LITERATURE REVIEW

DEFINITION
Dysmenorrhea (or dysmenorrhoea) is a gynecological medical condition of pain during menstruation that interferes with daily activities Greek words Dys meaning painful Meno meaning monthly Rhoe meaning flow
By American Congress of Obstetricians and Gynecologists, retrieved January 2011

EPIDEMIOLOGY
Prevalence: 25% of women. Severe dysmenorrhea: 10 to15% Greatest: late teens and 20s Races: no significant difference Leading cause of recurrent short-term school absence Childbearing
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eMedicine > Dysmenorrhea By Andre Holder, Laurel D Edmundson and Mert Erogul. Updated: Dec 31, 2009

CLASSIFICATION
Primary or idiopathic The pain has no obvious organic cause Secondary The pain is due to an underlying condition

Oxford Handbook of Gynaecology And Obstetrics 2nd Edition 2012.oup

PRIMARY DYSMENORRHEA: PROPOSED THEORIES

Abnormal Prostaglandin Ratios Or Sensitivities Venous Pelvic Congestion

Neuropathic Dysregulation

Psychological causes

Oxford Handbook of Gynaecology And Obstetrics 2nd Edition 2012

Ovulatory cycle

sequential exposure to oestrogen and progesterone

sloughing of the endometrium and prostaglandin release with the onset of menstruation

Estrogens

Progesterones

Sloughed endometrium & prostaglangins

Increased Conc.PGF2 alpha

frequent and dysrhythmic contractions & a higher basal uterine tone.

some degree of uterine ischemia &

Symptoms

Increased Conc.PGF2alpha

. The Washington Manual Obstetrics and Gynecology Survival Guide. Lippincott Williams
and Wilkins, 2003. ISBN 0-7817-4363-X

CAUSES: SECONDARY DYSMENORRHEA

Inside Uterine Cavity Within Uterine Wall Outside Uterine Cavity

Fibroid
Endometrial Polyp
Adenomyosis

Endometriosis PID Adhesions Ovarian tumours

Society of Obstetricians and Gynaecologists of Canada, 2005;

IUCD

Cervical Stenosis

DETERMINING THE CAUSE OF DYSMENORRHEA

HISTORY EXAMINATION INVESTIGATIONS

How should I assess a woman with painful periods?

ONSET:RELATION TO MENARCHE DESCRIPTION OF PAIN Character, Site, Radiation

TIMING & DURATION

ASSOCIATED SYMPTOMS

fatigue ,irritability , dizziness ,headache, lower backache ,diarrhoea ,nausea, vomiting

HISTORY
GYNAECOLOGICAL SYMPTOMS

RELIEVING FACTORS

post coital bleeding, intermenstrual bleeding, vaginal discharge deep dyspareunia Response to NSAIDs and OCP

FAMILY HISTORY

RISK FACTORS

Nulliparity Obesity Smoking

PRIMARY DYSMENORRHEA: ESSENTIALS OF DIAGNOSIS

Starts 612 months after the menarche, once cycles are regular. Pain often starts shortly before the onset of menstruation, and lasts for up to 72 hours, improving as the menses progress. Pelvic examination is normal. Non gynaecological symptoms are usually present. Other gynaecological symptoms are not usually present.

http://www.cks.nhs.uk/dysmenorrhoea/evidence/references#-370595

SECONDARY DYSMENORRHEA: ESSENTIALS OF DIAGNOSIS

After several years of painless periods.
May persist after menstruation finishes; or may be present throughout the menstrual cycle, but exacerbated by menstruation. Pelvic examination may be abnormal.

Other gynaecological symptoms are often present.

Rectal pain or bleeding may indicate recto-vaginal endometriosis.

http://www.cks.nhs.uk/dysmenorrhoea/evidence/references#-370595

FAR ANY NEW CASE OF DYSMENORRHEA

Onset soon after menarche or in a patient who is clearly anovulatory Menstrual pain appearing after several years of painless periods

Irregular periods possibility of an obstructing malformation bleeding in between periods thick or foul-smelling vaginal discharge of the genital tract

pain during intercourse

EXAMINATION
Pelvic examination :
To identify any areas of pain and exclude abnormal anatomy or pelvic masses usually unremarkable not usually indicated in young women who are not sexually active

INVESTIGATIONS

LABORATORY INVESTIGATION
Complete blood picture

DIRECT VISUALISATION OF THE UTERUS

USG laparoscopy rule out pelvic abnormalities such as endometriosis, pelvic inflammatory disease, or an accident in an ovarian cyst

TREATMENT

Approaches to the management of primary dysmenorrhea:

Pharmacological

Nonpharmacological

Surgical

PHARMACOLOGICAL
1-NSAID 1st line 80% effective Propionic acid derivatives Ibuprofen Naproxen Fenamates Mefenamic acid

2-ORAL CONTRACEPTIVES
90% effective If NSAID are not effective or contraindicated day 5day 21 for 3-6 cycles. Depot medroxyprogesterone acetate Levonorgestrel intrauterine system

FOLLOW UP
Some Patients may require combining both drugs Consider Secondary Dysmenorrhea if no improvement with therapy

NSAIDS

Inhibits prostaglandin production Antagonistic action at the receptor

ischemia &

Symptoms

InhibitPGF2alpha production

Marjoribanks, ^ J; Proctor, M, Farquhar, C, Derks, RS (2010 Jan 20). Marjoribanks, Jane. ed. "Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

 endometrial thickness PG through inhibition of

OCPs

ovulation & change the hormonal status to that of the early proliferative phase

ischemia &

Symptoms

InhibitPGF2alpha
Production & endometrial thickness

Proctor ML, Roberts H, Farquhar CM (2001). Wong, Chooi L. ed. "Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea

DMPA
Suppresses ovulation
Induces endometrial atrophy Decreases menstrual flow and cramping

LN-IUS
Releases progestin locally inside the uterine cavity local effect on the endometrium, which becomes atrophic and inactive. Menstrual blood loss is reduced

Gupta HP, Singh U, Sinha S (2007). "Laevonorgestrel intra-uterine system--a revolutionary intra-uterine device".

COMPLEMENTARY AND ALTERNATIVE MEDICINE(CAM)

Vitamin B1 Vitamin E Fish oil / Vitamin B12 combination Magnesium Vitamin B6 Fish oil Neptune krill oil
J Obstet Gynaecol Can 2005;27(12):11171130

NON-MEDICINAL THERAPEUTIC OPTIONS

EXERCISE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) ACUPUNCTURE SPINAL MANIPULATION BEHAVIOURAL INTERVENTIONS:
Relaxation Training

TOPICAL HEAT
J Obstet Gynaecol Can 2005;27(12):11171130

DIETARY CHANGES
Reducing Caffeine, Sugar, and Alcohol Herbal treatments: Corydalis, Ginger tea Intake of warm drinks High fat, salty and junk foods Fresh fruits, leafy vegetables and whole grain products

http://women.ygoy.com/2009/11/16/what-is-dysmenorrhea/

SURGICAL OPTIONS
LAPAROSCOPY HYSTERECTOMY PRESACRAL NEURECTOMY LAPAROSCOPIC UTEROSACRAL NERVE ABLATION (LUNA)

J Obstet Gynaecol Can 2005