2. Dysmenorrhea
Dysmenorrhea is chronic, cyclic pelvic pain associated with
menstruation.
Two main categories
1- Primary: painful menstruation without associated pelvic disease
2- Secondary: painful menstruation caused by pelvic pathology
3. Evaluating patient with dysmenorrhea
1- History
2- Physical examination: should be completely normal in Pt with 1ry
dysmenorrhea, however if evaluated during the pain uterus & cx will
be mildly tender
3- Investigations: not required if Hx & physical examination are
consistent with 1ry dysmenorrhea
*U/S
*HSG
*Laparoscopy
allow physician to confirm presence
*Hystroscopy
or absence of pelvic disease
*D&c
4. Primary dysmenorrhea
Primary dysmenorrhea is the most common gynecologic complaint
and one of the leading causes of absenteeism in young women
Increased levels of PG stimulates uterine smooth muscle contraction
→ vasoconstriction of the uterine arteries → uterine hypoxia → pain
of dysmenorrhea
Onset: within 6-12 months after menarche
Usually begins few hrs before or with the onset of menstruation
The pain is crampy/ colicky in the lower abdomen and suprapubic
area associated with nausea, vomitting, diarrhea, headache and
fatigue.
5. Treatment of 1ry dysmenorrhea
1- NSAIDs are 1st line treatment
*Propionic acid derivatives (Ibuprofen, naproxen)
*Fenamates (mefenamic acid)
2- Oral contraceptives
* If NSAID are not effective or contraindicated
* 90% effective within 3-4 months of use
3- Some Pt may require combining both drugs
4- Consider 2ry dysmenorrhea if no improvement with therapy
6. Causes of 2ry dysmenorrhea
Endometriosis
Adenomyosis
Endometrial polyp
Fibroid
Cx stenosis
Pelvic inflammatory disease
Presence of an IUD
Adhesions
7. Evaluating pt with 2ry dysmenorrhea
1- History
- Onset of symptoms : several years after menarche
- Recurrent pelvic infections (PID)
- Fever and vaginal discharge (PID)
- IUCD
- Recent pelvic surgery (adhesions)
- Heavy periods (adenomyosis, endometrial polyp, fibroid)
- Infertility and dysparunea (endometriosis)
2- Physical examination: may help in Dx by finding abnormalities
that point to a pelvic disease
8. Evaluating pt with 2ry dysmenorrhea
3- Investigations
CBC:
anaemia related to chronic menorrhagia, infection (PID)
Cervical/vaginal
swabs for cultures: PID
Transvaginal
ultrasound: pelvic masses, uterine fibroids and polyps,
pelvic abscess, adenomyosis.
Laparoscopy:
both diagnostic and therapeutic, particularly in the
management of endometriosis and where pain is of uncertain origin
Hysteroscopy:
defines intrauterine pathology and provides an
endometrial tissue sample for histology
9. CX STENOSIS
Causes:
- Congenital
- 2ry to cervical injury (electrocautery, cryocautery, conization, infection)
Presentation: Scanty menstrual flow & sever cramping through out the
menstrual cycle
Diagnosis: Internal os scarred & impossible to pass uterine sound or even
very thin probe
Treatment
- D&C
- Vaginal delivery afford more lasting cure
10. ENDOMETRIOSIS
Endometriosis: an ectopic endometrial tissue in extra-uterine
sites (ovaries, fallopian tubes or uterosacral ligaments)
History: Sever dysmenorrhea, infertility and dysparunea
Pelvic examination
- Evidence of endometriosis in vagina or cx
- Rectovaginal examination reveals tenderness and nodularity
along the uterosacral ligaments