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SALWA NEYAZI
COSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST
DYSMENORRHEA
WHAT IS DYSMENORRHEA? Painful menstruation WHAT IS ITS INCIDENCE? 50-75 % WHAT ARE THE TWO MAIN CATEGORIES? 1- Primary painful menstruation without associated pelvic disease 2-Secndary painful menstruation caused by pelvic pathology
DYSMENORRHEA
HOW TO EVALUATE A PATIENT WITH DYSMENORRHEA? 1-History 2-Physical examination should be completely Normal in Pt with 1ry dysmen, however if evaluated during the pain uterus & cx will be mildly tender 3-Investigations not required if Hx & physical examination are consistent with 1ry dysm
*U/S *HSG *Laparoscopy *Hystroscopy *D&c Allow the physician to confirm presence or absence of pelvic disease
1RY DYSMENORRHEA
PRIMARY DYSMENORRHEA
Usually begins few hrs before or with the onset of menstruation then gradually decrease +ve family Hx The pain is crampy/ colicky , in the lower abdomen most intense in the midline lasts for 12-72 hr Started with ovulatory cycles 6-12 M after menarche Associated symptoms -Back pain & pain in the upper thighs 60% -Nausea /vomitting 90% -Diarrhea 60% -Fatigue / malaise 85% -Headache (tension or migraine) 45% -Dizziness, nervousness, fainting in sever cases
1ry DYSMENORRHEA
WHAT IS THE CAUSE OF 1RY DYSMEN ?
-Prostaglandin (PG F2) release from endometrial cells uterine smooth muscle contraction, increased intra uterine pressure & some degree of uterine ischemia -PG production during the 1st 48-72 hrs of menses -PG may also cause hypersensitization of pain terminals to physical & chemical stimuli -Behavioral,cultural & psychological factors influence the Pt reaction to pain
1ry DYSMENORRHEA
WHAT IS THE TREATMENT OF 1RY DYSMEN? 1-NSAID 1st line 80% effective *Propionic a derivatives Ibuprofen Naproxen *Fenamates Mefenamic acid Ponstan
1ry DYSMENORRHEA
WHAT IS THE MECHANISM OF ACTION OF THESE DRUGS? 1- NSAID Inhibits prostaglandin production Antagonistic action at the receptor Ponstan Should be used with the start of pain regularly for 2- 3 days 2- ORAL CONTRACEPTIVES endometrial thickness PG through inhibition of ovulation & change the hormonal status to that of the early proliferative phase (which has the lowest level of PG)
1ry DYSMENORRHEA
WHAT ARE THE SIDE EFFECTS OF NSAID? Gastric irritation Nausea GIT ulceration Bleeding time Nephrotoxicity Fenamates blurred vision, headache & dizziness Bronchospasm in Pt with bronchial asthma Hypersensitivity reaction Autoimmune hemolytic anemia
1ry DYSMENORRHEA
HOW TO MANAGE A PT WHO CONTINUES TO HAVE PROBLEM ? Investigations to R/O 2ry dysmenorrhea If results are normal - Codeine may be helpful under close supervision to avoid addiction -Acupuncture
SECONDARY DYSMENORRHEA
2RY DYSMENORRHEA
Hx -Older patients with onset of symptoms several years after menarche -Recurrent pelvic infections -IUCD -Recent pelvic surgery -Heavy periods -Irregular cycles Physical examination May help in Dx by finding abnormalities that point to a pelvic disease
2RY DYSMENORRHEA
HOW TO EVALUATE PT WITH 2RY DYSMEN ? CBC ESR Cultures for std U/S HSG if intruterine scarring or fibroid is suspected Laparoscopy Hysteroscopy D&C TREATMENT OF 2RY DYSMENORRHEA Treat the cause
2RY DYSMENORRHEA
CX STENOSIS
Cx stenosis Intrauterine pressure during
menses Retrograde menstruation endometriosis Cx stenosis -Congenital -2ry to cervical injury *electrocautery *cryocautery *conization *infection Scanty menstrual flow & sever cramping through out the menstrual cycle
CX STENOSIS
Dx Internal os scarred & impossible to pass uterine sound or even very thin probe
Rx
-D&C -The problem frequently recurs repeat procedure -Vaginal delivery afford morelasting cure Pt with large endocervical polyp will have the same presentation
ENDOMETRIOSIS
Endometriosis Ectopic endometrial tissue Adenomyosis Endometrial tissue in the myometrium Hx Sever dysmenorrhea Infertility Dysparunea Pelvic examination Evidence of endometriosis in vagina or cx Tenderness Thickening / nodules of rectovaginal septum or uterosacral ligament Ovarian (chocolate) cyst
ENDOMETRIOSIS
Dx -Laparoscopy or laparotomy -Direct biopsy of vaginal or cx lesion
Rx
To supress menstruation by medication Cauterization of endometriotic spots Analgesics
PREMENSTRUAL SYNDROME
PMS
WHAT IS PMS ? A group of physical, emotional & behavioral symptoms that occur in the 2nd half (luteal phase) of the menstrual cycle often interfere with work & personal relationships followed by a period entirely free of symptoms starting with menstruation WHAT THE INCIDENCE OF PMS ? 40% Significantly affected at one time or another 2-3% Sever symptoms with impact on their work & lifestyle 5% by the American psychiatric association definition
PMS
WHAT SYMPTOMS ARE ASSOCIATED WITH PMS? PHYSICAL SYMPTOMS -Bloated feeling -Wt gain -Breast pain & tenderness -Skin disorders acne -Hot flushes -Headache -Pelvic pain -Changes in bowel habits -Joint or muscle pain -edema
ETIOLOGY
DO WE KNOW WHAT CAUSES PMS ? No, many theories have been postulated, most of them have to-do with various hormonal alterations Vit B6 deficiency Multifactorial psychoendocrine disoreder Alterations in the serotoninergic neuronal mechanism in the CNS (serotonin deficiency) Ovulation / progestrone production are important in this syndrome Drugs that inhibit ovulation relief of PMS symptoms Antiprogestrone RU486 No relief
ETIOLOGY
Abnormal response of the CNS to the normal fluctuations of estrogen & progestrone during the menstrual cycle Administration of estrogen & progestrone to women with PMS whose ovaries were suppressed with GnRH agonist analogues development of PMS symptoms
BIOPYCHOSOCIAL MODEL
Hormonal changes of the luteal phase of the menstrual cycle, that is the estradiol & progestrone act as a trigger to stimulate the development of PMS symptoms in women who are biologically, socially & psychologically predisposed to develop PMS Biological explanation abnormal response of the CNS to the hormonal changes could be related to serotonin or -aminobutyric acid Social explanation mimicking the behavior of other important females in her life, social expectations or pressure from others Psychological explanation rejection of the female role or that PMS could be a variation of other common affective disorder
EVALUATION
Pt should keep a diary of her symptoms throughout 2-3 menstrual cycles then the physician should review these symptoms with the Pt to determine what seems to be causing her the most difficulty
Complete Hx & physical examination to R/O any medical problem
DX
DIAGNOSTIC CRITERIA FOR THE PMDD (PreMenstrual Dysphoric Disorder) in the Diagnostic Statistical Manual for Mental Disorders Requires 5 of the following -Depressed mode -Anexiety -Labile mode -Irritability -Change in appetite - Lethargy -Sleep disturbance -Out of control -Lack of interest -Physical sympt *Occur in the week before menses in most menstrual cycles *Disappear few days after the onset of menses *Impair social, occupational function or the ability to interact with others
1- SUPPORTIVE Counseling & education the physician should reassure the Pt that her symptoms are real & can be treated The goal is to provide the Pt with greater control over her life Life style changes such as exercise & dietary modifications 2-MEDICATIONS The selection of medications should be tailored to the Pt main symptoms
TREATMENT
MEDICAL THERAPY
SYMPTOMATIC Rx 1- Bloating & feeling of fluid retention Diuretics (spironolactone) 2-Cramping, back pain, heat intolerance Antiprostaglandines 3-Breast tenderness Bromocriptine 4-Depression, anxiety, irritability Alprazolam 0.25 mg bd SSRI Fluoxetine (Prozac) 5-20 mg/D (D20-28)
SUPPRESSION OF OVULATION 1-Danazol 200 mg QID D 20-28 2-Oral Contraceptives 3-Medroxyprogestrone acetate 10 mg BID/TID contiuously MISCILANEOUS Rx 1-Micronized progestrone 100mg AM 200mg PM D 20-28 2-Multiple Vitamines 3-Pyridoxine B6 50 mg/ day or B-complex 4-Ca Carbonate 1200mg/D 5-Prime rose oil linolenic acid
MEDICAL THERAPY