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Dysmenorrhoea in Adult Women

Dys: difficult/painful/abnormal
Meno: month
Rrhoea: flow

By Vanessa Ting Ching Ching


The Menstrual Cycle
Primary Dysmenorrhoea
• ‘Spasmodic’: menstrual pain in the absence of
pelvic disease
• Starts in the first few years after menarche
• Risk factors:
▫ Earlier age at menarche (<12 years)
▫ Nulliparity
▫ Heavy or prolonged menstrual flow
▫ Smoking
▫ Positive family history
▫ Obesity & alcohol consumption
Pathophysiology
• Destruction of endometrial cells release
prostaglandins
▫ PGE2 & PGF2α - potent myometrial stimulants
and vasoconstrictors
▫ increases intrauterine pressure, vessel
constriction and decreases uterine blood flow
▫ Results in tissue ischemia, endometrial
disintegration, bleeding and pain
• Other mediators are also thought to be involved
▫ Leukotrienes, vasopressin, type C neurons
Secondary Dysmenorrhoea
• ‘Congestive’: menstrual pain resulting from
underlying disease, disorder or structural
abnormality either within or outside the uterus
▫ Endometriosis
▫ Adenomyosis
▫ Pelvic inflammatory disease
▫ Ovarian cysts and tumours
▫ Fibroids and uterine polyps
▫ Intrauterine adhesions
▫ Intrauterine contraceptive device
• Commonly affects women in 20’s or 30’s
Symptoms
Primary Secondary
• Onset within 6-12 months • Onset in 20s or 30s (previously
after menarche painless menstrual cycles)
• Lower abdominal/pelvic pain • Infertility
(begins with onset of menses • Heavy menstrual flow or
irregular bleeding
and lasts 8-72 hours)
• Dyspareunia
• Low back pain • Vaginal discharge
• Medial/anterior thigh pain • Lower abdominal or pelvic pain
• Headache during times other than menses
• Diarrhoea • Pain unrelieved by NSAIDS
• Nausea/vomiting
Diagnosis
• Medical history
• Laboratory tests
▫ WBC, UFEME, ESR, cervical swab, HCG level
• Ultrasound
▫ Abdominal, transvaginal, pelvic
• Invasive studies
▫ Laparascopy, hysteroscopy, dilatation & curretage
• Differential diagnosis
▫ Abortion, ectopic pregnancy, UTI, PID, IBS,
peritonitis, uterine neoplasm
NSAIDS
• Best-established first line treatment
▫ Inhibits prostaglandin synthesis & decreases
intrauterine pressure & menstrual blood flow
• Traditional NSAIDS are more effective than
paracetamol
▫ Diclofenac, naproxen, mefenamic acid &
ibuprofen
• Small studies show that selective COX-2
inhibitors are not superior to traditional NSAIDS
for pain relief
28-day Menstrual Cycle
Oral Contraception
• Off-label treatment of dysmenorrhoea
▫ Reduces secretion of LH and FSH from pituitary &
therefore prevents ovulation & prostaglandin
production
▫ May also reduce the number of menstrual cycles
 Long-term use of active pills and avoiding the pill-
free week or with extended-cycle formulations (eg:
12 weeks active hormones & 1 week placebo)
Other Hormonal Methods
• Depo-medroxyprogesterone acetate (Depo-Provera)
▫ Inhibits secretion of gonadotropins, thereby inhibiting
ovulation and decreasing thickness of endometrium
• Levonorgesterol intrauterine device (Mirena)
▫ Similar to Depo-Provera
• Intravaginal administration of OCs
▫ 30 mcg of ethinyl estradiol and 150 mg of
levonorgestrel daily
▫ Less systemic side effects
Other Pharmacologic Methods
• Hyoscine
▫ Blocks Ach & therefore decreases motility in GI &
urogenitary areas, leading to less spasms
• Transdermal glyceryl trinitrate
▫ Nitric oxide reduces uterine contractions
▫ less effective than diclofenac
▫ associated with a high incidence of headache
• Danazol or leuprolide acetate
▫ Suppresses the menstrual cycle
▫ Indicated for treatment of endometriosis
• Oral nifedipine
• Intravenous terbutaline
Surgery
• Mostly for the treatment of secondary
dysmenorrhoea
▫ Laparoscopic uterine nerve ablation (LUNA)
destruction of a small segment of ligament that
carries nerve fibres within the pelvis
▫ Hysterectomy (removal of the uterus)
▫ Ovary removal
▫ Presacral neurectomy
Diet & Lifestyle
• Low fat vegetarian diet
• Smoking cessation or reduction of passive smoking
• Exercise
▫ Strenuous or aerobic exercise produce endorphins
• Heat application
▫ warm bath or heating pad /hot water bottle on the abdomen
• Sleep
▫ Lying in the supine position
• Sexual intercourse
▫ Orgasms produce endorphins
• Relaxation
▫ Meditation/yoga
▫ Abdominal/back massage
Supplements & Complementary
Medicine
• Fish oil supplements
• Vitamin E
• Vitamin B1
• Magnesium & calcium
• Japanese herb toki-shakuyaku-san
• Ginger
• Acupuncture or acupressure
• transcutaneous electric nerve stimulation (TENS)
References
• Dawood MY. Dysmenorrhea. J Reprod Med. Mar 1985;30(3):154-67
• Calis KA, Dang DK, Popat V, Kalantaridou SN. General Gynaecology:
Dysmenorrhea. Emedicine. Last updated 28/01/2009
• French L. Dysmenorrhea. American Academy of Family Physicians. Last
updated 15/01/2005
• Dawood MY, Khan-Dawood FS. Clinical efficacy and differential inhibition
of menstrual fluid prostaglandin F2alpha in a randomized, double-blind,
crossover treatment with placebo, acetaminophen, and ibuprofen in
primary dysmenorrhea. Am J Obstet Gynecol. Jan 2007;196(1):35.e1-5
• Wilson ML, Murphy PA; Herbal and dietary therapies for primary and
secondary dysmenorrhoea. Cochrane Database Syst Rev. 2001;
(3):CD002124.
• Proctor ML, Roberts H, Farquhar CM; Combined oral contraceptive pill
(OCP) as treatment for primary dysmenorrhoea. Cochrane Database Syst
Rev. 2001;(4):CD002120.
• Samuels LA. Pharmacotherapy Update: Hyoscine Butylbromide
• in the Treatment of Abdominal Spasms. Clinical Medicine: Therapeutics
2009:1