Dysmenorrhea: Zohaib Ur Rahman Yousufzai R O L L N O - 1 6 - 2 4 2

Dysmenorrhea
ZOHAIB UR RAHMAN YOUSUFZAI

ROLL NO- 16-242
Definition:
2
 Dysmenorrhea is defined as Painful menstruation
 The term dysmenorrhea is derived from the Greek words:
 dys, meaning difficult/painful/abnormal

 meno, meaning month
 rrhea, meaning flow
Dr Zohaib Yousufzai 11/18/2021

Classification
3
1- Primary  painful menstruation not associated with pelvic

pathology
2- Secondary  painful menstruation caused by pelvic pathology

Epidemiology
4
 45-95 % of women reproductive age report dysmenorrhea
 Typical age range for primary dysmenorrhea is between 17 and

22 years
 Secondary dysmenorrhea is more common in older women

mostly in there 40s

5
Primary Dysmenorrhea

Etiology
6
 During menstruation, Prostaglandin F2α is released from
endometrial cells  uterine smooth muscle contraction,  some
degree of uterine ischemia.
 This is associated with painful and sometimes debilitating
cramps.
 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

7

Features of Primary Dysmenorrhea
8
 Starts with ovulatory cycles 6-12 M after menarche
 Begins few hrs before or with the onset of menstruation and

usually lasts 8 -72 hrs
 The pain is crampy/ colicky , usually strongest in the lower

abdomen (suprapubic) and may radiate to the back or inner
thighs

Features of Primary Dysmenorrhea
9
 Associated symptoms
-Back pain & pain in the upper thighs 60%
-Nausea /vomiting 89%
-Diarrhea 60%
-Fatigue / malaise 85%
-Headache 45%
-Dizziness, nervousness, fainting in severe cases

Risk factors
10
The following risk factors have been associated

with more severe episodes of dysmenorrhea:
 Earlier age at menarche
 Long menstrual periods (>5day)
 Heavy menstrual flow
 Smoking
 Positive family history

Management
11
1. NSAID  1st line  effective

 Ibuprofen (400 mg q 6 hrs)
 Naproxen(250 mg q 6 hrs)
 Mefenamic acid (500 mg q 8 hrs)
 Aspirin is less effective than the above mentioned NSAIDs
but more effectve than Placebo
2. ORAL CONTRACEPTIVES  effective If NSAID
are not effective or contraindicated
 Some Pt may require combining both drugs. Consider 2ry
Dysmenorrhea if no improvement with therapy.

Management
12
3. Tocolytics:
 Resistant cases may respond to tocolytic agents eg. salbutamol, nifedipine
4. Progestogens
 Especially medroxyprogestrone acetate or dydrogesterone in daily high
doses may also be beneficial in resistant cases
5. Nonpharmacologic pain management:
 Acupuncture
 Transcutaneous electrical stimulation
 Psychotherapy, hypnotherapy and heat patches
6. Surgical procedures
 Presacral neurectomy
 Uterosacral nerve ablation

13
Secondary Dysmenorrhea

14
Features which may indicate secondary

dysmenorrhea:
 Dysmenorrhea occurring during the first or second cycles after
menarche, which may indicate congenital outflow obstruction
 Dysmenorrhea beginning after the age of 25 years
 Pelvic abnormality with physical examination

15
 Dysmenorrhea not limited to the menses
 Less related to the first day of flow
 Little or no response to therapy with NSAIDs, OCs, or both.
 Usually associated with other symptoms such as dyspareunia ,

infertility or abnormal vaginal bleeding

Causes Of Secondary Dysmenorrhea
16
Endometriosis
Chronic PID
Adhesions (Asherman’s syndrome)
Adenomyosis
Mullerian duct anomalies
Endometrial polyp
Fibroids
Ovarian cysts
Pelvic congestion
Imperforate hymen, transverse vaginal septum
Cervical stenosis
IUCD

Causes of secondary dysmenorrhea:
17
 Endometriosis:
Pain extends to premenstrual or post menstrual phase or may be continuous,

may also have deep dysparueunia, premenstrual spotting and tender pelvic
nodules (especially on the uterosacral ligaments); onset is usually in the 20s
and 30s but may start in teens

18
 Pelvic inflammation
Initially pain may be menstrual, but often with each cycle it extends into the
premenstrual phase; may have intermenstrual bleeding, dyspareunia and
pelvic tenderness.

19
 Adenomyosis, Fibroid Tumors

Uterus is generally clinically and symmetrically enlarged and may be
mildly tender; dysmenorrhea is associated with a dull pelvic dragging
sensation.

20
 Pelvic Congestion
A dull, ill-defined pelvic ache, usually worse premenstrually, aggravated by
standing, relieved by menses; often a history of sexual problems.

Evaluation
21
1. History
Pain analysis
Associated symptoms
Menstrual history
Gravidity and parity status
Infertility
Previous pelvic infections
Dyspareunia
Pelvic surgeries, injuries or procedures
Sexual history

Evaluation
22
2. Examination
A pelvic exam is indicated at the initial evaluation which should be

performed to exclude uterine irregularities, cul du sac tenderness or
nodularity that may suggest endometriosis, PID or pelvic mass. It
should be completely normal in a Pt with 1ry dysmenorrhea, however
if evaluated during the pain uterus & cx will be mildly tender.

Evaluation
23
3. Investigation
 Not required if History & physical examination are consistent
with 1ry dysmenorrhea
 The following can performed to exclude organic causes of
dysmenorrhea:
 Cervical culture to exclude STDs
 WBC count to exclude infection, ESR
 HCG level to exclude ectopic pregnancy
 Abdominal or transvaginal ultrasound
 Other more invasive procedures such as laparoscopy , hysteroscopy;
to exclude Asherman’s and stenosis of cx

Management
24
 Treating the underlying disease
 The treatments used for primary dysmenorrhea are often

helpful

25
PREMENSTRUAL SYNDROME

Definition
26
 PMS is a group of physical, emotional & behavioral
symptoms that occur in the 2nd half (luteal phase) of the

menstrual cycle often interferes with work & personal
relationships followed by a period entirely free of symptoms
starting with menstruation.

Epidemiology
27
 the incidence of PMS in the United States range from 30 to 50%

of women of childbearing age
 It is estimated that 75 to 80 percent of all women experience

some PMS symptoms during their lifetime.
 Only in 5% are they sufficiently severe to cause significant

problems.

ETIOLOGY
 Incompletely understood 28
 Multifactorial
 Genetics likely play a role
 CNS-mediated neurotransmitter interactions with sex steroids

(progestrone, estrogen and testosterone)
 Serotonergic dysregulation-

Diagnosis
29
1. At least one of the following affective and somatic

symptoms during the five days before menses in
each of the three prior menstrual cycles:
 Affective
1. Depression
2. Angry outbursts
3. Irritability
4. Anxiety
5. Confusion
6. Social withdrawal

Diagnosis
30
 Somatic
1. Fatigue
2. Breast tenderness
3. Abdominal bloating
4. Headache
5. Swelling of the extremities
2. Symptoms relieved within four days of onset of menses
3. Symptoms present in the absence of any pharmacologic
therapy, drug or alcohol use

Diagnosis
31
4. Symptoms occur reproducibly during two cycles of

prospective recording
5. Patient suffers from identifiable dysfunction in social
or economic performance

Management
32
 A thorough history and physical examination should be

performed to rule out any other medical causes
 Goal: symptom relief
 No proven beneficial treatment, suggestions include:
 Psychological support
 Diet/supplements
 Avoid sodium, simple sugars and caffeine
 Calcium 1200-1600 mg/d
 magnesium 400-800 mg/d
 Vit E 400 IU/d
 Vit B6
 Regular aerobic exercise

Management
33
 Medications
 NSAIDs for discomfort and pain
 Spironolactone for fluid retention
 SSRI antidepressants
 Progesterone suppositories
 OCP for somatic symptoms
 Danazol
 GnRH agonists if severe PMS unresponsive to other treatments
 Herbal remedies

Premenstrual Dysphoric Disorder
34
 PMDD is described as a more severe form of PMS with specific
diagnostic criteria
 Treatment with SSRIs (first line) highly effective
11/18/2021 Dr Zohaib Yousufzai

Thank you for listening..

Dysmenorrhea: Zohaib Ur Rahman Yousufzai R O L L N O - 1 6 - 2 4 2

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dysmenorrhea: Zohaib Ur Rahman Yousufzai R O L L N O - 1 6 - 2 4 2

Uploaded by

Copyright:

Available Formats

Dysmenorrhea

ZOHAIB UR RAHMAN YOUSUFZAI

 Dysmenorrhea is defined as Painful menstruation

 The term dysmenorrhea is derived from the Greek words:

 dys, meaning difficult/painful/abnormal

Dr Zohaib Yousufzai 11/18/2021

1- Primary  painful menstruation not associated with pelvic

2- Secondary  painful menstruation caused by pelvic pathology

Dr Zohaib Yousufzai 11/18/2021

 Typical age range for primary dysmenorrhea is between 17 and

 Secondary dysmenorrhea is more common in older women

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

 PG may also cause hypersensitization of pain terminals to

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

 Starts with ovulatory cycles 6-12 M after menarche

 Begins few hrs before or with the onset of menstruation and

 The pain is crampy/ colicky , usually strongest in the lower

Dr Zohaib Yousufzai 11/18/2021

-Back pain & pain in the upper thighs 60%

-Nausea /vomiting 89%

-Fatigue / malaise 85%

-Dizziness, nervousness, fainting in severe cases

Dr Zohaib Yousufzai 11/18/2021

The following risk factors have been associated

Dr Zohaib Yousufzai 11/18/2021

1. NSAID  1st line  effective

 Some Pt may require combining both drugs. Consider 2ry

Dysmenorrhea if no improvement with therapy.

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

Features which may indicate secondary

 Dysmenorrhea beginning after the age of 25 years

 Pelvic abnormality with physical examination

Dr Zohaib Yousufzai 11/18/2021

 Dysmenorrhea not limited to the menses

 Less related to the first day of flow

 Little or no response to therapy with NSAIDs, OCs, or both.

 Usually associated with other symptoms such as dyspareunia ,

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

Pain extends to premenstrual or post menstrual phase or may be continuous,

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

 Adenomyosis, Fibroid Tumors

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

Gravidity and parity status

Previous pelvic infections

Pelvic surgeries, injuries or procedures

Dr Zohaib Yousufzai 11/18/2021

A pelvic exam is indicated at the initial evaluation which should be

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

 Treating the underlying disease

 The treatments used for primary dysmenorrhea are often

Dr Zohaib Yousufzai 11/18/2021

Dr Zohaib Yousufzai 11/18/2021

symptoms that occur in the 2nd half (luteal phase) of the

Dr Zohaib Yousufzai 11/18/2021

 the incidence of PMS in the United States range from 30 to 50%