Premenstrual Premenstrual syndromesyndrome

Dysmenorrhea Dysmenorrhea Dr.Roaa H. GadeerDr.Roaa H. Gadeer

MDMD

PMS/PMDDPMS/PMDD

The presence of physical and/or The presence of physical and/or behavioral symptoms that occur behavioral symptoms that occur repetitively in the second half of the repetitively in the second half of the menstrual cycle and often the first menstrual cycle and often the first few days of menses. few days of menses.

Incidence Incidence

70 - 80% 70 - 80% Only 20% are clinically significant.Only 20% are clinically significant.

PMDD affect only 5-6%PMDD affect only 5-6% Relatively high rates:Relatively high rates:

Mediterranean countries, the Middle Mediterranean countries, the Middle East, Iceland, Kenya, and New Zealand East, Iceland, Kenya, and New Zealand

Premenstrual syndrome :Premenstrual syndrome :1. The 1. The presencepresence by self report of at least by self report of at least

one of the following: one of the following: somaticsomatic and and affectiveaffective symptoms symptoms during the during the five days five days priorprior to menses in each of the to menses in each of the three three menstrual cyclesmenstrual cycles::

Affective:Affective: Depression, Angry, outbursts, Depression, Angry, outbursts, Irritability Confusion, Social withdrawal, Irritability Confusion, Social withdrawal, Fatigue.Fatigue.

Somatic:Somatic: Breast tenderness, Abdominal Breast tenderness, Abdominal bloating ,Headache, Swollen extremities. bloating ,Headache, Swollen extremities.

2. 2. ReliefRelief of the above symptoms within of the above symptoms within four daysfour days of the onset of menses, without of the onset of menses, without recurrence recurrence until at least cycle day 13.until at least cycle day 13.

3.The symptoms are present in 3.The symptoms are present in the the absenceabsence of any of any pharmacologicpharmacologic therapy, therapy, hormone hormone , , drug or alcohol use.drug or alcohol use.

4. 4. Identifiable dysfunctionIdentifiable dysfunction in social or in social or economic performance by one of the economic performance by one of the following criteria:following criteria:

Marital or relationship discord.Marital or relationship discord. Difficulties in parenting.Difficulties in parenting. Poor work or school performance.Poor work or school performance. Tiredness/Increased social isolation.Tiredness/Increased social isolation. Legal difficulties.Legal difficulties. Suicidal ideation.Suicidal ideation. Seeking medical attention for a somatic Seeking medical attention for a somatic

symptom.symptom.

PATHOGENESISPATHOGENESIS

interactioninteraction of cyclic changes in of cyclic changes in ovarian steroids with central ovarian steroids with central neurotransmitters.neurotransmitters.

Serotonin.Serotonin. Beta-endorphin.Beta-endorphin. Gamma-aminobutyric acid (GABA).Gamma-aminobutyric acid (GABA). Autonomic nervous system. Autonomic nervous system. Peripheral mechanisms. Peripheral mechanisms.

Symptom: Symptom: Fatigue 92Fatigue 92 Irritability 91Irritability 91 Bloating 90 Bloating 90 Anxiety/tension 89 Anxiety/tension 89 Breast tenderness 85Breast tenderness 85 Mood liability 81Mood liability 81 Depression 80Depression 80 Food cravings 78Food cravings 78 Acne 71Acne 71 Increased appetite 70Increased appetite 70 Over sensitivity 69Over sensitivity 69 Swelling 67Swelling 67 Expressed anger 67Expressed anger 67 Crying easily 65Crying easily 65 Feeling of isolation 65Feeling of isolation 65 Headache 60Headache 60 Forgetfulness 56Forgetfulness 56 Gastrointestinal symptoms 48Gastrointestinal symptoms 48 Poor concentration 47Poor concentration 47 Hot flashes 18Hot flashes 18 Heart palpitations 14Heart palpitations 14 Dizziness14Dizziness14

Diagnostic criteria are:Diagnostic criteria are: The American Psychiatric The American Psychiatric

Association DSM-IV criteria for Association DSM-IV criteria for PMDDPMDD

The University of California, San The University of California, San Diego (UCSD) criteria for PMSDiego (UCSD) criteria for PMS

DSM-IV criteriaDSM-IV criteria (PMDD) : (PMDD) : Documentation of physical and behavioral symptoms being Documentation of physical and behavioral symptoms being

present for most of the preceding year.present for most of the preceding year. Five or more of the following symptoms must have been Five or more of the following symptoms must have been

present during the week prior to menses.present during the week prior to menses. Resolving within a few days after menses starts.Resolving within a few days after menses starts. At least one of the five symptoms must be one of the first four At least one of the five symptoms must be one of the first four

on this list:on this list: Feeling sad, hopeless, or self- deprecating Feeling sad, hopeless, or self- deprecating Feeling tense, anxiousFeeling tense, anxious Marked liability of mood / tearfulness Marked liability of mood / tearfulness Persistent irritability, anger, and increased interpersonal Persistent irritability, anger, and increased interpersonal

conflicts conflicts Decreased interest in usual activities / withdrawal from social Decreased interest in usual activities / withdrawal from social

relationships relationships Difficulty concentrating Difficulty concentrating Feeling fatigued, lethargic, or lacking in energy Feeling fatigued, lethargic, or lacking in energy Marked changes in appetite, which may be associated with Marked changes in appetite, which may be associated with

binge eating or craving certain foods binge eating or craving certain foods Hypersomnia or insomnia Hypersomnia or insomnia Being overwhelmed or out of control Being overwhelmed or out of control Breast tenderness or swelling, headaches, joint or muscle Breast tenderness or swelling, headaches, joint or muscle

pain, a sensation of bloating, weight gain pain, a sensation of bloating, weight gain

UCSD criteria (PMS):UCSD criteria (PMS): In whom coexisting medical conditions or In whom coexisting medical conditions or

psychiatric disturbance were excluded by psychiatric disturbance were excluded by history, physical examination and history, physical examination and psychometric testing.psychometric testing.

The presence of at least one of the The presence of at least one of the following six following six BehavioralBehavioral symptoms: symptoms:

- Fatigue, irritability, depression, expressed - Fatigue, irritability, depression, expressed anger, poor concentration, and social anger, poor concentration, and social withdrawal.withdrawal.

at least one of the following four at least one of the following four SomaticSomatic symptoms:symptoms:

- Breast tenderness, abdominal bloating, - Breast tenderness, abdominal bloating, headache, or swollen extremitiesheadache, or swollen extremities

Therapies for the premenstrual Therapies for the premenstrual syndrome syndrome

Treatments with demonstrated efficacy:Treatments with demonstrated efficacy: Serotonin Serotonin reuptakereuptake inhibitors (NOT Anti inhibitors (NOT Anti

depressant)depressant) AlprazolamAlprazolam Agents that suppress ovulationAgents that suppress ovulation GnRH agonistsGnRH agonists DanazolDanazolTreatments with possible efficacyTreatments with possible efficacy Oral contraceptivesOral contraceptives DiureticsDiuretics ExerciseExerciseIneffective treatmentsIneffective treatments ProgesteroneProgesterone Vitamin supplements/Dietary restrictionsVitamin supplements/Dietary restrictions

Dysmenorrhea Dysmenorrhea

DysmenorrheaDysmenorrhea: : painful menstruationpainful menstruation.. Primary Dysmenorrhea (PD):Primary Dysmenorrhea (PD): The The

presence of recurrent, crampy, lower presence of recurrent, crampy, lower abdominal pain that occurs during abdominal pain that occurs during menses in menses in the absence of the absence of demonstrable pelvic disease. demonstrable pelvic disease.

Secondary Dysmenorrhea:Secondary Dysmenorrhea: The The occurrence of painful menstruation in occurrence of painful menstruation in the the presence presence of a pelvic pathology, of a pelvic pathology, such as such as endometriosisendometriosis, , adenomyosisadenomyosis, , uterine leiomyomatauterine leiomyomata, or , or chronic pelvic chronic pelvic inflammatory disease inflammatory disease

Incidence Incidence

  PD typically begins PD typically begins during adolescenceduring adolescence Not until ovulatory menstrual cycles are Not until ovulatory menstrual cycles are

established.established. At two years postmenarche (18 to 45%) At two years postmenarche (18 to 45%)

teens have ovulatory cycles.teens have ovulatory cycles. 80 % are ovulatory by four to five years 80 % are ovulatory by four to five years

postmenarche.postmenarche.

The prevalence of dysmenorrhea among The prevalence of dysmenorrhea among adolescent females ranges from 60 to 93 adolescent females ranges from 60 to 93 percent, but decreases with advancing age percent, but decreases with advancing age

RISK FACTORSRISK FACTORS Presentation at age less than 30 years.Presentation at age less than 30 years. Body mass index less than 20. Body mass index less than 20. Menarche before age 12. Menarche before age 12. Longer cycles/duration of bleeding.Longer cycles/duration of bleeding. Irregular or heavy menstrual flow.Irregular or heavy menstrual flow. Premenstrual symptoms.Premenstrual symptoms. Pelvic inflammatory disease.Pelvic inflammatory disease. Sterilization.Sterilization. History of sexual assault.History of sexual assault. Heavy smoking. Heavy smoking.

Reduced risk of Reduced risk of dysmenorrhea in:dysmenorrhea in:

Use of oral contraceptives.Use of oral contraceptives. Fish intake. Fish intake. Physical exercise.Physical exercise. Being married or in a stable Being married or in a stable

relationship.relationship. Higher parity. Higher parity.

Major causes of secondary Major causes of secondary dysmenorrhea dysmenorrhea

Gynecologic disorders Gynecologic disorders Endometriosis Endometriosis Adenomyosis Adenomyosis Ovarian cysts Ovarian cysts Pelvic adhesions Pelvic adhesions Pelvic inflammatory disease Pelvic inflammatory disease Uterine polyps Uterine polyps Congenital obstructive müllerian malformations Congenital obstructive müllerian malformations Cervical stenosis Cervical stenosis

Nongynecologic disordersNongynecologic disorders Inflammatory bowel disease Inflammatory bowel disease Irritable bowel syndrome Irritable bowel syndrome Uteropelvic junction obstruction Uteropelvic junction obstruction Psychogenic disorders Psychogenic disorders

PATHOGENESIS PATHOGENESIS 

PD is caused by frequent and prolonged uterine PD is caused by frequent and prolonged uterine contractions that decrease blood flow to the contractions that decrease blood flow to the myometrium resulting in ischemia (uterine myometrium resulting in ischemia (uterine "angina"). "angina").

Stimulation of the endometrium by estrogen Stimulation of the endometrium by estrogen (follicular and proliferative phase) followed by (follicular and proliferative phase) followed by progesterone (luteal and secretory phase)= progesterone (luteal and secretory phase)= increases endometrial stores of arachidonic acid.increases endometrial stores of arachidonic acid.

AA is a precursor to prostaglandin (PGF2),AA is a precursor to prostaglandin (PGF2),(PGE2) and leukotrienes. (PGE2) and leukotrienes.

Cyclooxygenase inhibitors decrease menstrual Cyclooxygenase inhibitors decrease menstrual fluid prostaglandin levels and decrease pain.fluid prostaglandin levels and decrease pain.

CLINICAL CLINICAL MANIFESTATIONSMANIFESTATIONS

Occurs during ovulatory cycles.Occurs during ovulatory cycles. The pain begins just before or with the onset of The pain begins just before or with the onset of

menstrual bleeding.menstrual bleeding. Gradually diminishes over 12 to 72 hours. Gradually diminishes over 12 to 72 hours. The cramps are confined to the lower abdomen The cramps are confined to the lower abdomen

(suprapubic).(suprapubic). Pain is strongest in the midline (back and thigh Pain is strongest in the midline (back and thigh

pain).pain). Nausea, diarrhea, fatigue, headache, and a Nausea, diarrhea, fatigue, headache, and a

general sense of malaise accompany the pain. general sense of malaise accompany the pain. By comparison, women with secondary By comparison, women with secondary

dysmenorrhea often have symptoms and physical dysmenorrhea often have symptoms and physical findings that alert the physician to the presence of findings that alert the physician to the presence of pelvic pathology (Endometriosis).pelvic pathology (Endometriosis).

Treatment Treatment

Nonpharmacological interventionsNonpharmacological interventions

    HeatHeat     Dietary, vitamin, and herbal Dietary, vitamin, and herbal

treatmentstreatments     ExerciseExercise

Pharmacologic interventions:Pharmacologic interventions: A placeboA placebo Nonsteroidal antiinflammatory Nonsteroidal antiinflammatory

agents (NSAIDs)agents (NSAIDs) Hormonal contraceptives.Hormonal contraceptives. Levonorgestrel intrauterine Levonorgestrel intrauterine

contraception IUDcontraception IUD

VAGINITISVAGINITIS NORMAL VAGINAL PHYSIOLOGY AND FLORA :NORMAL VAGINAL PHYSIOLOGY AND FLORA : Normal vaginal discharge consists of Normal vaginal discharge consists of 1 to 4 mL1 to 4 mL

fluid (per 24 hours).fluid (per 24 hours). White or transparent, thick, and mostly odorlessWhite or transparent, thick, and mostly odorless.. Is formed by mucoid endocervical secretions in Is formed by mucoid endocervical secretions in

combination with sloughing epithelial cells, normal combination with sloughing epithelial cells, normal bacteria, and vaginal transudate.bacteria, and vaginal transudate.

The discharge may become more noticeable The discharge may become more noticeable ( during ( during pregnancypregnancy, use of , use of estrogen-progestin estrogen-progestin contraceptivescontraceptives, midmenstrual cycle , midmenstrual cycle close to the close to the time of ovulationtime of ovulation..

The pH of the normal vaginal secretions is The pH of the normal vaginal secretions is 4.0 to 4.0 to 4.54.5..

Dozens of different bacterial isolates. Dozens of different bacterial isolates. LactobacillusLactobacillus DiphtheroidsDiphtheroids S. epidermidisS. epidermidis

Causes of vaginitisCauses of vaginitisInfectious vaginitis :Infectious vaginitis : Common causes Common causes Bacterial vaginosis (40 to 50 Bacterial vaginosis (40 to 50

percent of cases) percent of cases) Vulvovaginal candidiasis (20 to Vulvovaginal candidiasis (20 to

25 percent of cases) 25 percent of cases) Trichomoniasis (15 to 20 Trichomoniasis (15 to 20

percent of cases) percent of cases) Less common causesLess common causes Foreign body with secondary Foreign body with secondary

infection infection Desquamative inflammatory Desquamative inflammatory

vaginitisvaginitis Streptococcal vaginitis (group Streptococcal vaginitis (group

A) A) Ulcerative vaginitis associated Ulcerative vaginitis associated

with Staphylococcus aureus and with Staphylococcus aureus and toxic shock syndrome toxic shock syndrome

Idiopathic vulvovaginal Idiopathic vulvovaginal ulceration associated with HIV.ulceration associated with HIV.

Noninfectious vaginitis :Noninfectious vaginitis : Chemical or other irritant Chemical or other irritant Allergic, hypersensitivity, and Allergic, hypersensitivity, and

contact dermatitis (lichen contact dermatitis (lichen simplex) simplex)

Traumatic vaginitis Traumatic vaginitis Atrophic vaginitis Atrophic vaginitis Postpuerperal atrophic Postpuerperal atrophic

vaginitis vaginitis Desquamative inflammatory Desquamative inflammatory

vaginitis (steroid-responsive) vaginitis (steroid-responsive) Erosive lichen planus Erosive lichen planus Collagen vascular disease, Collagen vascular disease,

Behcet's syndrome,Behcet's syndrome, Idiopathic vaginitis Idiopathic vaginitis

GENERAL DIAGNOSTIC APPROACHGENERAL DIAGNOSTIC APPROACH

HistoryHistory : Symptoms of vaginitis include  : Symptoms of vaginitis include abnormalabnormal vaginal discharge, vaginal discharge, prurituspruritus, , irritationirritation, , burningburning, , sorenesssoreness, , odorodor, and, , and, less commonly, dyspareunialess commonly, dyspareunia

Physical examinationPhysical examination : : Appearance, Appearance, cervical motion tenderness.cervical motion tenderness. The vulva The vulva usually appears usually appears normal in bacterialnormal in bacterial vaginosis. Erythema, edema, or fissure vaginosis. Erythema, edema, or fissure formation suggest candidiasis, formation suggest candidiasis, trichomoniasis, or dermatitis.trichomoniasis, or dermatitis.

Diagnostic studiesDiagnostic studies Vaginal pH:Vaginal pH: Vaginal pH is the single most important finding.Vaginal pH is the single most important finding. A strip of pH paper is applied to the vaginal sidewall.A strip of pH paper is applied to the vaginal sidewall. A pH A pH above 4.5 inabove 4.5 in a premenopausala premenopausal woman suggests woman suggests

infections such as bacterial vaginosis or trichomoniasis infections such as bacterial vaginosis or trichomoniasis (pH 5 to 6), and helps to exclude candida vulvovaginitis (pH 5 to 6), and helps to exclude candida vulvovaginitis (pH 4 to 4.5).(pH 4 to 4.5).

Vaginal pH may be altered (usually to a higher pH) by Vaginal pH may be altered (usually to a higher pH) by contamination with contamination with lubricating gelslubricating gels, , semensemen, , douchesdouches, and , and intravaginal medicationsintravaginal medications..

Microscopy:Microscopy: Candidal buds or hyphaeCandidal buds or hyphae Motile Trichomonas Motile Trichomonas Epithelial cells studded with adherent coccobacilli (clue Epithelial cells studded with adherent coccobacilli (clue

cells) cells) Polymorphonuclear cells (PMNs).Polymorphonuclear cells (PMNs). The saline should be at room temperature and The saline should be at room temperature and

microscopy should be performed within 10 to 20 minutes.microscopy should be performed within 10 to 20 minutes.

Vaginal discharge processing:Vaginal discharge processing: is generally sampled with a cotton-tipped swab. The is generally sampled with a cotton-tipped swab. The

sample of vaginal discharge is mixed with one to two sample of vaginal discharge is mixed with one to two drops of drops of 0.9 percent normal saline0.9 percent normal saline solution on a glass solution on a glass slide. Cover slips are placed on the slides, which are slide. Cover slips are placed on the slides, which are examined under a microscope at low and high power.examined under a microscope at low and high power.

The addition of The addition of 10 percent potassium hydroxide (KOH)10 percent potassium hydroxide (KOH) to the wet mount of vaginal discharge destroys cellular to the wet mount of vaginal discharge destroys cellular elements (Candida vaginitis).elements (Candida vaginitis).

Smelling ("whiffing") the slide immediately after Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy (amine) applying KOH is useful for detecting the fishy (amine) odor of Bacterial Vaginosis.odor of Bacterial Vaginosis.

Excess WBCs without evidence of yeast, trichomonads, Excess WBCs without evidence of yeast, trichomonads, or clue cells suggests cervicitis.or clue cells suggests cervicitis.

If microscopy is not available, If microscopy is not available, diagnostic testing cardsdiagnostic testing cards are an alternative rapid test for confirming the clinical are an alternative rapid test for confirming the clinical suspicion.suspicion.

  Vaginal culture:Vaginal culture: For Candida or Trichomonas , if microscopy is For Candida or Trichomonas , if microscopy is

negative because microscopy is not sufficiently negative because microscopy is not sufficiently sensitive to exclude these diagnoses in symptomatic sensitive to exclude these diagnoses in symptomatic patients. patients.

Cervical culture:Cervical culture: For cervicitis, typically due to Neisseria gonorrhoeae For cervicitis, typically due to Neisseria gonorrhoeae

or or Chlamydia trachomatisChlamydia trachomatis, if you see a , if you see a purulent vaginal purulent vaginal dischargedischarge, , fever, or lower abdominal pain (PID). fever, or lower abdominal pain (PID).

Sexual behaviors that result in STD-related Sexual behaviors that result in STD-related vulvovaginitis (eg, trichomoniasis, herpes simplex vulvovaginitis (eg, trichomoniasis, herpes simplex virus) increase the odds of acquiring other STDs. The virus) increase the odds of acquiring other STDs. The presence of high risk behavior or any sexually presence of high risk behavior or any sexually transmitted disease requires screening for transmitted disease requires screening for HIV, HIV, hepatitis B, and other STDs.hepatitis B, and other STDs.

Candida AlbicansCandida Albicans

Trichomonas Trichomonas

Clue Cell (BV)Clue Cell (BV) Bacteroides species; anaerobic Peptostreptococcus species; Bacteroides species; anaerobic Peptostreptococcus species;

Fusobacterium sp. and Atopobium vaginae Fusobacterium sp. and Atopobium vaginae

Treatment Treatment Candida:Candida:A-non complicatedA-non complicated Butoconazole (Femstat)* Butoconazole (Femstat)* (Femstat)* 2 percent cream 5 g/day for 3 days or 1 day for (Femstat)* 2 percent cream 5 g/day for 3 days or 1 day for

sustained release formulation sustained release formulation (Gynazole) 2 percent cream 5 g/day for a single dose (Gynazole) 2 percent cream 5 g/day for a single dose Clotrimazole (Gyne- lotrimin, Mycelex)* 1 percent cream 5 g/day Clotrimazole (Gyne- lotrimin, Mycelex)* 1 percent cream 5 g/day

for 7 to 14 days for 7 to 14 days 100 mg vaginal tablet 1/day for 7 days 100 mg vaginal tablet 1/day for 7 days Miconazole (Monistat) 2 percent cream 5 g/day for 7 days Miconazole (Monistat) 2 percent cream 5 g/day for 7 days 100 mg vaginal suppository 1/day for 7 days 100 mg vaginal suppository 1/day for 7 days 200 mg vaginal suppository 1/day for 3 days 200 mg vaginal suppository 1/day for 3 days 1200 mg vaginal suppository 1 suppository 1200 mg vaginal suppository 1 suppository Tioconazole (Vagistat) 6.5 percent cream 5 g in a single dose Tioconazole (Vagistat) 6.5 percent cream 5 g in a single dose Terconazole (Terazol) 0.4 percent cream 5 g/day for 7 days Terconazole (Terazol) 0.4 percent cream 5 g/day for 7 days 80 mg vaginal suppository 1/day for 3 days 80 mg vaginal suppository 1/day for 3 days Nystatin (Mycostatin) 100,000 U vaginal tablet 1/day for 14 days Nystatin (Mycostatin) 100,000 U vaginal tablet 1/day for 14 days Fluconazole (Diflucan)Fluconazole (Diflucan)

B- complicated B- complicated Boric AcidBoric Acid

Trichomonas / BVTrichomonas / BV

MetronidazoleMetronidazole PO 500 mg bid x 7 days OR 2 gms PO 500 mg bid x 7 days OR 2 gms

single dose.single dose. PVPV ClindamycinClindamycin 300 mg po bid x 5 days 300 mg po bid x 5 days

for BV.for BV.

Treat the partner in TrichomoniasisTreat the partner in Trichomoniasis

Atrophic vaginitisAtrophic vaginitis

Lubricating /moisturizing gel.Lubricating /moisturizing gel.

Low dose Estrogen :Low dose Estrogen :- SystemicSystemic- LocalLocal

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