Womens Health - Dysmenorrhea Flashcards
Dysmenorrhea
- pelvic pain occuring at or around time of menses
- leading cause of absenteeism for women less than 30 yr
Primary Dysmenorrhea
Pelvic pain without pathologic cause
Secondary Dysmenorrhea
*More severe and results from pelvic pathology
- Mild, Pain rarely limits daily fx or requires analgesics
- Moderate, daily activity is affected. Not much absenteeism but requires analgesic
- Severe, daily activity affected, likelihood of absenteeism and limited benefits from analgesics.
Primary dysmenorrhea: Etiology and Patho
- elevated prostaglandin PGF2 production through indirect hormonal control (decrease in progesterone at the start of menses–> increased prostaglandins which causes nonrhythmic hypercontractility and increased uterine muscle tone with vasoconstriction)
—–uterine ischemia
——hypersensitization to a type C pain nerve fibers and this intensifies cramps directly proportional to amt of PGF2 released
Secondary Dysmenorrhea: Etiology and Patho
- endometriosis
- adenomyosis
- congential abnormalities
- cervical stenosis
- PID
- ovarian cysts
- Pelvic tumors (esp. leiomyomata, fibroids or uterine fibroids
Primary Dysmenorrhea Risk Factors
-Smoking
-ETOH
-early menarche under 12
-age under 30
- family history
- irregular or heavy menstrual flow
- non-use of oral contraceptives
- sexual abuse or hx of sex assault
-psychosocial symptoms
-nulliparity
Secondary Dysmenorrhea Risk factors
- pelvic infection
-use of IUD - structural pelvic malformation
-family hx endometriosis in 1st degee relative
Dysmenorrhea Age specific considerations
- onset with first menses raises probability of genital tract anatomic abnormalities like transverse vaginal septum, imperforate or minimally perforated hymen or uterine abnormalities
Primary dysmenorrhea History
- onset 6 - 12 months after menarchy
- associate N/V/D, HA, fatigue, insomnia, pain radiating to low back or inner thighs, rarely have syncope or fever
- recurrence at or before menses
——>pelvic pain b/t menses is not dysmenorrhea bc present with most menses - relief with NSAIDS, heat and orgasm.
- impact of symptoms daily determine severity
Secondary Dysmenorrhea History
- Chronic pelvic (mid-cycle) pain
- dyspareunia (painful sex)
- abnormal uterine bleeding
- onset after 25
- non-midline pain
- progression of severity
-lack of response of NSAIDs
-may have infertility
Primary Dysmenorrhea Physical Exam
- typically normal. exam to rule out secondary causes
- pelvic is recommended if pt is sexually active to r/o infection
Secondary Dysmenorrhea Physical Exam
- evaluate for cervical discharge, uterine enlargement, tenderness, irregularity or fixation
Dysmenorrhea Diagnostic Testing
*Only if indicated:
- preg test
-urine test for infection
—–Gonorrhea, chlamyia cervical testing 25 or under
**primary dysmen:
-consider pelvic u/s to r/o secondary abnormalities
**secondary:
- U/s and/or laparoscopy to define anatomy for severe refractory cases
- MRI as 2nd line non-invasive if US is nondiagnostic and fibroids, ovarian torsion, deep endometriosis or adenomyosis is suspected
Dysmenorrhea Treatment NONPHARM
- heating pad
-hot bath - exercise
-pelvic exercises - relaxation therapy
- laparoscopic nerve ablation
Dysmenorrhea Treatment Pharmacologic
*NSAIDs are first line:
- ibuprofen
-naproxen
- celecoxib
-mefenamic acid
*Hormonal Contraceptives are recommended in women desiring contraception
-suppresses ovulation and reduces prostaglandin
- continuous dosing superior for pain control
- estrogen containing contraceptives 1st line for secondary d/t endometriosis
-IUDs as effective as COC
-Progestin only contraceptives decrease primary but not as affective as COC and IUDs
