Women's Health : Dysmenorrhea

Question 1

What is the definition of dysmenorrhea?

Answer 1

Painful lower abdominal cramping that occurs before or during menstruation.

Question 2

Differentiate between primary and secondary dysmenorrhea.

Answer 2

● Primary dysmenorrhea - dysmenorrhea in the absence of identifiable pelvic pathology. ● Secondary dysmenorrhea - dysmenorrhea due to identifiable pelvic pathology:

Question 3

Name five secondary causes of dysmenorrhea.

Answer 3

○ Endometriosis ○ Adenomyosis ○ Fibroids ○ Pelvic Inflammatory Disease (PID) ○ Endometrial polyps

Question 4

What is the typical onset of primary dysmenorrhea?

Answer 4

: 6-12 months after menarche.

Question 5

What suggests secondary dysmenorrhea rather than primary?

Answer 5

Onset later in life, e.g., in a woman’s 20s or 30s.

Question 6

What causes pain in primary dysmenorrhea?

Answer 6

Progesterone withdrawal leads to prostaglandin release, sensitizing pain due to modulation of sensory neurons and facilitating uterine contractions.

Question 7

How does progesterone withdrawal contribute to spiral arteriolar vasoconstriction and ischemia?

Answer 7

spiral arteriolar vasoconstriction (and subsequent tissue ischaemia and stratum functionalis shedding) is related to increased endothelin release from upstream uterine arterial supply in response to progesterone withdrawal after the degeneration of the corpus luteum

Question 8

Endothelins are 3-peptide molecules which act as potent _______________, exerting their effect directly onto the smooth muscle cells found in the tunica media

Answer 8

local vasoconstrictors

Question 9

It has been demonstrated in vitro that progesterone withdrawal leads to increased ______ release by human uterine spiral arterioles.

Answer 9

endothelin

Question 10

What are the symptoms of primary dysmenorrhea?

Answer 10

Painful lower abdominal cramping before menstruation, improving during the bleed, along with systemic symptoms such as nausea, vomiting, fatigue, and bloating.

Question 11

Investigations of dysmenorrhea

Answer 11

Clinically diagnosed - if a secondary cause is suspected then this must be investigated appropriately.

Question 12

What is the first-line treatment for primary dysmenorrhea?

Answer 12

Oral NSAIDs (e.g., ibuprofen, naproxen) +/- paracetamol.

Question 13

Alternate first-line tx for dysmenorrhea

Answer 13

COCP

Question 14

What are second-line options for managing primary dysmenorrhea?

Answer 14

NSAIDs/paracetamol combined with COCP or alternative hormonal contraception.

Question 15

What is the definition of endometriosis?

Answer 15

The presence of endometrial glands and stroma outside the uterine cavity.

Question 16

What is the prevalence of endometriosis in reproductive-age women?

Answer 16

0.1

Question 17

What is the most widely accepted theory for the pathophysiology of endometriosis?

Answer 17

Retrograde menstruation, where endometrial tissue passes into the pelvis via the fallopian tubes during menstruation and undergoes painful inflammation. Fragments of endometrial tissue pass from the uterine cavity into the pelvis via
the open-ended fallopian tubes during menstruation.
○ This ectopic tissue is responsive to the normal hormonal fluctuations of the
menstrual cycle, so undergoes painful inflammation at the end of the cycle

Question 18

What is neuroangiogenesis, and how does it relate to endometriosis?

Answer 18

Neuroangiogenesis is the development of new blood vessels and nociceptive peripheral nerves, contributing to endometriosis pain.

Question 19

What systemic alterations are seen in women with endometriosis?

Answer 19

Altered gene expression related to the inflammatory response in eutopic endometrial tissue.Increased pro-inflammatory and pro-neurogenetic factors.

Question 20

What are potential infertility mechanisms associated with endometriosis?

Answer 20

altered hormonal levels / response, peritoneal inflammation and adhesion formation.

Question 21

What are the symptoms of endometriosis?

Answer 21

Dysmenorrhea, chronic pelvic pain, dyspareunia, dyschezia, and subfertility.

Question 22

What are the signs of endometriosis on examination?

Answer 22

Fixed retroverted uterus. Palpable mass (endometrioma).

Question 23

What investigations are used to diagnose endometriosis?

Answer 23

1. Clinical Examination - can identify endometriomas (cystic lesions) / deep nodules. 2. Transvaginal ultrasound - endometrioma, deep pelvic endometriosis 3. Gold Standard: Diagnostic laparoscopy - biopsy-confirmed glands / stroma outside of endometrial cavity

Question 24

What is the first-line medical management for endometriosis?

Answer 24

Oral NSAIDs (e.g., ibuprofen, naproxen).

Question 25

What is the alternative first-line medical management for endometriosis?

Answer 25

combined contraception (e.g. COCP) or progesterone contraception (LNG-IUS, implant, medroxyprogesterone).

Question 26

What is a second-line treatment for endometriosis, and why is its duration limited?

Answer 26

GnRH agonist (e.g. leuprorelin) or GnRH antagonist (e.g. elagolix). ○ N.B. limited duration of treatment due to bone mineral density issues.

Question 27

What surgical options are available for endometriosis management?

Answer 27

Laparoscopy with ablation or excision. (alternative second line