DysmenorrheaDysmenorrhea

Dr. Mashael ShebailiDr. Mashael Shebaili

Asst. Prof. & ConsultantAsst. Prof. & Consultant

Ob/Gyne DepartmentOb/Gyne Department

DysmenorrhoeaDysmenorrhoea

(Painful menstruation)(Painful menstruation)

PrimaryPrimary

SecondarySecondary

1.1. Primary dysmenorrhoeaPrimary dysmenorrhoea

No pelvic pathologyNo pelvic pathology

The pain is associated with bleeding The pain is associated with bleeding

in the first and second day.in the first and second day.

2.2. Secondary dysmenorrhoeaSecondary dysmenorrhoea Secondary to pelvic pathology as Secondary to pelvic pathology as

endometriosis, chronic pelvic infection endometriosis, chronic pelvic infection or endometrial polypsor endometrial polyps

The pain starts few days before The pain starts few days before menstruation, continues for the menstruation, continues for the duration of menses and may persist for duration of menses and may persist for days after. days after.

IncidenceIncidence

80% of patients attend family planning 80% of patients attend family planning clinic have dysmenorrhoea and was severe clinic have dysmenorrhoea and was severe in 18% of them (Robinson et al., 1992)in 18% of them (Robinson et al., 1992)

EpidemiologyEpidemiology

1.1.Long time smoker six time more than Long time smoker six time more than non-smokersnon-smokers

2.2.Age is inversely associated with Age is inversely associated with dysmenorrhoeadysmenorrhoea

3.3.Less common in parous women.Less common in parous women.

Primary dysmenorrhoeaPrimary dysmenorrhoea

AetiologyAetiology

Uterine hyperactivityUterine hyperactivity: abnormal : abnormal

(increased) uterine hyperactivity (increased) uterine hyperactivity

leading to uterine eschemia.leading to uterine eschemia.

Hyperalgesic substances Hyperalgesic substances e.g. e.g.

prostaglandin E.prostaglandin E.

CausesCauses

1.1. Increased uterotonic prostaglandins PGFIncreased uterotonic prostaglandins PGF22

2.2. Leucotrines produced by endometrium Leucotrines produced by endometrium

stimulates myometrial activitystimulates myometrial activity

3.3. Vasopressin is a vasoconstrictor substance Vasopressin is a vasoconstrictor substance

which stimulates uterine contraction. which stimulates uterine contraction.

Circulating vasopressin levels was found to Circulating vasopressin levels was found to

be higher on the first day of menstruation in be higher on the first day of menstruation in

women with dysmenorrhoea.women with dysmenorrhoea.

Treatment of primary Treatment of primary dysmenorrhoeadysmenorrhoea

A.A. Medical treatmentMedical treatment• Reassurance and simple analgesicReassurance and simple analgesic• NSAIDs are useful first line treatment with NSAIDs are useful first line treatment with

80-90% improvement, particularly the 80-90% improvement, particularly the mefenamic acid derivatives. mefenamic acid derivatives.

• If contraception is also required OCCP is If contraception is also required OCCP is appropriate.appropriate.

• Oxytocin antagonist for future.Oxytocin antagonist for future.

Surgical treatmentSurgical treatment

Used as last resortUsed as last resort

Laparoscopic uterosacral nerve ablation Laparoscopic uterosacral nerve ablation

LUNALUNA

HysterectomyHysterectomy

Cervical dilatation has no beneficial effectCervical dilatation has no beneficial effect

Secondary dysmenorrhoeaSecondary dysmenorrhoea

AetiologyAetiology

1.1. Endometriosis Endometriosis and adenomyosisand adenomyosis

2.2. Chronic PIDChronic PID

3.3. Congenital or Congenital or acquired uterine acquired uterine abnormalitiesabnormalities

InvestigationsInvestigations

1.1. USSUSS

2.2. HSGHSG

3.3. HysteroscopyHysteroscopy

4.4. laparoscopylaparoscopy

Treatment of secondary dysmenorrhoeaTreatment of secondary dysmenorrhoea

(that of the cause), e.g.(that of the cause), e.g.

EndometriosisEndometriosis

AdenomyosisAdenomyosis

Uterine abnormalitiesUterine abnormalities

Premenstrual tension syndromePremenstrual tension syndrome

Recurring cyclical disorder in the luteal Recurring cyclical disorder in the luteal phase of the menstrual cycle, involving phase of the menstrual cycle, involving behavioral, psychological and physical behavioral, psychological and physical changes resulting in loss of work or social changes resulting in loss of work or social impairment (Ried and Yen 1981)impairment (Ried and Yen 1981)

PMT may occur after hysterectomy with PMT may occur after hysterectomy with conservation of functioning ovariesconservation of functioning ovaries

DiagnosisDiagnosis

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

A.A.Symptoms are temporarily related to Symptoms are temporarily related to menstruationmenstruation

B.B.The diagnosis requires at least 5 of The diagnosis requires at least 5 of the following symptoms, and one of the the following symptoms, and one of the symptoms must be one of the first 4: symptoms must be one of the first 4:

1.1. Affective labiality sudden onset of being Affective labiality sudden onset of being

sad, tearful, irritable or angrysad, tearful, irritable or angry

2.2. Anxiety or tension Anxiety or tension

3.3. Depressed mode, feeling of hopelessnessDepressed mode, feeling of hopelessness

4.4. Decreased interest in usual activitiesDecreased interest in usual activities

5.5. Easy fatigability or marked lack of energyEasy fatigability or marked lack of energy

6.6. Difficulty in concentrationDifficulty in concentration

7.7. Changes in appetite (food craving or over Changes in appetite (food craving or over

eating)eating)

8.8. InsomniaInsomnia

9.9. Feeling of being overwhelmed or out of Feeling of being overwhelmed or out of

controlcontrol

10.10. Physical symptoms (bloating, breast Physical symptoms (bloating, breast

tenderness, headache, edema, joint or tenderness, headache, edema, joint or

muscular pain and weight gain.muscular pain and weight gain.

C.C. The symptom interfere with work, The symptom interfere with work, usual activities or relationshipusual activities or relationship

D.D. The symptoms are not an exacerbation The symptoms are not an exacerbation of another psychiatric disorderof another psychiatric disorder

PrevalencePrevalence

Difficult to ascertain; 40% reported mild Difficult to ascertain; 40% reported mild symptoms, of them 2-10% the symptoms, of them 2-10% the symptoms interfere with their work or symptoms interfere with their work or life stylelife style

EtiologyEtiologyList of biological theoriesList of biological theories

1)1) Estrogen excessEstrogen excess

2)2) Progesterone Progesterone deficiencydeficiency

3)3) HyperprolactinemiaHyperprolactinemia

4)4) Hypoglycemia Hypoglycemia

5)5) Vit. B deficiencyVit. B deficiency

6)6) Increased Increased aldosteron activityaldosteron activity

7)7) Increased activity Increased activity of renin angiotensin of renin angiotensin systemsystem

8)8) Recently, alteration Recently, alteration in neurotransmitters in neurotransmitters particularly the particularly the serotoninergic and serotoninergic and opioid pathwaysopioid pathways

Treatment of PMSTreatment of PMSA. A. Non pharmacological treatmentNon pharmacological treatment

1)1) Reassurance and supportReassurance and support2)2) Relaxation and stress managementRelaxation and stress management3)3) Reflexology therapy that reduce Reflexology therapy that reduce

somatic and psychological PMS somatic and psychological PMS symptomssymptoms

4)4) Increase aerobic exercise ? By altering Increase aerobic exercise ? By altering endorphinsendorphins

5)5) Well balanced diet with low sodium and fat Well balanced diet with low sodium and fat

contentscontents

6)6) Restriction of alcohol, chocolate, caffeine Restriction of alcohol, chocolate, caffeine

and dairy productsand dairy products

7)7) Supplementation with vitamin BSupplementation with vitamin B66, E, , E,

magnesium and calciummagnesium and calcium

8)8) Evening primrose oilEvening primrose oil

Women on estrogen Women on estrogen

replacement therapy does not replacement therapy does not

develop symptoms of PMS develop symptoms of PMS

unless progesterone is addedunless progesterone is added

Women on estrogen Women on estrogen

replacement therapy does not replacement therapy does not

develop symptoms of PMS develop symptoms of PMS

unless progesterone is addedunless progesterone is added

B.B. Medical treatmentMedical treatment

Pharmacological suppression of the Pharmacological suppression of the

hypothalamopituitary ovarian axis hypothalamopituitary ovarian axis

should offer a logical approach to should offer a logical approach to

therapy (to stop cyclical ovarian therapy (to stop cyclical ovarian

activity)activity)

1.1. Ovarian suppression using OCCP is Ovarian suppression using OCCP is

beneficial in some patients but cause beneficial in some patients but cause

exacerbation of symptoms in othersexacerbation of symptoms in others

2.2. Danazol for breast symptomsDanazol for breast symptoms

3.3. GnRH agonist: it improve symptoms in some GnRH agonist: it improve symptoms in some

women & can be used as a treatmentwomen & can be used as a treatment

4.4. Diuretics in patients complaining of bloating, Diuretics in patients complaining of bloating,

edema and weight gainedema and weight gain

5.5. NSAIDs: reduce many of the somatic NSAIDs: reduce many of the somatic

symptoms as dysmenorrhoeasymptoms as dysmenorrhoea

6.6. For emotional and psychological For emotional and psychological

manifestations serotoninergic antidepressent manifestations serotoninergic antidepressent

offer good first line approach. Fluoxetine offer good first line approach. Fluoxetine

(Prozac)(Prozac)

7.7. Anoxiolytic as alprazola (Xanox) also offer Anoxiolytic as alprazola (Xanox) also offer

some help.some help.

C.C. Surgical treatmentSurgical treatment

Reserved only to patients with severe Reserved only to patients with severe symptoms not responding to medical symptoms not responding to medical treatmenttreatmentHysterectomyHysterectomyBilateral oophorectomy (balance between Bilateral oophorectomy (balance between

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

Thank Thank youyouThank Thank youyou