DYSMENORRHOEA

Definition :
Painful menstruation. It is a very common complaint with at least 50 %
post menarchial women experience some degree of dysmenorrhea.
10 % of
women it is severe enough to interfere with daily activities.

Classification : into either :

1 – Primary dysmenorrhoea.
2 – Secondary dysmenorrhoea.
3 – membranous ( cast of endometrial cavity shed as a single entity ). It is a rare ty
it causes entense cramping pain due to passage of a cast of endometrium through
undilated cervix.
 Primary dysmenorrhoea :
Refers to the presence of painful menses where there is no underlying pathology.

Aetiology : a number of factors claimed to have a role in the presence of primary

dysmenorrhoea :
1 – Endocrine :
by definition ovulatory cycle are necessory for the development of primary
dysmenorrhoea which implicates a role for oestrogen and progesteron and backed
the
2 – fact that oral
Abnormal CCP activity
uterine may allivate
: the dysmenorrhoea to some extent.
Some studies shown that women with primary dysmenorrhoe may have an elevate
resting uterine tone or pressure which may be mediated by increase PG levels or
elevated
levels of vassopressine ( but atosiban, a vasopressin antagonist , have shown no e
on studies have confirmed increased leukotriene levels as a contributing factor.
Other
menstrual pain ) while the pain is often improved with the use of anti PG .

.
 3 – Psuchological :
unlikely to be the primary cause of dysmenorrhoe but may influence individual perce
to painful stimuli, including attitude passed from mother to daughter. Girls should receiv
accurate informations about menstruation before menarche. Emotional anxiety due to
academic or social demands may also be a cofactor.

Diagnosis :
Primary dysmrnorrhoe usually begins prior to or during menses and last for the durat
the flow only. Because dysmenorrhoe is almost always associated with ovulatory cyc
does is not usually occur at menarche but rather later in adolescence. Usually describ
crampy in nature, and is most intense in the suprapubic region. It may occur in assoc
with other symptoms such as nausea, vomiting , diarrhea, fatigue and headache .
Diagnosis is usually based on the history and normal finding on clinical examination.
Further invasive tests only indicated if there is a strong suspicion of underlying patholo
( secondary dysmenohrrea.
Management :
A sympathetic approach to the patient, including consideration of
psychological and behavioral element will enhance the likelihood of a
positive outcome for the patient .
1 – Anti prostaglandin ( Non steroidal anti inflammatory drugs ) :
act via suppression of menstrual fluid PG. usually taken during the
first few days of menstruation and may be used in conjunction with o
CCP for example ibuprofin or mefenamic acid. The drug must be used
the earliest onset of symptoms, usually at the onset of, and sometim
-2 days prior to , bleeding or cramping.

2 – Oral contraceptives :
Act by inhibiting ovulation thereby decreasing menstrual PG level
via a reduction in endometrial thickness. At least 90 % of patient
experience a significant relief of symptoms.
3 – Surgical treatment :
In a few women, no medication will control dysmenorrheal. Cervical
dilatation is of little use. Laparoscopic uterosacral ligament division an
pre sacral neurectomy are infrequently performed. Similarly ablation o
the uterine nerve is rarely used , especially in patient resistant to
treatment .
patient who remain unresponsive to medical therapy should be
investigated for a pathological cause . In general laparoscopy is the
diagnostic procedure of choice .

4-adjuvant treatment :
continuous low level topical heat therapy has been shown to be as
effective as ibuprofine. Many studies have indicated that exercise
decreases prevalence and or improve symptomatology though solid
evidence is lacking.
analgensics such as codine and bed rest can be used also.
Secondary dysmenohrroea
occurs in the presence of an identifiable pathologic cause. It is more
common in older women and often the pain is more severe prior to
menstruation.

Aetiology :
1 – Endometrosis :
it is the presence of functioning endometrium outside the uterine
cavity, commonly associated with this dysmenohrroea , the severity of
which is not necessarily related to the extent of the disease . It may also
be associated with dyspareunia and meonorrhegia.
2 – Adenomyosis :
It is the presence of endometrium embedded within the myometrium,
it is a difficult diagnosis to confirm although ultrasound and MRI may
show typically diagnostic images in sever diseases.
at least one third of hysterectomy specimens show evidence of
adenomyosis classically associated with severe dysmenohhreoa
3 – Pelvic inflammatory disease :
Particularly in patient with residue of pelvic infection.
4 – intrauterine adhesions ( Asherman's syndrome ) :
it can develop after uterine instrumentation or infection.
5 - Cervical stenosis :
Narrowing of endocervial canal may result from conization of chronic
infection. Painful mense is a common association with this condition.
6 - Uterine fibroid :
Especially fibroid polyps.
7 – Intrauterine contraceptive device :
8 – Uterine retroversion especially with fixation.
Management :
Secondary dysmenohrroea easily diagnosed from the history but the
underlying cause may not be readily identified from clinical examination.
Important investigations include :
1 – Laparoscopy : generally the single most useful diagnostic procedure
that can also provide an opportunity to treat certain condition.
2 – Pelvic ultrasound : show ovarian endometriosis and may
demonstrate the fixity of the ovaries in PID.
3 – Hysterosalpingogram : useful in identifying intrauterine adhesions.
4 – Microbiological cultures : from endocervix, form peritoneal cavity if
PID is suspected.

Treatment :
1 – Treat underlying cause.
2 – Supportive measures such as analgesics and NSAID in a similar
manner to that used in primary dysmenohroea.
3 – in patients with intractable dysmenohrroea, hysterectomy often with
bilateral oophorectomy may be the ultimate end result.
Premenstrual syndrome
Symptoms :
The variety of symptoms that may be associated with PMS is broad in
fact more than 150 different symptoms have been linked to PMS when
these symptoms disrupt daily functioning they are clustered under the
name premenstrual dysphoric disorder ( PMDD ) ( should include
irritability, dysphoria and mode liability ).
The most common symptoms include :
1 – Bloating.
2 – Cyclical weight gain.
3 – Mastalgia ( breast tenderness )
4 – Abdominal cramps
5 – Fatigue.
6 – Headache.
7 – Depression.
8 – Irritability.
9 – Lack of energy.
10 – Sleep changes and mode swings.
 PMS is a psyconeuroendocrine disorder. Defined as cyclical presence
of somatic, psycological and emotional symptoms that worsen as mense
approach and ameliorated by the onset of the menstrual flow. Nearly all
women with regular menses do experience some form of symptomatolo
in the premenstrual phase, 20 – 40 % are mentally or physically
incapacitated to some degree and 5 % experience severe and debilitatin
disease.
The highest incidence is in women in their late twenties to early
thirties. PMS is rarely encountered in adolescent.

Aetiology :
It is not known but several theories have been proposed including
oestrogen – progesteron imbalance, excess aldosterone,
hyperprolactenemia, hyoglycemia and changes in serotonin levels within
the CNS with psychogenic factors.
Diagnosis :
By definition PMS is a clinical diagnosis in order to confirm the diagnosis
a number of certain criteria that need to be met :
1 – Symptoms are cyclic and occur only during the luteal phase.
2 – Symptoms increase in severity on the cyclic progress.
3 – Symptoms are releived with the onset of menses and are absent by
day 3 of flow.
4 – There must be a post menstrual symptom – free period of at least 7
days.
5 – Symptom must be present for at least 3 consecutive cycle.
6 – Symptoms should be of a severity to interfere with daily activity.

It is important that PMS is distinguished from any underlying psychiatric

conditions such as depression.
Treatment :
Many pharmacological preparations have been used for the
treatment of PMS but very few have been tested by appropriate clin
trials.
1 – Vit B6 ( Pyridoxine ) widely prescribed but its efficacy and safety
not been adequately studied.
2 – Psychotherapy involving both behavioral and congnitive methods.
3 – Suppression of ovulation using oral CCP, danazol, GnRH analogue.
4 – Selective serotonin inhibitors i.e fluoxetin.

in addition factors such as diet alteration or modification, exercise or

stress relaxative technique may improve many individual symptoms.
In situations where PMS is refractory to pharmacological treatment,
hysterectomy and oopherectomy may be considered as a last option
and is generally curative.