30-11-2014 Gynaecology Dysmenorrhoea د.شيماءعبداالميرالجميلي Dysmenorrhoea is defined as painful menstruation. It is experienced by 45 95 per cent of women of reproductive age.primary Spasmodic Dysmenorrhea is Painful menstruation without underlying pathology. It is commonest in teens/early twenties and its onset 1 or more years after menarche.secondary dysmenorrhea is Painful menses secondary to pathology.pain may begin before bleeding and may last for entire duration,commoner in 30s and 40s. There is some evidence to support the assertion that dysmenorrhoea improves after childbirth, and it also appears to decline with increasing age. Aetiology of secondary dysmenorrhea It includes: 1 Endometriosis is most prevalent in patients of reproductive age, is the presence of endometrial tissue outside the uterine cavity including the ovary, the pelvic walls, the pouch of Douglas, the uterosacral ligaments and the bowel. These patches of ectopic tissue are under hormonal influence and hence symptoms are exacerbated at the time of menstruation. Laparoscopy is the gold standard diagnostic tool. Complications of endometriosis include the formation of adhesions, chocolate ovarian cysts (endometriomas) and infertility. 1
2 Adenomyosis; is the presence of ectopic endometrial tissue within the myometrium. It is associated with previous procedures which may break the barrier between the endometrium and the myometrium, e.g. Caesarean section or suction termination of pregnancy. 3 Pelvic inflammatory disease; 4 Uterine fibroid. 5 Cervical stenosis and haematometra (rarely). Diagnosis History and examination Patients will have different ideas as to what constitutes a painful period. To ascertain the severity of the pain, questions about the need to take painkillers for this pain,type of tablets help and the need to take any time off work/school due to the pain may be useful. An abdominal and pelvic examination should be performed. Certain signs associated with endometriosis include a pelvic mass (if an endometrioma is present), a fixed uterus (if adhesions are present) and endometriotic nodules (palpable in the pouch of Douglas or on the uterosacral ligaments). Investigation High vaginal and endocervical swabs These should be carried out to exclude pelvic infection, in particular Chlamydia trachomatis and Neisseria gonorrhoea. 2
Pelvic ultrasound scan Pelvic ultrasound scan may be useful to detect endometriomas or appearances suggestive of adenomyosis (enlarged uterus with heterogeneous texture). Diagnostic laparoscopy Diagnostic laparoscopy if performed: when the history is suggestive of endometriosis; when swabs and USS are normal, yet symptoms persist; when the patient wants a definite diagnosis or wants reassurance that their pelvis is normal. Discussion about laparoscopy should include: the risks of the procedure, including anaesthetic complications, damage to blood vessels/bladder/ bowel and infection; the fact that this investigation may show no obvious causes for their symptoms. If features in the history suggest cervical stenosis, ultrasound and hysteroscopy can be used to investigate further. However, this condition is an infrequent cause of dysmenorrhoea, and this investigation should not be routine. Treatment Non-steroidal anti-inflammatory drugs NSAIDs are effective in a large proportion of women. Some examples are naproxen, ibuprofen and mefenamic acid. 3
Oral contraceptives These are widely used but, surprisingly, a recent review of randomized controlled trials provides little evidence supporting this treatment as being effective. LNG-IUS There is recent evidence that this is beneficial for dysmenorrhoea and indeed can be an effective treatment for underlying causes, such as endometriosis and adenomyosis. DMPA It is an injectable contraception that inhibts ovulation. Lifestyle changes There is some evidence to suggest that a low fat, vegetarian diet may improve dysmenorrhoea. There are suggestions that exercise may improve symptoms by improving blood flow to the pelvis. GnRH analogues This is not a first-line treatment nor an option for prolonged management due to the resulting hypooestrogenic state. These are best used to manage symptoms if awaiting hysterectomy or as a form of assessment as to the benefits of hysterectomy. If the pain does not settle with the GnRH analogue, it is unlikely to be resolved by removing the ovaries at hysterectomy. Danazole Is a synthetic steroid with hyperandrogenic antioestrogenic and antiprogestagenic properties Heat 4
Although this may seem a rather old-fashioned method for helping dysmenorrhoea, there is strong evidence to prove its benefit. It appears to be as effective as NSAIDs. Surgery If other treatments do not work in relieving dysmenorrhea, surgery may be needed. The type of surgery depends on the cause. If fibroids are causing the pain, sometimes they can be removed with surgery. Endometriosis tissue can be removed during surgery. Endometriosis tissue may return after the surgery, but removing it can reduce the pain in the short term. Taking hormonal birth control or other medications after surgery may delay or prevent the return of pain. Hysterectomy may be done if other treatments have not worked and if the disease causing the dysmenorrhea is severe. This procedure normally is the last resort. Premenstrual syndrome Premenstrual syndrome (PMS) is the occurrence of cyclical somatic, psychological and emotional symptoms that occur in the luteal (premenstrual) phase of the menstrual cycle and resolve by the time menstruation ceases. Premenstrual symptoms occur in almost all women of reproductive age. In 3 60 per cent, symptoms are severe, causing disruption to everyday life, in particular interpersonal relationships. 5
Aetiology The precise aetiology of PMS is unknown, but cyclical ovarian activity and the effects of oestradiol and progesterone on certain neurotransmitters, including serotonin, appear to play a role. History and examination The patient is likely to complain of some or all of the following: Bloating; Cyclical weight gain; Mastalgia; Abdominal cramps; Fatigue; Headache; Depression; Irritability. The cyclical nature of PMS is the cornerstone of the diagnosis. A symptom chart, to be filled in by the patient prospectively, may help. Treatment Simple therapies.they include: stress reduction; alcohol and caffeine limitation; 6
exercise Medical treatments Combined oral contraceptive pill The most effective preparation appears to be Yasmin, which contains an anti-mineralocorticoid and an anti-androgenic progestogen. The most effective regime appears to be bicycling or tricycling pill packets (i.e. taking two or three packets in a row without a scheduled break). Transdermal oestrogen (Oestadiol patches) It is given PLUS Oral progestogen OR LNG-IUS (Mirena) This has been shown to significantly reduce PMS symptoms. GnRH analogues GnRH analogues are a very effective treatment for PMS as ovarian activity is switched off. However, this generally a short-term treatment. If used for more than six months, HRT should be given to reduce the risk of osteoporosis. Selective serotonin reuptake inhibitors There is good evidence that this group of drugs significantly improve PMS. It is given in Continuous regemin or luteal phase Hysterectomy with bilateral salpingo-oopherectomy This procedure obviously completely removes the ovarian cycle. It should only be performed if all other treatments have failed. It is essential for such patients to have a preoperative trial of GnRH analogue 7
as a test to ensure that switching off ovarian function (by removing the ovaries at hysterectomy) will indeed cure the problem. Vitamins Initial studies suggest that magnesium, calcium and isoflavones may be useful in treating PMS. Alternative therapies Initial results of St John s Wort are promising, particularly in improving mood. Although Evening primrose oil is commonly used, there is no evidence to support this treatment for PMS. Cognitive-behavioural therapy Cognitive-behavioural therapy (CBT) appears to be particularly effective when combined with selective serotonin reuptake inhibitors (SSRIs). 8