DYSMENORRHEA
A cyclic, painful cramping sensation in the lower abdomen accompanied by other biologic symptoms |
Primary dysmenorrhea refers to pain with no obvious pathologic pelvic disease. It is currently recognized that these patients are suffering from the effects of endogenous prostaglandin. |
Secondary dysmenorrhea is associated with pelvic conditions or pathology that causes pelvic pain in conjunction with the menses |
INDICDENCE AND EPIDEMIOLOGY
approximately 75% |
younger age at first childbirth, high parity, and physical exercise |
pregnancy itself without actual birth does not seem to alleviate dysmenorrhea |
RISK FACTORS
- age less than 30 |
- BMI less than 20 |
- premenstrual syndrome |
- PID |
- sterilization |
- history of sexual assault |
- heavy smoking |
PRIMARY DYSMENORRHEA
- elevated prostaglandin F2a (PGF2a) levels in the secretory endometrium and the symptoms of dysmenorrhea |
- arachidonic acid, has been found in increased amounts on the endometrium during ovulatory cycles |
- converted to PGF2a, PGE2, and leukotrienes |
- PGF2a and PGE2 correlate with the severity of dysmenorrhea |
- nausea, vomiting, and diarrhea |
DIAGNOSIS
- History and physical exam |
- midline, crampy, lower abdominal pain, which begins with the onset of menstration |
- the pain can be severe and can also involve the lower back and thighs. Pain does not occur at tines other than menses and only occurs during ovulatory cycles |
- diarrhea, headache, fatigue, and malaise |
- normal pelvic examination |
- no laboratory or imaging abnormalities |
TREATMENT
- treatment for primary dysmenorrhea begins with providing patient education and reassurance |
- individualized, supportive therapy can be tailored to the patient's specific symptoms, degree of disability from those symptoms, and other health care considerations, such as need for contraception |
NONPHARMACOLOGIC INTERVENTION |
- exercise |
- heat |
- behavioral interventions |
- vitamins and diet |
MEDICATIONS |
- NSAIDs |
- prostaglandin synthase inhibitors (PGSIs) |
- these substances are non-steroidal and anti-inflammatory |
- arylcarboxylic acids, which include acetylsalicylic acid (aspirin) and fenamates (mefenamic acid) |
- arylalkanoic acids, including the arylpropionic acids (ibuprofen, naproxen, and ketoprofen) and the indoleacetic acids (indomethacin) |
- Cyclooxygenase (COX2) inhibitors have similarly been shown to alleviate the primary dysmenorrheal symptoms |
- reduction of contractility |
- COX-2 expression in the uterine glandular epithelium was maximal during menstruation in one trial of ovulatory women |
- COX-2 inhibitors may be considered for women with gastrointestinal toxicity due to NSAISs |
- Estrogen and progesterone will relieve the symptoms of primary dysmenorrhea in approximately 905 of patients |
- Suppress ovulation and endometrial proliferation and the progestin component also blocks the production of the precursor to prostaglandin formation |
- The thinned endometrium from CCs then contains less arachidonic acid, which is the precursor to prostaglandins |
- If the woman also requires contraception, CC therapy may prove to be the treatment of choice |
- The vaginal ring CC reduce dysmenorrhea in a similar fashion as COCs |
- Dysmenorrhea was not, however, as well controlled in women using the transdermal CC patch as compared with COCs |
PROGESTIN-ONLY FORMULATIONS |
- Depot medroxyprogesterone, a long-acting injectable contraceptive, has been studied specifically for primary dysmenorrhea |
- The 20ug levonorgestrel releasing intrauterine system (LNGIUS) has been shown in randomized controlled trails to reduce menstrual pain |
- Copper T380A intrauterine device (IUD) |
- Etonogestrel-releasing contraceptive (Implanon) / Nexplanon |
TOCOLYTICS |
- tocolytics may be beneficial in the treatment of dysmenorrhea |
- nifedipine at a dose of 20-40mg orally |
- glyceryl trinitrate and magnesium |
- not often utilized for contemporary management of dysmenorrhea |
OTHER TREATMENTS |
- narcotic analgesics |
- acupuncture |
- laparoscopic uterine nerve ablation (LUNA) or laparoscopic presacral neurectomy (LPSN) |
SECONDARY DYSMENORRHEA: CAUSES AND MANAGEMENT
- Pelvic disease considered in patients who do not respond to NSAIDs or CCs or combination of these agents |
- The diagnosis should also be considered when symptoms appear after many years of painless menses |
- cervical stenosis |
- endometriosis |
- adenomyosis |
- fibroids |
- pelvic inflammation |
- pelvic congestion, congenital obstructive Mullerian malformations, diseases of the gastrointestinal tract, and mental health conditions |
CERVICAL STENOSIS
- Severe narrowing of the cervical canal causing an increase in intrauterine pressure at the time of menses |
- Associated with pelvic endometriosis |
- Congenital or secondary to cervical injury |
- Inflammatory process |
- History of scant menstrual flow and if severe cramping continues throughout the menstrual period |
- Diagnosis is generally documented by the inability to pass a thin probe of a few millimeters' diameter through the internal os or by a hysterosalpingogram, which demostrates a thin, stringy-appearing canal |
- Treatment consists of dilating the cervix |
- often recurs after therapy, necessitating repeat procedures |
ECTOPIC ENDOMETRIAL TISSUE
Endometriosis |
- presence of endometrial glands and stroma outside of the uterus defines endometriosis |
- generalized pelvic pain, cyclic pain, dysmenorrhea, infertility, and bowel or bladder dysfunction |
- history of pain becoming more severe during menses |
Adenomyosis |
- presence of endometrial glands and stroma in the myometrium |
- this ectopic endometrial tissue may induce hypertrophy and hyperplasia of the adjacent myometrium |
- manifest in heavy |
- painful menses that tends to be progressive |
- Prostaglandin level in endometriosis implants increase painful menstruation |
PELVIC CONGESTION SYNDROME
- Pelvic congestion syndrome (PCS), which was first described by Taylor in 1949, results from the engorgement of pelvic vasculature |
- Chronic pelvic discomfort (often burning or throbbing in nature) worsened by prolonged standing and intercourse in women who have periovarian varicosities on imaging studies |
- Etiology is unclear and optimum treatment is uncertain |
- Pelvic pain, dysuria, dysmenorrhea, and dyspareunia |
PREMENSTRUAL SYNDROME
- A group of mild to moderate symptoms, physical and behavioral, that occur in the second half of the menstrual cycle and that may interfere with work and personal relationships |
- Breast tenderness, bloating, and headache |
- These are followed by a period entirely free of symptoms |
- Family history of PMS in the mother, personal past or current psychiatric illness involving mood or anxiety disorders, history of alcohol abuse, and history of postpartum depression |
PREMENSTRUAL DYSPHORIC DISORDER
- A more severe disorder, with marked behavioral and emotional symptoms. |
- PMDD differs from PMS in the severity of symptoms and the fact that women with PMDD must have one severe affective symptom. |
- Markedly depressed mood or hopelessness, anxiety or tension, affective lability, or persistent anger, which occur regularly during the last week of the luteal phase in most menstrual cycles |
- PMDD also differs from PMS because there is substantial impairment in personal functioning |
- PMS and PMDD are similar in that the symptoms manifest in the luteal phase of the menstrual cycle and resolve during menses |
- Premenstrual symptoms occur in 75% of women at some point in their reproductive lives. The incidence of clinically relevant PMS occurs in 3% to 8% of women and 2% of reproductive-age women will suffer from PMDD |
SYMPTOMS |
- Abdominal bloating, breast tenderness, and various pain constellations, such as headache |
- Fatigue, irritability, and tension to anxiety, labile mood, and depression |
- Depression |
- Causes |
- Estrogen excess |
- Imbalance of estrogen and progesterone, endogenous hormone allergy, hypoglycemia, vitamin B6 deficiency, prolactin excess, fluid retention, inappropriate prostaglandin activity, elevated monoamine oxidase (MAO) levels, endorphin malfunction, and a number of psychological disturbances. |
DIAGNOSIS |
- History of two consecutive menstrual cycles demonstrating luteal phase symptoms of PMS and PMDD. |
- After a complete history and physical examination, the physician should rule out any medical problems that could be influencing the symptomatology |
- DSM-V criteria, which require 5 of 11 symptoms of PMS, including one affective symptom |
- feeling sad or hopeless or having self-deprecating thoughts, anxiety or tension, mood lability and crying, and persistent irritability, anger, and increased interpersonal conflicts |
TREATMENT
Pharmacologic Agents |
- Psychoactive Drugs |
- SSRIs have been shown to be extremely effective for treating PMS and have become first-line treatment for PMDD |
Hormonal Suppression |
- Progesterone |
- Oral Contraceptives |
- Nonsteroidal Anti-inflammatory Drugs |
- Diuretics |
- Bromocriptine |
- Gonadotropin-Releasing Hormone Agonists |
Surgical Treatment: Bilateral Oophorectomy with or without Hysterectomy |
- For women with severe, disabling symptoms who have been refractory to other medical therapies, surgical management may be considered |
- Reasonable alternative for select patients for whom all other treatment regimens have failed. |
- GnRH analogue for 3 to 6 months, with or without estrogen add-back |
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SECONDARY DYSMENORRHEA: CAUSES AND MANAGEMENT
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