CASE 8: DYSMENORRHEA & ENDOMETRIOSIS

DYSMENORRHEA

Crampy hypogastric pain

Occurs before, during and immediately after menses

Accompanying symptoms: Nausea, Vomiting, Headache

CLASSIFICATION:
PRIMARY DYSMENORRHEA

Set in at the time related to menarche (post-menarcheal)

Theory/ Causes of Endometriosis:

1. Sampsons Theory of Transtubal Reflux/ Regurgitation

Retrogade menstruation/ Accumulation of Menstrual

Blood due to Outflow Obstruction:

Most common theory because a lot of the endometriosis

sites can be explained by this theory & the most frequent
sites are the ovaries, cul de sac, rectosigmoid & the
peritoneum .

After menarche, the menstrual cycles are anovulatory hence NO

dysmenorrhea. During anovulatory cycles chances are menstrual cycles
are without phase because there is a lot more PG from the
endometrium in a woman with a secretory endometrium. That is the
reason why when a patient have menarche at 12, most likely at 14, 15
or 16 that will be the time they will experience dysmenorrhea. This is
the age where cycles start to be ovulatory where time has passed for
the maturity of HPO axis.

Causes:

Review Case 3, Amenorrhea & Congenital Anomalies:

Imperforate Hymen & Complete Transverse Vaginal
Septum

Cervical Stenosis (may be Acquired) from those who

had previous procedure or operation done on the
cervix

The most common site of endometriosis is the ovaries. As

the menses will come out from the tube they will just implant
on the ovaries. Usually it is in this area of the pelvis that will
have a lot of endometriosis.
Remember the abdominal wall: skin, subcutaneous, fascia,
muscle, & peritoneum. There can be peritoneal endometriosis
& this will not be explained by Trans tubal theory. In the Transtubal regurgitation, it will dislodge in the most dependent area
of the pelvis:
In the area of the cul de sac that goes from the posterior
peritoneum of the vagina (cul de sac is between the posterior
surface of the uterus & the rectosigmoid or at the area of the
uterosacral ligaments)

Pathology: PGF2
Pelvic examination: Normal (Cannot demonstrate an
organic or anatomic pathology to explain the pain)
Treatment:

Medication:

Standard: NSAIDS (PG Synthetase Inhibitor)

o Mefenamic acid (Lesser SE: GI upset)
o Ibuprofen, Naproxen (Flanax), Indomethacin
Diet:

Just before period, a woman is heavier because of

nd
the retention of water in the 2 half of the cycle

Green mango + salt/ bagoong adds to the

premenstrual retention of water
SECONDARY DYSMENORRHEA

Set in after age 20 (several years, after 20 years)

Pathology: Positive anatomic problems

CAUSES:
1. Endometriosis
2. Adenomyosis

Old Term: Endometriosis Interna

Still WITHIN the confines of the myometrium

At the time of menstruation, there is bleeding within

the fibers of myometrium giving rise to pain
3. PID
4. Pelvic Congestion Syndrome
5. Anything within the endometrial cavity
o
Submucous myoma
o
IUD
TX: Geared towards organic/anatomic causes
ENDOMETRIOSIS

Presence of the endometrial glands or stroma outside the

confines of the endometrium

Anything outside the confines of the uterus

Pathogenesis:
In the histology of the uterus, it is made up of
endometrium, myometrium & serosa. The endometrium is
made up of 3 layers: Compacta, Spongiosa & the Basalis (C & S
- Functional layer, B Regeneration)
During menses, the glands and stroma that are in the
functional layer dislodge (sloughed off). If the glands & stroma
are supposed to be coming out as menstrual discharge BUT
reflux back to the tube, then this is the MOST COMMON
pathogenesis of endometriosis.

2.

Vascular / Lymphatic Dissemination

Anything that is FAR from the pelvis can be explained by
this

During menses, the blood vessels in the endometrium, the

spiral arterioles are open so endometrial glands may only go
into the myometrium & the vascular supply of the uterine
vessels, dislodged endometrium may only go to the blood
vessel or the lymphatic.
3.

Coelomic Metaplasia
Peritoneal endometriosis
Tissues of the peritoneum develop into endometrial like
tissue

Both theories: Vascular & Coelomic Metaplasia may explain

endometriosis in other areas of the body.

Epistaxis Endometrial glands in the nasal mucosa. A

woman who nose bleeds every during menses
TX: Destroy the endometrial implants of the nasal mucosa
(Localized focal depending on how much epistaxis)

Hemoptysis Endometriosis of the Pleura

4.

Immunologic Theory of endometriosis

Newest theory
Those who developed endometriosis have something that
nourishes the endometrial glands & stroma to grow.
Present certain substances: interleukins, cytokines

No one of these theories will explain it solely. If laparoscopy is

done, scoped at the time of menstruation, all will have blood in
the pelvic cavity. So all will have reflux of menses into the
tubes & into the pelvic cavity but NOT all will develop
menstruation so Trantubal Theory will go hand in hand with
what we term as Immunologic Theory of endometriosis. For
those with endometriosis, there is something more than
Transtubal regurgitation.
5.

Genetics Family History

6.

Direct implantation
Iatrogenic
Endometriosis of episiotomy wound, incision in the
abdomen for CS
Symptoms: Lump on episiotomy during menses &
disappears when there is no menstruation.
For patients who had undergone episiotomy with
episiorrhapy:

After delivery of the placenta, the decidua (remember

endometrium) some will come out & during episiotomy, if
some of the decidual cells are caught during episiotomy then
this decidua will becomes endometrial glands & stroma
Clinical Diagnosis of Endometriosis:
1. Secondary Dysmenorrhea
2.

Acquired & Progressive Pain + Bowel Symptoms

Usually GIT symptoms are prominent with Endometriosis
The most dependent area: endometrial implants on the
serosa of recto-sigmoid that bleeds every menstruation
causing colon to do peristalsis.
At the time of
menstruation there is rectal discomfort (pain) or at the
time menstruating there is a need to go to the rest room
because there is feeling to move the bowels.
Pain that lets the patient stay home from work & class

3.

Dyspareunia, particularly on deep penetration

Sometimes endometriosis would be felt at the uterosacral ligaments

4.

Infertility problem

Pelvic examination:
1. Retroverted uterus

Normal position: Anteversoflexed

Retroverted: directed towards the back because it is being

held up by the endometrial implants or adhesions at the
posterior portion of the uterus

Because there are adhesions between the rectosigmoid

(RS) and the uterus. It keeps the uterus close to the RS.
2.

Uterosacral nodularities
To elicit tenderness, it is ideal to check at the time of
menstruation because that will be the time it will be very
tender

3.

Enlarged ovaries
May or may not have
May feel an adnexal mass, an enlarged cystic ovaries

Definitive Diagnostic Procedure:

1. UTZ (+) ENDOMETRIAL CYSTS OF THE OVARIES

Can be pelvic, trans-vaginal or trans-rectal dependent on

the intactness of the hymen

Medium to low level echoes within the mass

corresponding to the old menstrual blood
In endometriosis, because of the presence of endometrial
glands & stroma, when the woman menstruates, blood will
accumulate to the ovaries. Over so many years, blood
accumulated in the ovaries would make it grow bigger.
Hopefully before the endometrial cyst will rupture, she would
seek consult & usually this is one cyst that would let the
sonologist think of endometrial cyst
Sonologist will detect an adnexal mass but will not tell the type
of ovarian cyst but in endometrial cyst because of the presence
of medium to low level echoes they can come up with the
diagnosis of Endometrial cyst of Ovaries
HOWEVER IF it does not involve the ovaries, you will not see
anything

2.

Laparoscopy: (+) ENDOMETRIOSIS

A minimally invasive procedure to visualize the abdominal
cavity
An endoscopic procedure
GOLD STANDARD: PID & ENDOMETRIOSIS

For diagnosis if there is no result from the UTZ

For therapy, if there is (+) Endometrial Cyst from UTZ

What can you see in laparoscopy?

See external architecture of pelvic organs (outside)

Endometrium cannot be seen by laparoscopy which is

inside the endometrial cavity but with hysteroscopy

Elevate the uterus to be able to see the back which are

the: (+) Nodularities of uterosacral ligaments, Implants of
endometriosis on the surface of the uterus or ovaries or
fallopian tubes

Via laparoscopy, there is a need to know the different

picture of the endometrial glands:
It can be a vesicular type of endometriosis, chicken pox-like on
the surface of the ovary. These would mean the beginning of
the endometrial implant becoming red, yellow then bluish
black color (cigarette burns).
You can see the endometrial implants on the surface of the
pelvic organs, peritoneal surface of the abdominal cavity.
Once diagnosis has been made, we can go to therapeutic
operative laparoscopy. By principle, destroy/ eradicate of the
endometrial implants via excise, cauterize or laser. But with
this the patient can always have a recurrence.
NOT CA 125:

NOT SPECIFIC

: Pregnancy, PID, Myomas, Ovarian CA & Endometriosis

Treatment
Definitive Treatment: Bilateral Oophorectomy

Get rid of the culprit, ovaries. If the ovaries are no longer

present then there would be no menses & no longer make
Estrogen which responsible for the stimulation of
endometrial implants

Many times, it cannot be done on patient in 20s to 30s,

making her menopausic because endometriosis usually
affects young patients.
Alternative treatment:
Medical:

Objective: to make her AMENORRHEIC

Principles: make her PSEUDO-MENOPAUSIC OR PSEUDOPREGNANT because in both conditions, pregnancy &
menopause are situation where you have physiologic
amenorrhea.
Pseudo-pregnancy:

Continuous OCP

Continuous Progesterone because in the pregnant the

most predominant is progesterone

But OCP for contraception - Take it for 21 days

Pseudo-menopausic

Danazol
Worst SE: Masculinizing effect of the drug

GnRH Agonist
SE: symptoms of menopause
Read about add-back therapy which means you are
giving small doses of hormones to offset the symptoms of
menopause
Surgery
Radical

Take out everything uterus: TAHBSO for endometriosis

Do not mistake this as radical surgery for cancer

Conservative

Oophorocystectomy - take out endometrial cyst of the

ovary

Salphingooophorectomy - adnexa

Also excision cautery of all the endometrial implants

As long as there is menstruation, there is recurrence because
definitive treatment is to GET RID OF THE OVARIES.
Incidence: because women try to postpone pregnancy, more
focus in the career.

Remember:

The extent of the symptoms do not always parallel the

extent of disease

Endometriosis is an ENIGMATIC disease

E.g.

A young girl 21 years feels comfortable except for the

slight dysmenorrhea, she comes becomes shes bothered
by it & she never had it before. You do pelvic examination
it is Stage 4 Endometriosis

22, F not in school because shes practically in pain, you

do pelvic examination & its normal.

CASE 8
32 year old G2P1 (1011) complains of hypogastric pain during menses. She has been experiencing this pain for the past 3
menses. There was also increase in amount of menses. She used to consume: 1 2 pads/day but for the past 3 months, she
rd
nd
consumed 2 3 pads/day. LMP: May 3 wk, 2013. PMP: April 2 wk, 2013 PPE: BMI 22; pink palpebral conjuctival abdomen:
flabby soft non-tender, no palpable mass; Speculum: cervix, pink smooth; IE: cervix firm, long, closed; uterus symmetrically
enlarged to 3 mos., retroverted; adnexa no palpable mass nor tenderness.
DX: ADENOMYOSIS
Basis:

Dysmenorrhea x 3 months: Secondary dysmenorrhea

HMB x 3 months

Symmetrically enlarged x 3 months

32 Gravida 2
Symmetric: Adenomyosis or Pregnancy
Asymmetric Nodular Enlargement: Myoma
Difference is the consistency of the uterus

Pregnant: soft symmetrical enlargement

Adenomyosis: Firm, symmetrical enlargement

Remember:
Endometriosis
Nulligravid
Younger

Adenomyosis
Nulligravid Multiparous?
Older

DX: Confirmed bu UTZ

TX:

do HYSTERECTOMY (DEFINITIVE TREATMENT to remove

the uterus to get rid of the pain & other problems)
BUT IF want to have another child:

Initially just treat the symptoms

Give NSAIDS:
o Causes myometrial relaxation
o Decreases the menstrual blood flow
Conservative Surgical objective of Endometriosis:

Try to restore the normal anatomy of the pelvis

Try to restore also the fertility of the patient