(20) Dysmenorrhea (Causes, Differential

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Report on Dysmenorrhea (Causes, Differential diagnosis, management)

Definition: Painful menstruation.

Incidence: The most common medical problem in young women. About 50% of menstruating women are affected by dysmenorrhea. 5% ­ 15% have severe symptoms. Peak age incidence is 20 – 24 years.

Importance: 1­ A distressing problem that can have an impact on a female’s well being and productivity.

2­ can represent an underlying organic gynecologic pathology that requires medical attention.

Classification: According to causes dysmenorrhea is classified into 2 main types.

(1) Primary/functional dysmenorrhea (2) Secondary/ acquired dysmenorrhea Primary dysmenorrhea: Cyclic Pain associated with ovulatory cycles without demonstrable lesions affecting reproductive structures.

Secondary dysmenorrhea: Pain with menses caused by demonstrable gynecologic organic pathology.

Causes & Pathogenesis of causes: (1) Primary dysmenorrhea Pain occurs mainly due to the following 5 processes that take place during the menstrual cycle, in different degrees, in different women.

1­ Endometrial tissue break­down 2­ Myometrial contractions 3­ Ischemia resulting from contractions 4­ Irritation of the peritoneum by retrograde menstrual flow into the peritoneal cavity 5­ Irritations of nerve endings by Prostaglandin and Endoperoxides.

Progesterone levels regresses at the end of the luteal phase, when corpus luteum is regressing.

Decreasing progesterone amounts cause a release of phospholipase A2 from endometrial cells.

This enzyme acts on lipid cell membranes to produce arachidonic acid.

Arachidonic acid activates enzyme cyclooxigenase, which in turn acts on arachidonic acid to produce endoperoxide.

Endoperoxide is the precursor of Prostaglandin (PG) PGE2 & PGF2α PG causes: ­ 1­ necrosis of endometrium 2­ contractions resulting in areas of ischaemia Women with dysmenorrhea have higher concentrations of PGE2 & PGF2α ∴ They have increased uterine activity manifesting as 1­ ↑ resting tone 2­ ↑ contractility 3­ ↑ frequency of contractions 4­ ± dysrrhythmia Contributory factors­ 1­ passage of large endometrial casts or clots through an undilated cervix causing spasms 2­ anatomic variations of uterine position – retrovertion ( in most of the cases – anteverted) 3­ lack of exercise 4­ psychological ( increased sensitivity to pain) / social stress 5­ anxiety about menses (2) Secondary dysmenorrhea 1­ Endometriosis: ­ Most common cause of secondary dysmenorrhea. Characterized by proliferation of foci of normal endometrium outside the inner lining of the uterine cavity. Usually affected areas in order of frequency are­ ovaries (>1/2 of cases), cul­de­sac, uterosacral ligament, and posterior surface of uterus, broad ligament, pelvic peritoneum & extra pelvic sites (e.g.: intestinal & urinary tracts).

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Pain is caused by local tissue destruction, distortion, obstruction, adhesions & scar formation.

• Adenomyosis: Endometrial tissue that is found within the myometrial layer of the uterus. These endometrial tissue cause bleeding into the myometrium resulting in swelling of the myometrial layer & local destruction of the myometrial layer causing pain.

2­ Leiomyomas (fibroids/myomas): benign uterine tumors of muscle & fibrous connective tissue intramurally, subserosally or submucosally.

3­ PID 4­ Uterine synechiae:­ Occurs secondarily to chronic PID, endometriosis, post surgically 5­ Congenital anomalies: ­ May cause obstruction to the menstrual flow with resultant haematoma (accumulation of menstrual blood in the vagina secondarily to cervical obstruction ) or haematometra ( accumulation of menstrual blood in the vagina secondarily to introital obstruction).

E.g.: ­ Imperforated hymen Non communicating horn of the uterus Pain is caused by distention & peritoneal irritation caused by back­flow of menstrual fluid into the peritoneal cavity, through the fallopian tubes.

6­ Cervical stenosis secondary to previous surgery. Pain is caused by passage of menstrual blood & endometrial tissue through a very narrow cervix, distending & damaging it.

7­ Endometrial cancers Clinical Features (1) Primary dysmenorrhea Subjective 1­ Pain – cramp­like strongest over the lower abdomen radiating to the lower back & middle & inner thighs begins a few hours before or together with or just after the menstrual flow. Peaks after 24 hours. Lasts for 2­3 days (on the 1st 2­3 days) Initial Onset: 90% experience pain within 2 years of menache (∴when ovulation begins). Becomes less severe with age & after pregnancy 2­ Associated symptoms – Nausea & vomiting – 89%, Fatigue, Constipation/ diarrhea – 60%, Headache – 45%, Urinary frequency, PMS symptoms may persist during part or all of the menses – irritability, nervousness, depression, abdominal bloating Hypertension Objective Patient is physically healthy although tensed.

PV or PR (if the hymen is intact) no pelvic pathology.

(2) Secondary dysmenorrhea Subjective 1­ Pain – Usual onset is after 20 years of age Progresses with age Less timed with menses 2­ associated symptoms – associated with other gynecologic symptoms such as dyspareunia, infertility, abnormal bleeding patterns Objective PV or PR may reveal uterosacral nodules Diagnosis 1­Symptoms – Characteristic cyclic pain & associated symptoms 2­History – Past menstrual history, family history, review of systems, level of debility and psychological overlay, 3­Physical examination – PV or PR in all cases 4­Lab tests – Not usually necessary. If indicated by H&P, consider Pap smear, cultures, endometrial biopsy, ultrasonography, laparoscopy

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Differential Diagnosis (1) Primary dysmenorrhea should be differentiated from secondary dysmenorrhea In Secondary dysmenorrhea, characteristics of pain & other associated symptoms & signs are different from primary dysmenorrhea & also from each other.

Secondary Characteristic of pain Other associated Main physical cause symptoms findings (1) Pain extends to premenstrual or Deep dyspareunia, Tender pelvic Endometriosis postmenstrual phase or may be premenstrual spotting, nodules on PV or PR continuous Infertility Onset is usually in the 20s or 30s but may also start in teens.

(2) PID Initially pain may be menstrual, but May have pelvic tenderness often with each cycle it extends into the intermenstrual premenstrual phase. bleeding, dyspareunia (3) Fibroids Dysmenorrhea is associated with a dull Enlarged abdomen Enlarged uterus & pelvic dragging sensation. mild tenderness (4) Pelvic A dull, ill­defined pelvic ache, usually A history of sexual congestion worse premenstrually , relieved by problems menses Treatment (1) Primary dysmenorrhea 1­General measures: Reassurance & explanation that the genital tract is normal heating pad to the lower abdomen or back; nutritional, aerobic exercise; Nutritional therapy includes a well­ balanced diet with an adequate intake of calcium (1200 mg. per day). An adequate fluid intake of 2 quarts of water each day is very important. Vitamin B6 , 50 to 100 mg. each day, may occasionally be helpful.

2­Medical measures: Medication for dysmenorrhea may involve two complimentary strategies: decreasing prostaglandin production and hormonal alteration.

1/ NSAIDS are highly effective for mild, moderate & severe pain. Acts by decreasing prostaglandin by inhibiting cyclooxigenase enzyme Mild pain – Aspirin, if Aspirin is contraindicated (e.g. in gastric ulcers) Acetaminophen can be given.

Severe pain (not relieved by above)­ Ibuprofen 400mg – 800mg PO TID or, Naproxen sodium 500mg PO BID or, Mefenamic acid 500mg initially and then 250mg PO TID Start 3 days before expected menses and continue through days of flow that patient has pain. Reassess need for medications in 1 year.

2/ if above drugs are inadequate: Consider oral combined contraceptives. Prevents ovulation, decreases the thickness of the endometrium. and, as a result, fewer prostaglandins are made For those who do not want contraception, OCPs can be stooped a/f 6­12 months. Many continue to be pain free a/f discontinuing the drug.

Depo­Provera, 150 mg. every 10­12 weeks, can also be used. If Depo­Provera is used to alter the hormones, it is extremely important that the woman obtain an adequate daily intake of calcium (1500 mg.).

3/Resistant cases may respond to tocolytic agents (e.g.: ­ Salbutamol) or a Calcium channel blocker (e.g.:nifedipine), Medroxyprogesterone acetate or dydrogesterone 3­ surgical measures: Dilation of a narrow cervix Presacral neurectomy ­ conservative surgery Uterosacral Ligament section ­ ’’

4­ other measures: Psychotherapy, Hypnotherapy, Acupuncture (2) Secondary dysmenorrhea 1­ To relieve the pain NSAIDs are the first line drugs.

2­ Underlying disease should be treated.

3­ Conditions that will require eventual hysterectomy with or without ovarectomy – Adenomyosis, Residual pelvic infections unresponsive to medical or conservative surgical measures A patient without an organic source rarely need this THIS IS NOT A CONDITION THAT CAUSES INFERTILITY Report on Dysmenorrhea (Causes, Differential diagnosis, management) Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.

2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.

3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania.

Contact: publications [at] infekcijas.eu

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