Dysmenorrhea and PMS

Nazila Karamy-MD

Obstetric and Gynecology Specialist

www.doctorkaramy.ir

Primary Dysmenorrhea

• Painful menstruation without underlying pathology

• Commonest in teens(13-19),early twenties

• Onset 1 or Max 2 years after menarche(cos of it occurs only in ovulation cycle tht it happens 1 year after menarche)

If it occurs 2 y after menarch almost always it’s not primary dysmenorhea

Clinical characteristics

pain:happaens with mense onset

it takes long Max 2-3 days

The kind:colic or cramp

Location:usually :Midline in suprapubic,

sth in back ,flunk,thigh

Associated: vomiting and faintness,loss of appetite,diarhea,headache

Reduce with increasing age @after NVD

Etiology (primary dysmenorhea)

• Decrease of progestrone in the end of luteal phase(near to next mense)=>lysosome rupture => phospholipase A2 + =>

Increase PG E2,PF2@=>Contraction of uterus ,vasoconstrictor

Secondary Dysmenorrhea

• Painful menses secondary to pathology

• Onset =>always after 20 y

Pain may begin before bleeding and may last for entire duration

• Commoner 30s and 40s

Secondary Dysmenorrhea

• Endometriosis

• Polyp(source=>endometer)

• Fibroidce (source=>myometer)

Pelvic Inflammatory Disease(PID)

• Uterine anomalies(Bicorn uterus,...)

• Ovarian cysts @tumors

History Taking so according tht treat

• Timing

• Severity

• Disruption in life-style

• Previous gynae history

• Contraceptive needs

• Wish for fertility

Examination

• Vaginal exam not essential in young female with ? Primary dysmenorrhea

• Vagina ?septum/ tenderness in BME

• Uterus? size / mobility/ position/tenderness

• Adnexa ?tenderness/ enlargement

Investigations

• Transabdominal ultrasound with full bladder

• Transvaginal ultrasound –increased sensitivity

• Laparoscopy –gold standard for endometriosis

• Risks versus benefits

• @U CAN’T FIND ANY PATHOLOGY

Management Primary Spasmodic Dysmenorrhea

• Education esp husband

• Nutrition:decrease taking sweet ,fatty ,alchohol,coffeine,choclate,salt,red meat

• Increase sea food,vegetable,fruit

• Exercise:aerobic(Min 30 minutes, 4times/weeks

• Calcium supplement=>decrease mood disorders

MEDICAL THERAPY

• Prostaglandin synthetase inhibitors(NSAIDS)=>Mefenamic acid or Ibuprofen(Advil) taking regular from first day till 3 days(No need taking before mestural cycle)

• Combined oral contraceptive pill-choose a progestagen dominant pill Such as Tricycle” pill

• IN RESISTANT CASES:

Presacral neurectomy

hystrectomy

• In Failure to respond to Pill=>> Regard secondary dysmenorhea

• increases likelihood of underlying

pathology tht treatment is due to the patology

PMS(Premenstrual Syndrome)

• Physiological premenstrual change

• About 95% of females experience one or more symptom

Symptoms

• Physical :bloating/breast tenderness/headache/flushing

• Psychological:agression/agitation/crying bouts/depression/irritability

Etiology

• PMS exists only in ovulation cycle SO it’s not in menapause ,oophorectomy,non ovulatory cycles

• It happens in luteal phase not in follicular phase

Etiology

SO Endocrine changes =>decrease endocrine,serotonin in PG metabolism, IN LUTEAL PHASE,change

Treatment

• Control nutrition @exercise as dysmenorhea

• Psychologic treatment by relaxation or medical therapy if needed

• SSRI inhibitors:Floxetin( both continuous ,intermittant are effective)

• Nortriptilin in severe deppression)(25 mg /day through the cycle)

• Alprazolam in severe anxiety

• Bromocriptin in breast congestion

(2.5 mg from the Day 10 to 26 of the cycle)

In severe breast congestion =>danazole is OK

• Spirinolactone in severe weight gain ,edema ,abdomen bloating

If no response to usual Treatment???

• Temporary or permanent abolition of ovulation by:

• GnRH analogue plus Add back regimen

• OCP,High dose of progestrone (Depo provera 150 mg every 3 months)

• Hysterectomy and Oophorectomy if not response to other treatment @not want to be pregnant