03. dysmenorrhoe

8/4/2019 03. Dysmenorrhoe

1/25

Dysmenorrhea

Dr. Mashael Shebaili

Asst. Prof. & Consultant

Ob/Gyne Department


2/25

Dysmenorrhoea

(Painful menstruation)

Primary

Secondary


3/25

1. Primary dysmenorrhoea

No pelvic pathology

The pain is associated with bleeding

in the first and second day.


4/25

2. Secondary dysmenorrhoea

Secondary to pelvic pathology as

endometriosis, chronic pelvic infection

or endometrial polyps The pain starts few days before

menstruation, continues for the

duration of menses and may persist for

days after.


5/25

Incidence

80% of patients attend family planning

clinic have dysmenorrhoea and was severe

in 18% of them (Robinson et al., 1992)

Epidemiology

1. Long time smoker six time more than

non-smokers

2. Age is inversely associated with

dysmenorrhoea

3. Less common in parous women.


6/25

Primary dysmenorrhoea

Aetiology

Uterine hyperactivity: abnormal

(increased) uterine hyperactivity

leading to uterine eschemia.

Hyperalgesic substances e.g.

prostaglandin E.


7/25

Causes

1. Increased uterotonic prostaglandins PGF2a

2. Leucotrines produced by endometrium

stimulates myometrial activity

3. Vasopressin is a vasoconstrictor substance

which stimulates uterine contraction.

Circulating vasopressin levels was found tobe higher on the first day of menstruation in

women with dysmenorrhoea.


8/25

Treatment of primary

dysmenorrhoeaA. Medical treatment

Reassurance and simple analgesic

NSAIDs are useful first line treatment with80-90% improvement, particularly the

mefenamic acid derivatives.

If contraception is also required OCCP isappropriate.

Oxytocin antagonist for future.


9/25

Surgical treatment

Used as last resort

Laparoscopic uterosacral nerve ablation

LUNA

Hysterectomy

Cervical dilatation has no beneficial effect


10/25

Secondary dysmenorrhoea

Aetiology

1. Endometriosis

and adenomyosis2. Chronic PID

3. Congenital or

acquired uterine

abnormalities

Investigations

1. USS

2. HSG

3. Hysteroscopy

4. laparoscopy


11/25

Treatment of secondary dysmenorrhoea

(that of the cause), e.g.

Endometriosis

Adenomyosis

Uterine abnormalities


12/25

Premenstrual tension syndrome

Recurring cyclical disorder in the luteal

phase of the menstrual cycle, involving

behavioral, psychological and physicalchanges resulting in loss of work or social

impairment (Ried and Yen 1981)

PMT may occur after hysterectomy with

conservation of functioning ovaries


13/25

Diagnosis

The American psychiatric association(APA) criteria for diagnosis are:

A.Symptoms are temporarily related tomenstruation

B. The diagnosis requires at least 5 of the

following symptoms, and one of thesymptoms must be one of the first 4:


14/25

1. Affective labiality sudden onset of being

sad, tearful, irritable or angry

2. Anxiety or tension

3. Depressed mode, feeling of hopelessness

4. Decreased interest in usual activities

5. Easy fatigability or marked lack of energy

6. Difficulty in concentration


15/25

7. Changes in appetite (food craving or over

eating)

8. Insomnia

9. Feeling of being overwhelmed or out ofcontrol

10. Physical symptoms (bloating, breast

tenderness, headache, edema, joint or

muscular pain and weight gain.


16/25

C. The symptom interfere with work,

usual activities or relationshipD. The symptoms are not an exacerbation

of another psychiatric disorder

Prevalence

Difficult to ascertain; 40% reported mild

symptoms, of them 2-10% the

symptoms interfere with their work or

life style


17/25

EtiologyList of biological theories

1) Estrogen excess

2) Progesterone

deficiency

3) Hyperprolactinemia

4) Hypoglycemia

5) Vit. B deficiency6) Increased

aldosteron activity

7) Increased activity of

renin angiotensin

system

8) Recently, alteration

in neurotransmitters

particularly the

serotoninergic andopioid pathways


18/25

Treatment of PMS

A.Non pharmacological treatment

1) Reassurance and support

2) Relaxation and stress management3) Reflexology therapy that reduce

somatic and psychological PMS

symptoms4) Increase aerobic exercise ? By altering

endorphins


19/25

5) Well balanced diet with low sodium and fat

contents

6) Restriction of alcohol, chocolate, caffeine

and dairy products

7) Supplementation with vitamin B6, E,

magnesium and calcium8) Evening primrose oil


20/25

Women on estrogen

replacement therapy does not

develop symptoms of PMS

unless progesterone is added


21/25

B.Medical treatment

Pharmacological suppression of the

hypothalamopituitary ovarian axis

should offer a logical approach to

therapy (to stop cyclical ovarianactivity)


22/25

1. Ovarian suppression using OCCP is

beneficial in some patients but causeexacerbation of symptoms in others

2. Danazol for breast symptoms

3. GnRH agonist: it improve symptoms in some

women & can be used as a treatment

4. Diuretics in patients complaining of bloating,edema and weight gain


23/25

5. NSAIDs: reduce many of the somatic

symptoms as dysmenorrhoea6. For emotional and psychological

manifestations serotoninergic antidepressent

offer good first line approach. Fluoxetine

(Prozac)

7. Anoxiolytic as alprazola (Xanox) also offersome help.


24/25

C.Surgical treatmentReserved only to patients with severe

symptoms not responding to medical

treatment

Hysterectomy

Bilateral oophorectomy (balance between

symptoms relief and hypoestrogenic stateand complications and the coast of HRT.


25/25

Thank you

03. dysmenorrhoe

Documents