An overview of the causes of dysmenorrhea and its features for students and primary care physicians

1. Associate Professor Dr Hanifullah Khan
DYSMENORRHEA
Debunking some myths
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2. DECLARATION OF CONFLICT OF INTEREST
Affiliation / Financial Interest Organisation
Research Grants (Principal Investigator) Nil
Advisory Board Member Nil
Honoraria for Speaker Engagement Medtronic/MMA
Funding / Sponsorship for Conference
Attendance
Nil

3. Outline
The following topics are presented
1. Introduction
2. Pathogenesis
3. Diagnosis
4. Management
5. Myths
6. The role of the primary care physician
7. Red flags
8. Conclusion
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4. Introduction
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5. Definition
• Abdominal pain that occurs during or is associated with menstruation
• Primary vs Secondary
• Based on absence or presence of gross pelvic pathology
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6. Prevalence
• Leading cause of morbidity in women
restricts daily activities, poor sleep quality & decreased academic performance
• Prevalence ranges from 50-90% of young women
• 33% adolescents may have severe dysmenorrhea
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1. Ortiz MI, Rangel-Flores E, Carillo-Alarcon LC, et al. Prevalence and impact of primary
dysmenorrhea among Mexican high school students. Int J Gynecol Obstet 2009;107(3):240-
243.
2. Zannoni L, Giorgi M, Spagnolo E, et al. Dysmenorrhea, absenteeism from school and
symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol
2014;27(5):258-265.

7. Under reporting
Many women may not report dysmenorrhea because:
• Dysmenorrhoea is normal
• No treatment is available for dysmenorrhea
• Cultural taboos and religious beliefs
• A perceived lack of physician knowledge and interest
Dysmenorrhoea is of psychogenic origin
A myth debunked only with the advent of oral contraceptives
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8. Pathogenesis
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9. Primary Dysmenorrhea
• Normal pelvis
• Hyper production of prostaglandins
& leukotrienes in endometrium
• Under the influence of progesterone
Dysmenorrhea not seen in
anovulatory cycles
Occurs very shortly after the onset of
menstruation
Can be curtailed by ovulatory
inhibition with oral contraceptives
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Hacker & Moore's Essentials of Obstetrics and Gynecology:
5th ed. Rapkin AJ et al
No gross underlying pathology detected

10. Prostaglandin synthesis
Biochemistry
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Novella, Susana & Hermenegildo, Carlos. (2011). Estradiol Regulation of
Prostanoids Production in Endothelium. 10.5772/17172.

11. Many causes
• However, the most common
cause is endometriosis
• Adenomyosis - easier to
diagnose because of imaging
• Salpingitis & pelvic infection
• Uterine anomalies - hymenal,
vaginal or Müllerian
• IUCD
Secondary Dysmenorrhea
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12. 12
Nodule
Endometriosis
Blue lesions
Pink patterns
Red lesions

13. • 20 dysmenorrhea x 2 years
• Heavy, cyclical menstruation
• MRI done
Adenomyosis
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42 year old P3A2 previous LSCS
&
D&C

14. 14
Adhesions

15. Two- and Three-Dimensional Ultrasonography and Sonohysterography versus
Hysteroscopy With Laparoscopy in the Differential Diagnosis of Septate, Bicornuate,
and Arcuate Uteri
Artur Ludwin, MD, PhD, Kazimierz Pityński, MD, PhD, Inga Ludwin, MD, PhD, Tomasz Banas, MD, PhD, MPH and Anna Knafel,
MD, PhD
Journal of Minimally Invasive Gynecology
Volume 20, Issue 1, Pages 90-99 (January 2013)
DOI: 10.1016/j.jmig.2012.09.011
Copyright © 2013 AAGL Terms and Conditions

16. IUD translocated
A cause of secondary
dysmenorrhea
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17. Diagnosis
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18. Clinical features
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19. 19

20. 20
Laparoscopy

21. Management
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22. Primary dysmenorrhea
Aims of treatment
• Primary dysmenorrhea- pain relief
• Secondary dysmenorrhea -
Manage underlying problem
Pain relief
Prevent recurrence
Maintain fertility
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23. NSAIDs
First line
• Recommended for at least 3 cycles
• Taken right at the onset of
menstruation or even before
mode of action is blocking the
production of prostaglandin
• Cyclooxygenase (COX-2) inhibitors
more efficacious and safe
23
Harel, Z. Mini-Review Dysmenorrhea in Adolescents and
Young Adults : Etiology and Management.

24. Hormonal treatment
May be combined with NSAIDs
• Oral contraceptives most common & quite safe
May have systemic side effects
• Long acting reversible progestin contraceptives
intrauterine system or the subdermal implant
avoids systemic hormonal side effects and applied long term
• LNG-IUS - effective in reducing endometriosis-associated dysmenorrhea
(Vercellini P et al 2003)
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25. Surgery
Usually required in the case
of 20 dysmenorrhea
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26. 26

27. Myths
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28. Misconceptions
These cause the patient to delay treatment
• Menstrual pain is normal
• There is no treatment for this pain
• It is shameful to talk about periods
• It is normal for girls and adolescents to have menstrual pain
• Dysmenorrhea after childbearing is normal
• Manchester United are a good team
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29. Dysmenorrhea since menarche
• Stays in school hostel
• Previous pain mild but worse last
6 months
• Teacher concerned as student
starts skipping class
• S/B govt clinic nearby &
medicated but ineffective
• Clinically normal, including U/S
15 year old
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30. Severe period pain
• Normal menarche at 11+ yrs
• Dysmenorrhea since admission
to hostel x 2 yrs
• Last 6 months almost monthly
A&E visits due to severe pain
• MC for 2-3 days
• Hostel I/C requests parents to
talk to patient as suspected
malingering
14 year old student
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31. single woman
• Just began work
• Cyclical pain since menarche
• Severe pain last 6 months
• U/S - bulky uterus
• Laparoscopy - POD obliterated,
dense adhesions! Very unexpected
• Adhesiolysis & resection -
restoration of anatomy
21 year old
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32. Cyclical pain in
distant sites
• 36 P1 - developed
dysmenorrhea + pain at LSCS
Scar
• Diagnosis - scar endometriosis
• Key to diagnosis - pain during
menstruation
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33. Role of primary care physician
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34. In any case of dysmenorrhoea…
You should aim to locate an underlying cause
• h/o the onset, location, duration, intensity and characteristics of the pain
should be obtained.
• Any relieving factors specifically with medication
• Abdominal examination - look for areas of tenderness and masses
• Speculum examination - indicated in sexually active women if there is vaginal
discharge or abnormal bleeding.
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35. Manage
May begin empirical therapy
• If you diagnose 10 dysmenorrhea
- paracetamol or NSAIDs can be
started
surveillance for gastric,
hypersensitivity and bleeding
problems is mandatory.
• The combined oral contraceptive
is a suitable and safe alternative.
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36. Keep in mind
Understand
1. Adolescents are unlikely to have underlying disease - do not require a pelvic
examination.
2. Most adolescents have 10 dysmenorrhea and can safely be started on
empiric treatment
3. Specialist referral - indicated if empiric therapy is ineffective/clinical
evaluation suggests an underlying cause.
4. The levonorgestrel intrauterine system can also be used in adolescents and
not necessarily only in married women.
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37. Red Flags
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38. Red Flags
Identifying signs & symptoms that may help to make an earlier
diagnosis of an underlying pathology
• Onset of dysmenorrhea at an early age
• Absenteeism from school or work
• Adolescent dysmenorrhoea that gets worse over time
• Radiation of pain to the thighs and legs
• Dysmenorrhoea that develops after childbirth
• Severe dysmenorrhea that does not respond to medical tx
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39. Conclusion
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40. Primary dysmenorrhea is a diagnosis of
exclusion. An index of suspicion for an
underlying cause must always be maintained.
The myth that a “woman must suffer” should be
expunged.
No woman should be handicapped by
dysmenorrhoea.
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41. THANK YOU
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