Dysmenorrhea , AndPremenstrual syndrome

(PMS)

Dysmenorrhea , AndPremenstrual syndrome

(PMS)

Dysmenorrhea, or painfulDysmenorrhea, or painfulmenstruationmenstruation,, is one of the mostis one of the mostcommon gynecologic problems.common gynecologic problems.For clinical purposes, dysmenorrhea isFor clinical purposes, dysmenorrhea isdivided into two broad categories:divided into two broad categories:primary and secondaryprimary and secondary

Dysmenorrhea, or painfulDysmenorrhea, or painfulmenstruationmenstruation,, is one of the mostis one of the mostcommon gynecologic problems.common gynecologic problems.For clinical purposes, dysmenorrhea isFor clinical purposes, dysmenorrhea isdivided into two broad categories:divided into two broad categories:primary and secondaryprimary and secondary

Primary dysmenorrhea (PD)or calledspasmodic dysmenorrhea Refers tothe presence of recurrent, cramps, lowerabdominal pain that occurs duringmenses in the absence of demonstrablepelvic disease

Primary dysmenorrhea (PD)or calledspasmodic dysmenorrhea Refers tothe presence of recurrent, cramps, lowerabdominal pain that occurs duringmenses in the absence of demonstrablepelvic disease

Risk factors :Risk factors :--11--body mass index less thanbody mass index less than 2020..22--menarche before agemenarche before age 1212..33--longer cycles/duration of bleeding,longer cycles/duration of bleeding,44-- irregular or heavy menstrual flow.irregular or heavy menstrual flow.55-- premenstrual symptoms.premenstrual symptoms.66--history of sexual assault,history of sexual assault,77--heavy smokingheavy smoking

Risk factors :Risk factors :--11--body mass index less thanbody mass index less than 2020..22--menarche before agemenarche before age 1212..33--longer cycles/duration of bleeding,longer cycles/duration of bleeding,44-- irregular or heavy menstrual flow.irregular or heavy menstrual flow.55-- premenstrual symptoms.premenstrual symptoms.66--history of sexual assault,history of sexual assault,77--heavy smokingheavy smoking

Pathogenesis :Pathogenesis :--11-- Abnormal uterine activityAbnormal uterine activity22-- Hormonal factorsHormonal factors33--Psychological elementPsychological element

Pathogenesis :Pathogenesis :--11-- Abnormal uterine activityAbnormal uterine activity22-- Hormonal factorsHormonal factors33--Psychological elementPsychological element

Clinical manifestations :-PD only occurs during ovulatory cycles. The pain

characteristically begins just before or with the onsetof menstrual bleeding and gradually diminishes over12 to 72 hours. The cramps are intermittently intenseand usually confined to the lower abdomen(suprapubic). Pain is strongest in the midline,although in some women back and thigh pain mayalso be severe. Patients will often illustrate the painby opening and closing their fist, closely mimickingthe underlying uterine activity. Nausea, diarrhea,fatigue, headache, and a general sense of malaiseaccompany the pain.

Clinical manifestations :-PD only occurs during ovulatory cycles. The pain

characteristically begins just before or with the onsetof menstrual bleeding and gradually diminishes over12 to 72 hours. The cramps are intermittently intenseand usually confined to the lower abdomen(suprapubic). Pain is strongest in the midline,although in some women back and thigh pain mayalso be severe. Patients will often illustrate the painby opening and closing their fist, closely mimickingthe underlying uterine activity. Nausea, diarrhea,fatigue, headache, and a general sense of malaiseaccompany the pain.

Approach to the patient :Approach to the patient :--History :History :--Physical examination :Physical examination :--Laboratory tests and imaging :Laboratory tests and imaging :11--SonographySonography22-- CACA 12512533-- Test for chlamydiaTest for chlamydia

Approach to the patient :Approach to the patient :--History :History :--Physical examination :Physical examination :--Laboratory tests and imaging :Laboratory tests and imaging :11--SonographySonography22-- CACA 12512533-- Test for chlamydiaTest for chlamydia

Treatment :Treatment :----Nonpharmacological interventions:Nonpharmacological interventions:--AA

11-- HeatHeat 22--Dietary, vitamin, and herbal treatmentsDietary, vitamin, and herbal treatments33--ExerciseExercise

Pharmacologic interventionsPharmacologic interventions--BB11-- Nonsteroidal antiinflammatory agentsNonsteroidal antiinflammatory agents

22--Hormonal contraceptivesHormonal contraceptives

33--TocolyticsTocolytics

Complementary or alternative medicineComplementary or alternative medicine--CCSurgical interruption of pelvic nerve pathwaysSurgical interruption of pelvic nerve pathways--DDOtherOther--EE

Treatment :Treatment :----Nonpharmacological interventions:Nonpharmacological interventions:--AA

11-- HeatHeat 22--Dietary, vitamin, and herbal treatmentsDietary, vitamin, and herbal treatments33--ExerciseExercise

Pharmacologic interventionsPharmacologic interventions--BB11-- Nonsteroidal antiinflammatory agentsNonsteroidal antiinflammatory agents

22--Hormonal contraceptivesHormonal contraceptives

33--TocolyticsTocolytics

Complementary or alternative medicineComplementary or alternative medicine--CCSurgical interruption of pelvic nerve pathwaysSurgical interruption of pelvic nerve pathways--DDOtherOther--EE

Secondary dysmenorrheaSecondary dysmenorrhea ::--is the occurrence of painful menstruation inis the occurrence of painful menstruation inthe presence of a pelvic pathology, such asthe presence of a pelvic pathology, such asendometriosis, adenomyosis, uterineendometriosis, adenomyosis, uterineleiomyomata, or chronic pelvicleiomyomata, or chronic pelvicinflammatory disease .inflammatory disease .

Secondary dysmenorrheaSecondary dysmenorrhea ::--is the occurrence of painful menstruation inis the occurrence of painful menstruation inthe presence of a pelvic pathology, such asthe presence of a pelvic pathology, such asendometriosis, adenomyosis, uterineendometriosis, adenomyosis, uterineleiomyomata, or chronic pelvicleiomyomata, or chronic pelvicinflammatory disease .inflammatory disease .

Presentation :Presentation :--The onset of pain is oftenThe onset of pain is often 11--22 weeks priorweeks priorto menstruation, and continues for few daysto menstruation, and continues for few daysafter cessation of bleeding . The pain isafter cessation of bleeding . The pain ismore severe prior to menses.more severe prior to menses.

Presentation :Presentation :--The onset of pain is oftenThe onset of pain is often 11--22 weeks priorweeks priorto menstruation, and continues for few daysto menstruation, and continues for few daysafter cessation of bleeding . The pain isafter cessation of bleeding . The pain ismore severe prior to menses.more severe prior to menses.

Pathogenesis :Pathogenesis :--The mechanism is alsoThe mechanism is alsoPGfPGf22 alpha and myomaterialalpha and myomaterialcontractions due to mass. adhesion, orcontractions due to mass. adhesion, orobstruction to the menstrual flow.obstruction to the menstrual flow.

Pathogenesis :Pathogenesis :--The mechanism is alsoThe mechanism is alsoPGfPGf22 alpha and myomaterialalpha and myomaterialcontractions due to mass. adhesion, orcontractions due to mass. adhesion, orobstruction to the menstrual flow.obstruction to the menstrual flow.

Major causes of secondary dysmenorrheaMajor causes of secondary dysmenorrheaGynecological disorders:Gynecological disorders:--11--Endometriosis.Endometriosis.22--Adenomyosis.Adenomyosis.33--Uterine leiomyomataUterine leiomyomata44-- Uterine polyps.Uterine polyps.55-- Ovarian cysts.Ovarian cysts.66--Pelvic inflammatory disease.Pelvic inflammatory disease.77-- Pelvic adhesions.Pelvic adhesions.88--Congenital obstructive müllerian malformations.Congenital obstructive müllerian malformations.99--Cervical stenosis .Cervical stenosis .1010-- IUCD.IUCD.

Major causes of secondary dysmenorrheaMajor causes of secondary dysmenorrheaGynecological disorders:Gynecological disorders:--11--Endometriosis.Endometriosis.22--Adenomyosis.Adenomyosis.33--Uterine leiomyomataUterine leiomyomata44-- Uterine polyps.Uterine polyps.55-- Ovarian cysts.Ovarian cysts.66--Pelvic inflammatory disease.Pelvic inflammatory disease.77-- Pelvic adhesions.Pelvic adhesions.88--Congenital obstructive müllerian malformations.Congenital obstructive müllerian malformations.99--Cervical stenosis .Cervical stenosis .1010-- IUCD.IUCD.

Non gynaecological disorders:Non gynaecological disorders:--11.Inflammatory bowel disease..Inflammatory bowel disease.22.Irritable bowel syndrome..Irritable bowel syndrome.33.Psychogenic disorders..Psychogenic disorders.

Non gynaecological disorders:Non gynaecological disorders:--11.Inflammatory bowel disease..Inflammatory bowel disease.22.Irritable bowel syndrome..Irritable bowel syndrome.33.Psychogenic disorders..Psychogenic disorders.

Diagnosis :Diagnosis :--By history, physical examination , andBy history, physical examination , andinvestigations like pelvic Uinvestigations like pelvic U\\S ,S ,laparoscopy , hystrosalpingiography ,laparoscopy , hystrosalpingiography ,hysteroscopy, and microbiologicalhysteroscopy, and microbiologicalcultures from the cervix and pelviccultures from the cervix and pelviccavity .cavity .

Diagnosis :Diagnosis :--By history, physical examination , andBy history, physical examination , andinvestigations like pelvic Uinvestigations like pelvic U\\S ,S ,laparoscopy , hystrosalpingiography ,laparoscopy , hystrosalpingiography ,hysteroscopy, and microbiologicalhysteroscopy, and microbiologicalcultures from the cervix and pelviccultures from the cervix and pelviccavity .cavity .

Treatment of Secondary dysmenorrhea :Treatment of Secondary dysmenorrhea :--11--Identify the underlying cause and treat it .Identify the underlying cause and treat it .22--Use supportive treatment , analgesia , or hormonalUse supportive treatment , analgesia , or hormonaltreatment in a similar manner to that of primarytreatment in a similar manner to that of primarydysmenorrhea.dysmenorrhea.33--GnRH analogue ( in cases of endometriosis ).GnRH analogue ( in cases of endometriosis ).44--Surgical options to deal with the underlyingSurgical options to deal with the underlyingpathology .pathology .55--Laparoscopical laser or electrocautery division ofLaparoscopical laser or electrocautery division ofthe uterosacral nerve .the uterosacral nerve .66--Hysterectomy and bilateral salpingoHysterectomy and bilateral salpingo--oophoroctomyoophoroctomy(with hormonal replacement ) and this is done when(with hormonal replacement ) and this is done whenshe has complete her family.she has complete her family.

Treatment of Secondary dysmenorrhea :Treatment of Secondary dysmenorrhea :--11--Identify the underlying cause and treat it .Identify the underlying cause and treat it .22--Use supportive treatment , analgesia , or hormonalUse supportive treatment , analgesia , or hormonaltreatment in a similar manner to that of primarytreatment in a similar manner to that of primarydysmenorrhea.dysmenorrhea.33--GnRH analogue ( in cases of endometriosis ).GnRH analogue ( in cases of endometriosis ).44--Surgical options to deal with the underlyingSurgical options to deal with the underlyingpathology .pathology .55--Laparoscopical laser or electrocautery division ofLaparoscopical laser or electrocautery division ofthe uterosacral nerve .the uterosacral nerve .66--Hysterectomy and bilateral salpingoHysterectomy and bilateral salpingo--oophoroctomyoophoroctomy(with hormonal replacement ) and this is done when(with hormonal replacement ) and this is done whenshe has complete her family.she has complete her family.

The premenstrual syndrome (PMS)The premenstrual syndrome (PMS)is characterized by the presence of both physical andis characterized by the presence of both physical andbehavioral symptoms that occur repetitively in thebehavioral symptoms that occur repetitively in thesecond half of the menstrual cycle and interfere withsecond half of the menstrual cycle and interfere withsome aspects of the woman's life. The Americansome aspects of the woman's life. The AmericanPsychiatric Association DSMPsychiatric Association DSM--IV defines premenstrualIV defines premenstrualdysphoric disorder (PMDD) as a severe form of PMSdysphoric disorder (PMDD) as a severe form of PMSin which symptoms of anger, irritability, and internalin which symptoms of anger, irritability, and internaltension are prominent .tension are prominent .

The premenstrual syndrome (PMS)The premenstrual syndrome (PMS)is characterized by the presence of both physical andis characterized by the presence of both physical andbehavioral symptoms that occur repetitively in thebehavioral symptoms that occur repetitively in thesecond half of the menstrual cycle and interfere withsecond half of the menstrual cycle and interfere withsome aspects of the woman's life. The Americansome aspects of the woman's life. The AmericanPsychiatric Association DSMPsychiatric Association DSM--IV defines premenstrualIV defines premenstrualdysphoric disorder (PMDD) as a severe form of PMSdysphoric disorder (PMDD) as a severe form of PMSin which symptoms of anger, irritability, and internalin which symptoms of anger, irritability, and internaltension are prominent .tension are prominent .

Pathogenesis :Pathogenesis :--11--Ovarian steroidsOvarian steroids22--NeurotransmittersNeurotransmitters33--Vitamins and mineralsVitamins and minerals44--Psychosocial factors and stressPsychosocial factors and stress

Pathogenesis :Pathogenesis :--11--Ovarian steroidsOvarian steroids22--NeurotransmittersNeurotransmitters33--Vitamins and mineralsVitamins and minerals44--Psychosocial factors and stressPsychosocial factors and stress

Symptoms of premenstrualSymptoms of premenstrualsyndromesyndromeBroad classification of symptoms :Broad classification of symptoms :--somatic.somatic.Behavioral.Behavioral.Psycological.Psycological.

Symptoms of premenstrualSymptoms of premenstrualsyndromesyndromeBroad classification of symptoms :Broad classification of symptoms :--somatic.somatic.Behavioral.Behavioral.Psycological.Psycological.

11--somatic symptoms :somatic symptoms :--..FatigueFatigue**

headache , backache , cramps.headache , backache , cramps.Pain:Pain:**dizziness , hot flashes,dizziness , hot flashes,::Autonomic reactionAutonomic reaction**

faintness, cold sweating ,nausea,faintness, cold sweating ,nausea,vomiting, and palpitation.vomiting, and palpitation.

bloating ,bloating ,Water retention (cause edema ):Water retention (cause edema ):**breast tenderness , weight gain. Skin disorders (breast tenderness , weight gain. Skin disorders (edema , acne).edema , acne).

11--somatic symptoms :somatic symptoms :--..FatigueFatigue**

headache , backache , cramps.headache , backache , cramps.Pain:Pain:**dizziness , hot flashes,dizziness , hot flashes,::Autonomic reactionAutonomic reaction**

faintness, cold sweating ,nausea,faintness, cold sweating ,nausea,vomiting, and palpitation.vomiting, and palpitation.

bloating ,bloating ,Water retention (cause edema ):Water retention (cause edema ):**breast tenderness , weight gain. Skin disorders (breast tenderness , weight gain. Skin disorders (edema , acne).edema , acne).

22-- Behavioral symptoms :Behavioral symptoms :--avoid socialavoid socialMood changes:Mood changes:**

communication, lowered work performance,communication, lowered work performance,food cravings, stay home, insomniafood cravings, stay home, insomnia

forgetfulness,forgetfulness,::Poor concentrationPoor concentration**confusion, increase incidence of accidents,confusion, increase incidence of accidents,

lowered judgment.lowered judgment.33--Psycological symptoms :Psycological symptoms :--

anxiety/tension, depression,anxiety/tension, depression,Negative effect:Negative effect:**

crying easily, irritability, restlessness.crying easily, irritability, restlessness.

22-- Behavioral symptoms :Behavioral symptoms :--avoid socialavoid socialMood changes:Mood changes:**

communication, lowered work performance,communication, lowered work performance,food cravings, stay home, insomniafood cravings, stay home, insomnia

forgetfulness,forgetfulness,::Poor concentrationPoor concentration**confusion, increase incidence of accidents,confusion, increase incidence of accidents,

lowered judgment.lowered judgment.33--Psycological symptoms :Psycological symptoms :--

anxiety/tension, depression,anxiety/tension, depression,Negative effect:Negative effect:**

crying easily, irritability, restlessness.crying easily, irritability, restlessness.

Diagnosis o premenstrual syndromeDiagnosis o premenstrual syndrome

AA--Diagnostic criteria :Diagnostic criteria :--11-- At leastAt least 55 of the above specific symptoms shouldof the above specific symptoms shouldbe present , and they should impair some facet of thebe present , and they should impair some facet of thewoman's life .woman's life .22-- Cyclicity of symptoms must be confirmed byCyclicity of symptoms must be confirmed bymenstrual calendar (symptoms should occur in themenstrual calendar (symptoms should occur in theluteal phase and remitting after the onset of menstrualluteal phase and remitting after the onset of menstrualflow.flow.33-- Increase the severity of symptoms with time.Increase the severity of symptoms with time.44-- Symptomes should be present inSymptomes should be present in 33 consecutiveconsecutivecycles.cycles.55-- The absence of hormone or drug ingestion and theThe absence of hormone or drug ingestion and theexclusion of other diagnoses like psychiatric disordersexclusion of other diagnoses like psychiatric disorders

AA--Diagnostic criteria :Diagnostic criteria :--11-- At leastAt least 55 of the above specific symptoms shouldof the above specific symptoms shouldbe present , and they should impair some facet of thebe present , and they should impair some facet of thewoman's life .woman's life .22-- Cyclicity of symptoms must be confirmed byCyclicity of symptoms must be confirmed bymenstrual calendar (symptoms should occur in themenstrual calendar (symptoms should occur in theluteal phase and remitting after the onset of menstrualluteal phase and remitting after the onset of menstrualflow.flow.33-- Increase the severity of symptoms with time.Increase the severity of symptoms with time.44-- Symptomes should be present inSymptomes should be present in 33 consecutiveconsecutivecycles.cycles.55-- The absence of hormone or drug ingestion and theThe absence of hormone or drug ingestion and theexclusion of other diagnoses like psychiatric disordersexclusion of other diagnoses like psychiatric disorders

BB--Gonadotrophin analogue test:Gonadotrophin analogue test:--GnRHGnRH analogue test may be of benefit inanalogue test may be of benefit inclarifying the diagnosisclarifying the diagnosis

BB--Gonadotrophin analogue test:Gonadotrophin analogue test:--GnRHGnRH analogue test may be of benefit inanalogue test may be of benefit inclarifying the diagnosisclarifying the diagnosis

Treatment of premenstrual syndromeTreatment of premenstrual syndrome

There areThere are 33 major modalities of treatment inmajor modalities of treatment inPMS:PMS:--

II-- Non pharmacological treatment.Non pharmacological treatment.IIII-- pharmacological treatment.pharmacological treatment.IIIIII-- Surgical treatment.Surgical treatment.

Treatment of premenstrual syndromeTreatment of premenstrual syndrome

There areThere are 33 major modalities of treatment inmajor modalities of treatment inPMS:PMS:--

II-- Non pharmacological treatment.Non pharmacological treatment.IIII-- pharmacological treatment.pharmacological treatment.IIIIII-- Surgical treatment.Surgical treatment.

II-- Non pharmacological treatmentNon pharmacological treatment11-- General measuresGeneral measures including healthy life style,including healthy life style,regular exercise and relaxation techniquesregular exercise and relaxation techniques

22--Essential fatty acidsEssential fatty acids: evening primrose oil: evening primrose oilwhich contains polyunsaturated fatty acids.which contains polyunsaturated fatty acids.33-- Vitamins and mineralsVitamins and minerals::

II-- Non pharmacological treatmentNon pharmacological treatment11-- General measuresGeneral measures including healthy life style,including healthy life style,regular exercise and relaxation techniquesregular exercise and relaxation techniques

22--Essential fatty acidsEssential fatty acids: evening primrose oil: evening primrose oilwhich contains polyunsaturated fatty acids.which contains polyunsaturated fatty acids.33-- Vitamins and mineralsVitamins and minerals::

--IIII-- pharmacological treatmentpharmacological treatment11-- Diuretics:Diuretics: indicated for women with waterindicated for women with waterretention (Spironolactoneretention (Spironolactone 100100 mgmg\\ day)day)22-- Selective serotonin reuptake inhibitors (SSRIs)Selective serotonin reuptake inhibitors (SSRIs) likelikefluoxetine, paroxetne, citalopram, and antidepressantfluoxetine, paroxetne, citalopram, and antidepressantlike alprazolam.like alprazolam.

FluoxetineFluoxetine :: 2020--6060 mgmg\\day forday for 22--33 months, ormonths, orintermittently forintermittently for 77--1414 days in luteal phase todays in luteal phase tominimize side effects ( like loss of libido, fatigue, GITminimize side effects ( like loss of libido, fatigue, GITdisturbance).disturbance).VenlaxafineVenlaxafine, a drug that selectively inhibits the, a drug that selectively inhibits thereuptake of both serotonin and norepinephrine, is alsoreuptake of both serotonin and norepinephrine, is alsomore effective (more effective (5050 toto 200200 mg/day) than placebo.mg/day) than placebo.AlprazolamAlprazolam = Benzodiazepine( anxiolytic)= Benzodiazepine( anxiolytic) 00..2525 mgmg22--33\\day .day .

--IIII-- pharmacological treatmentpharmacological treatment11-- Diuretics:Diuretics: indicated for women with waterindicated for women with waterretention (Spironolactoneretention (Spironolactone 100100 mgmg\\ day)day)22-- Selective serotonin reuptake inhibitors (SSRIs)Selective serotonin reuptake inhibitors (SSRIs) likelikefluoxetine, paroxetne, citalopram, and antidepressantfluoxetine, paroxetne, citalopram, and antidepressantlike alprazolam.like alprazolam.

FluoxetineFluoxetine :: 2020--6060 mgmg\\day forday for 22--33 months, ormonths, orintermittently forintermittently for 77--1414 days in luteal phase todays in luteal phase tominimize side effects ( like loss of libido, fatigue, GITminimize side effects ( like loss of libido, fatigue, GITdisturbance).disturbance).VenlaxafineVenlaxafine, a drug that selectively inhibits the, a drug that selectively inhibits thereuptake of both serotonin and norepinephrine, is alsoreuptake of both serotonin and norepinephrine, is alsomore effective (more effective (5050 toto 200200 mg/day) than placebo.mg/day) than placebo.AlprazolamAlprazolam = Benzodiazepine( anxiolytic)= Benzodiazepine( anxiolytic) 00..2525 mgmg22--33\\day .day .

33-- Hormonal treatment: For ovulationHormonal treatment: For ovulation

suppressionsuppression..

AA-- EstrogenEstrogen

BB-- Oral contraceptivesOral contraceptives

CC--GnRH agonistGnRH agonist

DD-- DanazolDanazol

33-- Hormonal treatment: For ovulationHormonal treatment: For ovulation

suppressionsuppression..

AA-- EstrogenEstrogen

BB-- Oral contraceptivesOral contraceptives

CC--GnRH agonistGnRH agonist

DD-- DanazolDanazol

IIIIII-- Surgical treatmentSurgical treatmentindication of bilateral oophorectomy, andindication of bilateral oophorectomy, andhysterectomy :hysterectomy :--11--Failure of all other treatment options ( i.eFailure of all other treatment options ( i.esurgery is the last choice).surgery is the last choice).22--Unbearable side effects.Unbearable side effects.33--Coexisting pathology in the uterus or theCoexisting pathology in the uterus or theovary.ovary.

The surgery followed by long term hormonalThe surgery followed by long term hormonalreplacement therapy (HRT).replacement therapy (HRT).

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IIIIII-- Surgical treatmentSurgical treatmentindication of bilateral oophorectomy, andindication of bilateral oophorectomy, andhysterectomy :hysterectomy :--11--Failure of all other treatment options ( i.eFailure of all other treatment options ( i.esurgery is the last choice).surgery is the last choice).22--Unbearable side effects.Unbearable side effects.33--Coexisting pathology in the uterus or theCoexisting pathology in the uterus or theovary.ovary.

The surgery followed by long term hormonalThe surgery followed by long term hormonalreplacement therapy (HRT).replacement therapy (HRT).

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