Dysmenorrhea and other menstrual disorders

  • Painful menstruation of sufficient capacity, to affect day to day activity
  • It is a symptom complex, with cramping lower abdominal pain, radiating to back and leg, often accompanied by GI and neurological symptoms as well as general malaise.

Types of dysmenorrhea

Primary dysmenorrhea
The pain of uterine is directly linked to menstruation with no visible pelvic pathology.

Secondary dysmenorrhea
Pain associated with uterine or pelvic pathology
dysmenorrhea and other menstrual disorders

History taking questions for dysmenorrhea

  • When does pain occur—before, during, intermenstrual, most intense
  • Duration of pain
  • Site
  • Other associated symptoms like menorrhagia, intermenstrual bleeding, discharge per vagina etc.

Primary dysmenorrhea

  • The incidence of 5-10% of girls. Late teen and early 20s. Decreasing trend.

Etiology of Primary dysmenorrhea

  1. Behavioral and psychological
    • Emotionally unstable before and during menstruation
    • Decrease with advancing age
    • Family Hx in mother and sister
    • Unhappy home
    • Unsatisfied sexual urge
    • Cured by stability in many cases
  2. Muscular incoordination and uterine hyperactivity
    • Incoordinate muscle action of the uterus
    • Imbalance in autonomic nervous control of muscle overactive sympathetic system hypertonus circular muscles of the isthmus and internal os
    • Usually seen in cases with bowel and bladder problems
  3. Hormone imbalance
    • Progesterone stimulation of uterus seen in ovulatory cycles only. It causes high tone in the isthmus and upper cervix which causes incoordinate ut contraction. Cured by cx dilatation, vaginal delivery
    •  Prostaglandins–an excess of Pg f2α in the uterus. High in secretory endometrium. Increase ms contraction and vessel constriction cause ischemic pain.
    • PgE2 increases sensitivity to nerve endings. eg. Pg synthetase inhibitors relieve pain-80%
  4. Others Circulating vasopressin- stimulates uterine contraction, Endothelin

Clinical features

  • Age group—18-24yrs, 2-4yrs of menarche
  • Pain abdomen- hypogastrium, inner thighs, colicky, few hours to 12-24hrs before menstruation.
T12 L1 L2—iliohypogastric, ilioinguinal
  • Associated symptoms sweating, nausea, vomiting, headache, diarrhea, rectal and bladder tenesmus

Treatment for dysmenorrhea

  1. General
  2. Counseling
  3. Proper outlook in menstruation, sex, health
  4. Improve malnutrition and ill health
  5. Regular physical exercise
  6. Short-lived, improve with marriage and pregnancy
  7. Drugs

Drugs

NSAID:

Mefenemic acid, Indomethacin, Naproxen, Ibuprofen, Piroxicam for 1-3days of menstruation. Contraindication – GI ulcers, asthma, sensitive to aspirin NEVER USE – PETHIDINE, MORPHINE

Hormones: 

anovulatory cycles are painless. combined OCP– 5-25 days.
For 3-6 cycles added benefit –contraceptive

Diagnostic  

Ca channel blockers--Nefidipine

Surgical

Surgical treatment in dysmenorrhea is always a last resort and is done after medical treatment failure with severe incapacitating pain. Psychological and other pathological bases must be excluded before opting out for surgery.

Methods of surgical treatment in a patient with dysmenorrhea

1. laparoscopy—medical failure, diagnostic—to exclude pelvic and uterine lesion

2. Dilatation of cervix: Stretches fibromuscular tissue at the internal os, dilate up to hegar 10, Risk of injury to the cervix causing cervical incompetence later.

3. Injection of pelvic plexus with anesthetics, paracervical block

4. Presacral neurectomy: eliminate motor impulse, increase uterine vascularity, interrupt sensory pathway T11-L2. LUNA (laparoscopic ultrasound nerve ablation) can be performed as well.

Secondary dysmenorrhea

Causes of secondary dysmenorrhea

  1. Pelvic lesion
  2. Endometriosis
  3. Acute and chronic PID
  4. Uterine lesion
    Adenomyosis, leiomyoma, polyp, IUCD, congenital malformation of the uterus (abnormal muscles arrangement-septate, bicornuate uterus)

Types of secondary dysmenorrhea

Congestive

Diffuse dull ache in pelvis, backache
Increased tension in pelvic tissue associated with inflammation, exacerbated by premenstrual engorgement
pain 2-3 days before to throughout menstruation
usually with menorrhagia, polymenorrhoea

Spasmodic

submucous fibroid, polyps, IUCD

Investigations for secondary dysmenorrhea

  • USG– leiomyoma, polyps, uterine malformations, ovarian tumors
  • Laparoscopy
  • Hysteroscopy
  • MRI
  • HSG

Membranous Dysmenorrhea

  • Rare and familial
  • Endometrium strips off in pieces causing severe colic
  • Over-mature corpus luteum induces an excessive decidual reaction that does not disintegrate easily and comes out in pieces.
  • Does not interfere with conception
  • Refractory to treatment
  • Suppression of ovulation with OCP for 1-2 yrs sometimes effective

Other menstrual disorders

Ovulation pain (mid-cycle pain, Mittelschmerz’s syndrome)

  • Usually 10-15th day of the cycle
  • Pain hypogastric or iliac region sometimes referred to the rectum
  • Usually on the same side
  • Varies in severity
  • lasts 12-24 hours
Causes
  • Contraction of tubes and ovaries
  • Increase tension in Graafian follicles
  • Irritation of peritoneum from discharged fluid and blood
Treatment
  • Reassurance and explanation
  • Analgesics
  • OCP if severe

Premenstrual Syndrome

  • Psychosomatic disorder
  • Cyclic appearance in the last 7-10 days of the cycle
Main feature
  • Not related to organic lesion
  • Occurs in the luteal phase
  • Severe to disturb her lifestyle
  • Rest of the period symptom-free
Premenstrual dysphoric disorder –when daily functioning is affected.

Pathophysiology
  • Exact cause not known
  • Alteration in E:P ratio or diminished progesterone
  • Neuroendocrine
  • Decrease serotonin secretion in the luteal phase
  • Withdrawal of endorphins from CNS
  • Decrease in GABA
  • Psychological and psychosocial factors
Clinical features
  • Age group- 30-45 yrs
  • Disturbing life events, childbirth
Treatment
  • Assurance, yoga, diet
  • Avoidance of high salt, caffeine, alcohol
  • Antidepressants- decrease emotional instability
  • Pyridoxine 100mg BD
  • Alprazolam- decrease anxiety
  • Selective serotonin reuptake inhibitors--fluoxetine
  • Hormones
    • OCP—suppress ovulation
    • Progesterone
    • GnRH analogues (medical oophorectomy)
Surgical
  • Last resort- TAH BSO especially in perimenopausal women

References: 

  • https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Dysmenorrhea-and-Endometriosis-in-the-Adolescent
  • https://www.acog.org/Patients/FAQs/Dysmenorrhea-Painful-Periods

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