DYSMENORRHOEA

D R K I S H WA R N A H E E D A SS I S T P R O F G Y N A E / O B S

DEFINITION

• Painful menstruation 45-95%

•Primary dysmenorrhea•Secondary dysmenorrhoea

PRIMARY DYSMENORRHOEA

• Increased prostaglandin• Increased vasopressin

SECONDARY DYSMENORRHOEA

•Endometriosis and adenomyosis•Fibroid uterus•Endometrial polyp•Pelvic inflammatory disease•Cervical stenosis•Congenital malformation of uterus

ENDOMETRIOSIS• Presence of endometrial tissue outside the uterine

cavity including ovary,pelvic wall,pouch of douglas,uterosacral ligament and bowel• These tissues are under hormonal control • So symptoms are exacerbated at the time of

menstruation• Laproscopy is gold standard diagnostic tool• Treatment• Combined pill• Mirena IUS• Surgical approach with laser,diathermy or excision of

endometriotic tissue

COMPLICATIONS •Formation of adhesions•Chocolate ovarian cyst•Infertility

ADENOMYOSIS•Presence of ectopic endometrial tissue within endometrium• It is associated with previous procedures which may break the barrier between the endometrium and myometrium•eg caesarean section and suction termination of pregnancy

HISTORY AND EXAMINATION

HISTORY• A complete history should include the following[26] :• Age at menarche• Menstrual frequency, length of period, estimated menstrual

flow, and presence or absence of intermenstrual bleeding• Associated symptoms• Onset, duration, type, and severity of pain, as well as its

relation to the menstrual cycle• External factors affecting the pain• Impact of dysmenorrhea on physical and social activity• Progression of symptom severity• Sexual and obstetric history

CHARACTER OF PAIN IN PRIMARY DYSMENORRHOEA• Onset shortly after menarche (typically within• 6 months)• Usual duration of 48-72 hours (often • starting several hours before or just after • the menstrual flow)• Cramping or laborlike pain• Background of constant lower abdominal pain• , radiating to the back or the anterior or • medial thigh• Often unremarkable pelvic examination findings (including rectal)

CHARACTER OF PAIN IN SECONDARY DYSMENORRHOEA• A different pattern of pain is observed with secondary

dysmenorrhea that is not limited to the onset of menses; this is usually associated with abdominal bloating, pelvic heaviness, and back pain. Typically, the pain progressively increases during the luteal phase until it peaks around the onset of menstruation.• The following may indicate secondary dysmenorrhea[1, 2] :• Dysmenorrhea beginning in the 20s or 30s, after relatively

painless menstrual cycles in the past• Heavy menstrual flow or irregular bleeding• Dysmenorrhea occurring during the first or second cycles after

menarche, which may indicate congenital outflow obstruction

• Pelvic abnormality with physical examination (consider endometriosis, pelvic inflammatory disease [PID], pelvic adhesions, and adenomyosis)• Little or no response to nonsteroidal anti-inflammatory

drugs (NSAIDs) or OCs• Infertility• Dyspareunia• Vaginal discharge

SEVERITY OF PAIN• Do you need to take pain killer for this pain?•Have you needed to take any time off work/school due to pain?•EXAMINATION•ABDMINAL EXAMINATION•For any mass

• PELVIC EXAMINATION• Inspection of the external genitalia for rashes,

swelling, or discoloration• Inspection of the vaginal vault for discharge, blood, or

foreign bodies• Inspection of the cervix for the above, plus any

masses or signs of infection• BIMANUAL EXAMINATION• To assess cervical motion tenderness, uterine or

adnexal tenderness, or any masses in the pelvis• Fixed uterus• Endometriotic nodules

INVESTIGATIONS• PELVIC ULTRASOUND TO RULE OUT ENDOMETRIOMAS AND

ADENOMYOSIS• HIGH VAGINAL AND ENDOCERVICAL SWAB• DIAGNOSTIC LAPROSCOPY • INDICATIONS• HISTORY SDUGGESTIVE OF ENDOMETRIOSIS• WHEN SWAB AND USG ARE NORMAL• WHEN PT WANTS DEFINITE DIAGNOSIS • WHEN PT WANTS TO KNOW HER PELVIS IS OK • DISCUSSION• RISKS OF PROCEDURE• ANAESTHESIA AND DAMAGE TO BOWEL AND BLADDER

MANAGEMENT

SELECTION OF TREATMEJNT•PATIENT PREFERENCE OF TREATMENT•RISKS/BENEFIT OF EACH OPTION•CONTRACEPTIVE REQUIREME•PAST MEDICAL HISTORY• ANY CONTRAINDICATIONS TO MEDICAL THERAPIES

NON HORMONALNSAIDSCOX-2 INHIBITORTRANS DERMAL GLYCERYL TRINATEHORMONALOCPS PROGESTOGENSURGICAL NON MEDICAL TENS,EXERCISE,HEATALTERNATIVES

•NSAIDS•ORAL CONTRACEPTIVES•LNG-IUS•GnRH ANALOUES•LIFE STYLE CHANGES•HEAT

DYSPAREUNEA

PAIN DURING SEXUAL INTERCOURSE TYPESSUPERFICIAL DEEP CAUSESENDOMETRIOSISPELVIC INFLAMMATORY DISEASE ON MANY OCCASION NO CAUSE FOUND AND PSYCHOLOGICAL SUPPORT IS OFFERED

PREMENSTRUAL SYNDROME

OCCURRENCE OF CYCLICAL,PSYCHOLOGICAL AND

EMOTIONAL SYMPTOMS THAT OCCUR IN LUTEAL PHASE AND CEASE BY THE

TIME MENSTRUATION CEASES

•Occur in women of reproductive age

•3-60%

What Causes PMS?

CYCLICAL OVARIAN ACTIVITY AND EFFECTS OF ESTRADIOL AND PROGESTERONE ON CERTAIN NEUROTRANSMITTOR LIKE SEROTONIN

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SYMPTOMS• Mood swings• Bloating• Cyclical weight gain• Mastalgia• Abdominal cramps• Fatigue• Headache• Depression• Irritability• Food cravings

Cyclical nature of PMS is cornerstone of diagnosis

No objective test can confirm PMS the diagnosis is made on the basis of prospective daily symptoms recording using various rating scales

MONTH________________         (provided by http://www.pms-relief.org)                              

                                                               

Chart your PMS symptoms according to the following criteria.                                          

Colour the boxes according to your symptoms:  NONE = leave blank.   MILD = GREEN.   MODERATE = YELLOW.    SEVERE = RED          

                                                               

PMS SYMPTOMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

   Abdominal Pain                                                              

Acne                                                               

Anger, Aggression                                                                

Anxiety                                                               

Back Pain                                                              

Breast Swelling                                                               

Breast Tenderness                                                               

Cervical Fluid                                                               

Constipation                                                               

Cramps                                                               

Diarrhea                                                               

Difficulty Concentrating                                                               

Fatigue                                                               

Food Cravings & Binges                                                              

Headache                                                               

Irritability                                                               

Joint Pain                                                               

Libido (Decreased)                                                               

Libido (Increased)                                                               

Moody                                                               

Muscle Pain                                                               

Nausea                                                               

Ovarian Pain                                                               

Sadness                                                               

Sleep (Decreased)                                                               

Sleep (Increased)                                                               

Tension                                                               

Urinary difficulties                                                              

Water Retention                                                               

Weight Gain                                                               

The symptoms of PMS can be similar to or overlap with other conditions, including:PerimenopauseDepression or anxietyChronic fatigue syndromeThyroid diseaseThe key difference is that PMS symptoms come and go in a distinct pattern, month after month.

PMS or Something Else?

Diagnosing PMS: Symptom TrackerTo figure out whether you have PMS, record your symptoms on a tracking form. You may have PMS if:Symptoms occur during the five days before your period.Once your period starts, symptoms end within four days.Symptoms return for at least three menstrual cycles.

It is important to keep a daily diary or log to record the type of symptoms you have, how severe they are, and how long they last. You should keep this "symptom diary" for at least 3 months. It will help your doctor make an accurate PMS diagnosis and recommend appropriate treatment.

Premenstrual Dysphoric DisorderPremenstrual dysphoric disorder (PMDD) follows the same pPremenstrual dysphoric disorder (PMDD) follows the same pattern as PMS, but the symptoms are more disruptive. Women with PMDD may experience panic attacks, crying spells, suicidal thoughts, insomnia, or other problems than interfere with daily life. Fortunately, many of the same strategies that relieve PMS can be effective against PMDD.Risk factors for PMDD include a personal or family history of depression, mood disorders, or trauma.disruptive. Women with PMDD may experience panic attacks, crying spells, suicidal thoughts, insomnia, or other problems than interfere with daily life. Fortunately, many of the same strategies that relieve PMS can be effective against PMDD.Risk factors for PMDD include a personal or family history of depression, mood disorders, or trauma.

MANAGEMENTFIRST LINE

• LIFE STYLE MODIFICATION• COCP• SSRI• COGNITIVE BEHAVIOURAL THERAPY

SECOND LINE •OESTRADIOL PATCHES PLUS ORAL PROGESTOGEN OR LNG-IUS•SSRIS..HIGH DOSE ,CONTINUOUS OR LUTEAL PHASE

THIRD LINE• GnRH Analogues+add-back

HRT{CONTINUOUS COMBINED ESTROGEN AND PROGESTOGEN OR TIBOLONE}

FOURTH LINE •TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL OOPHRECTOMY+HRT {INCLUDING TESTOSTERONE

PMS Remedy

(a) Exercise

Exercise can help boost your mood and fight fatigue. To get the benefits, you need to exercise regularly -- not just when PMS symptoms appear. Aim for 30 minutes of moderate physical activity on most days of the week. Vigorous exercise on fewer days can also be effective.

(b)Diet Rich in B VitaminsThere's evidence that foods rich in B vitamins may help ward off PMS. In one study, researchers followed more than 2,000 women for 10 years. They found that women who ate foods high in thiamine and riboflavin (eggs, dairy products) were far less likely to develop PMS. Taking supplements did not have the same effect

You may be able to reduce PMS symptoms by cutting back on these foods:Salt, which can increase bloatingCaffeine, which can cause irritabilitySugar, which can make cravings worseAlcohol, which can affect mood

(d) Foods to Avoid

Prevention

Some of the lifestyles changes often recommended for treating PMS may help prevent symptoms or keep them from getting worse.

Getting regular exercise and eating a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol, and caffeine) may prove beneficial.

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