بسم الله الرحمن الرحيم 1Module 6 - ppt 5 Dr. Maysoon Al-Amoud

بسم الله بسم الله الرحمن الرحمن الرحيمالرحيم

1Module 6 - ppt 5 Dr. Maysoon Al-Amoud

Dysmenorrhea

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

Introduction to Primary Care

a course of the Center of Post Graduate Studies in FM

Objectives• General considerations.• Classification of dysmenorrhea• Causes of dysmenorrhea• Clinical picture of dysmenorrhea• Management of dysmenorrhea


Introduction


Dysmenorrhoea - painful menstruation- is one of the most common gynaecologic problems seen by the family physician.

It affects 50% of all women and between 20% & 90% of all adolescent women.

~ 1% of all adult & 15% of adolescent women describe their dysmenorrhoea as severe.

It is the leading cause of morbidity in female high school students, resulting in absence from school and nonparticipation in sports.

Classification


1. Primary : The presence of painful menses in the

absence of disease 2. Secondary : The occurrence of painful menstruation

caused by pelvic disease.

Risk factors of dysmenorrhea

Age < 20 years Attempts to lose weight Depression/Anxiety Heavy menses Nulliparity Smoking Disruption of social network


No underlying pelvic pathology.

Caused by release of prostaglandin F2 from

tendometrium at time of ovulatory menstruation

uterine hypercontactility .

Ischemia of uterine wall during a contraction causes

pain.

Causes of dysmenorrhoea Primary dysmenorrhea


Prostaglandins induce smooth muscle contraction in the uterus, as well as in intestine, bronchi, & vasculature,

Account for the systemic symptoms of diarrhea, asthma exacerbation, hypertension, & headache experienced by women with 1o dysmenorrhea.

As contractions cause the pressure within uterus to exceed that of the systemic circulation, ischemia ensues, causing an anginal epuivalent in uterus.

Primary dysmenorrhea ... continue

Causes of dysmenorrhoea


•Underlying pelvic pathology with variable severity : •Adenomyosis, myomas, polyps, •Infections – chronic pelvic, endometriosis, •Tumors, dhesions, leiomyomas, •Intrauterine devices, •Anatomic causes, •Bladder pathology & GI pathology•Psychosexual problems•Blind uterine horn(rare).

Secondary dysmenorrhea

Causes of dysmenorrhoea


Clinical findings Symptoms: History of : • Pain at menses onset for 12-72 hrs• Pain is : crampy & intermittent in nature• Pain most intense in lower abdomen, ± to back or

upper thighs.• Headache, nausea, vomiting, diarrhea & fatigue• Worst on 1st day of menses then gradually resolve• Onset: gradual with 1st yr then worsen as menses

become regular.• If 2ry: onset >20 yrs old, for 5-7 ds & worsen

progressively. ± pelvic pain not with menses.

Painful MenstruationPainful Menstruation

Dysmenorrhea

SpasmodicSpasmodicCyclic Cyclic Radiate to back, inner aspect of Radiate to back, inner aspect of thighsthighs


Clinical findings

Physical examination:

•Pelvic examination + cervical smear pain not with menses & culture should be for all married pts presenting with a chief complaint of dysmenorrhea

•If find cul-de-sac induration & uterosacal ligament nodularity on pelvic examination endometriosis.•Uterine abnormalities or tenderness raise index of suspicion for underlying pathology as a cause.


Management

•Medical therapy•Physical modalities•Alternative & complementary therapy•Behavioral modification•Surgical intervention


Medical therapy

Drug groups:• NSAIDs – diclofenac, ibuprofen,• Danzol • Leuprolide• Depo-methroxyprogesteron-terone acetate• CC :oral & intravaginal• COX-2 inhibitors• Levonorgestrel IUD• Nifedipine• Transdermal CC patch

Aim: endometrial prostaglandin production; ± CC

Inhibition of ovulationDesire contraceptionNo relief or cannot tolerate NSAIDsNo contraindication

Oral Contraceptive PillsOral Contraceptive Pills

OCsOCsMinipillMinipillDMPADMPAGnRHaGnRHa

Agents used in the treatment of dysmenorrhea


Physical modalities

Utilize :1. Heat 2. Acupuncture or acupressure3. Spinal manipulation• A heated abdominal patch was demonstrated to

have efficacy similar to ibuprofen (400 mg) quicker - not greater relief of heat + ibuprofen• Acupuncture : in91% relief as compared 36% of

control.


Alternative & complementary therapy

• Numerous supplements & herbal formulations.

• Few are backed by solid evidence.Example:

Vitamin E 200mg units bd daily, beginning 2 days

before menses & continuing through 1st 3 days of

bleeding shorter duration & lower intensity of

pain than in placebo.


Behavioral modification

• Life-style: strenuous Ex. & caffeine intake can modulate prostaglandin-induced uterine

contractions.• Strenuous Ex. : uterine tone uterine

“angina” periods + prostaglandins ......• strenuous Ex. In 1st few days of menses

± dysmenorrhea.• Caffeine : controversial effect, it uterine tone

by uterine cyclic adenosine monophosphote level.


Surgical intervention

• Continues to have significant dysmenorrhea + preceding treatment testing for secondary dysmenorrhea .

• Chronic pelvic pain not responding to supportive therapy adhesions, endometriosis or chronic PID discovered on diagnostic laparoscopy.

• Hysterectomy is an option for refractory 1o amenorrhea.


Treatment at PHC centres

• primary dysmenorrhea: try previously mentioned methods.

• Secondary dysmenorrhea: refer to investigate (e.g. laparoscopy) & treat underlying cause

Have patience and empathy.

Tips for general practitioners

Adolescents are unlikely to have underlying disease and so do not usually require a pelvic examination

First line treatment for dysmenorrhoea should be oral contraceptives and/or non-steroidal anti-inflammatory drugs

Specialist referral is indicated if oral contraceptives and non-steroidal anti-inflammatory drugs fail

The levonorgestrel intrauterine system is useful in managing secondary dysmenorrhoea

When to refer

Referral for laparoscopy is indicated if initial measures, such as oral contraceptives and NSAIDs, have not improved symptoms.

Referral is also indicated if secondary dysmenorrhoea is suspected (for example, associated menstrual symptoms

Menorrhagia, Intermenstrual or postcoital bleeding Dyspareunia Abnormal pelvic examination If the patient has pain management problems with

disruption to daily living.

Summary

Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated

Simple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of women

Oral contraceptives can be considered for women who wish to avoid pregnancy

For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective

تم بحمد تم بحمد ThankاللهاللهyouDr. Maysoon Al-Amoud


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بسم الله الرحمن الرحيم 1Module 6 - ppt 5 Dr. Maysoon Al-Amoud