubes, and/or ovaries) due to infection (most often polymicrobial)
peak incidence of PID
15-25 yrs old, 85% from sexually transmitted bacteria
sx of PID
asymptomatic or pelvic/lower abdominal pain, vaginal discharge, dyspareunia, and/or abnormal uterine bleeding, increased urinary frequency or dysuria
diagnose PID
pelvic exam: adnexal or uterine tenderness, cervical discharge
ESR, CRP elevated
vaginal swab
nucleic acid amplification test (NAAT) for gonorrhoea or chalmydia
PID physical exam findings with higher LR+
NAAT positive for n. gonorrhoea of chlamydia (45-98)
purulent endocervical secretion (3.3)
rebound tenderness (2.5)
determining treatment of PID
sexually active? screen for STI
ab pain?
cervical motion tenderness, uterine tenderness, or adnexal tenderness present
additional test to consider other causes of pain or empirical treatment of PID
(LOOK AT SLIDE 33 flow chart)
(functional) ovarian cyst
fluid-filled structures that may be simple or complex
risk factors for functional ovarian cyst
fertility treatment, Tamoxifen, pregnancy, hypothyroidism, maternal gonadotropins, smoking, tubal ligation
symptoms of functional ovarian cyst
often asymptomatic; unilateral pain/pressure in lower abdomen, pain may be intermittent or constant, characterized as sharp or dull; with rupture - acute, severe pain possibly with N/V
diagnose ovarian cyst
TVUS
hCG (pregnancy) and UA (UTI)
CA125
pelvic exam -palpate enlarged and tender ovary
prognosis of functional ovarian cyst
70-80% spontaneously resolve
but can rupture, hemorrhage, ovarian torsion
ectopic pregnancy
the implantation of an embryo outside of the uterine cavity, most commonly in the fallopian tube (> 90% of ectopic pregnancies)
how many ectopic pregnancies are in fallopian tube
> 90%
risk for ectopic pregnancy
older age, smoking, hx of ectopic pregnancy, tubal surgery, pelvic infections, IUD, assisted reproductive techonologies, DES (estrogen)
sx of ectopic pregnancy
pelvic or abdominal discomfort/pain, nausea/vomiting, syncope, lightheadedness, vaginal bleeding
diagnose ectopic pregnancy
hCG, TVUS
vitals (hypotension, tachycardia)
ab exam: tender, guard
pelvic: palpable adnexal mass
ectopic pregnancy manangemnt
ER (emergent)
prognosis of ectopic pregnancy
100% mortality for developing embryo
maternal mortality in 1st trimester, pregnancy death
interstitial cystitis / bladder pain syndrome (IC / BPS)
a complex, chronic condition characterized by inflammation of the bladder’s lining
possibly
esp older men and women
sx of interstitial cystitis / bladder pain syndrome (IC / BPS)
suprapubic pelvic discomfort/pressure/pain > 6 weeks (worse with bladder filling, relieved with urination), severe urinary frequency, urinary urgency, nocturia; possibly dysuria, dyspareunia
what type of diagnosis is interstitial cystitis / bladder pain syndrome (IC / BPS)
by exclusion
diagnostic tests for interstitial cystitis / bladder pain syndrome (IC / BPS)
CBC, FBS, HbA1c, electrolytes, creatinine/eGFR, ALT, albumin
urine culture negative
neurological; CN, reflexes, power
pelvic exam, cystoscopy
diagnosis of exclusion
prognosis of interstitial cystitis / bladder pain syndrome (IC / BPS)
can last for 9 yrs, psychological and social health, sleep, sex, anxiety/depression
irritable bowel syndrome (IBS) ROME IV criteria
recurrent abdominal pain at least 1 day per week in the last 3 months, and is associated with at least two of the following: defecation, change in stool frequency, and/or change in stool appearance (form)
risks for IBS
psychologic distress, Hx of gastroenteritis (e.g. norovirus, rotavirus), ingestion of food high in fermentable carbohydrates, visceral hyperalgesia
sx of IBS
altered motility (constipation or diarrhea), cramping (often lower quadrants, relieved with BM), abdominal distention, sensation of incomplete evacuation, mucous with stool, urgency; fatigue, chronic headaches, disturbed sleep, anxiety and/or depressed mood
diagnose IBS
history and physical exam, ROME IV criteria
CBC, BMP (FBG, electrolytes, BUN, creatinine), CRP, IgA, fecal calprotectin, TSH, LFTs
SLIDE 39-41 for diagnosing dysmenorrhea
normal history and physical = primary dysmenorrhea
if trial OCP or NSAID and gets better in 6 months then its primary dysmenorrhea
if have ESR, CBC, urinalysis, gonororrhea or chlamydia then treat as secondary dysmenorrhea for PID
CONTTT
primary and secondary dysmenorrhea will
respond to the same treatment
so initial treatment doesnt need a precise diagnosis
dont need pelvic exam before initiating treatment
when is pelvic exam indicated
in patients not responding to conventional therapy and when organic pathology is suspected.
first line for dysmenorrhea
NSAIDs
hormonal therapies for primary dysmenorrhea
offered to women and girls who are not currently
planning pregnancy unless contraindications exist.
are combined hormonal contraceptives recommended for primary dysmenorrhea (consensus guideline)
yes
alternative therapies for primary dysmenorrhea in consnensus guideline
regular exercise
heating pads
high frequency transcutaneous electrical nerve stimulation
acupoint stimulation
ginger
prognosis for primary dysmenorrhea
chronic, recurring
usually better in 3rd decade or after childbirth
responds well to NSAIDs
prognosis for seocnady dysmenorrhea
depends on condition causing it
complications can include: infertility, pelvic organ prolapse, menorrhagia,
anemia
psychological considerations of dysmenorrhea
depression, anxiety, stress increased
increased pain sensitivity
impact of primary and secondary dysmenorrhea
primary- not life threatening but impacts daily activities, absenteeism
secondary causes absenteeism and many healthcare costs
primary vs secondary dysmenorrhea key notes
primary::::
- no identifiable pelvic pathology
- most severe in young, nulliparous
women
- onset within 2 yrs after menarche
- tends to improve with age
- more common in people who
smoke
- pain relieved by NSAIDs or
ovulation suppression (OCP)
secondary:::
- associated with pelvic pathology
- age of onset is variable
- suspect in women >25 yrs with no
prior history of dysmenorrhea
- only partial symptomatic improvement with NSAIDs
gynaecological and non-gycenocological differentials for dysmenorrhea
gyne: primary, endometriosis, adenomyosis, PID, membranous dysmenorrhea
non-gyne: IBS, UTI, intersitital cystitis, MSK
SLIDE 53 flow chart to evaluate dysmenorrhea
xx
how long to do empiric therapy in suspected dysmenorrhea
3-6 months
