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  1. 1. DYSMENORRHEA By Dr Faisal Al Hadad Consultant of Family Medicine, PSMMC
  2. 2. Dysmenorrhea  Dysmenorrhea is chronic, cyclic pelvic pain associated with menstruation.  Two main categories 1- Primary: painful menstruation without associated pelvic disease 2- Secondary: painful menstruation caused by pelvic pathology
  3. 3. Evaluating patient with dysmenorrhea 1- History 2- Physical examination: should be completely normal in Pt with 1ry dysmenorrhea, however if evaluated during the pain uterus & cx will be mildly tender 3- Investigations: not required if Hx & physical examination are consistent with 1ry dysmenorrhea *U/S *HSG *Laparoscopy allow physician to confirm presence *Hystroscopy or absence of pelvic disease *D&c
  4. 4. Primary dysmenorrhea  Primary dysmenorrhea is the most common gynecologic complaint and one of the leading causes of absenteeism in young women  Increased levels of PG stimulates uterine smooth muscle contraction → vasoconstriction of the uterine arteries → uterine hypoxia → pain of dysmenorrhea  Onset: within 6-12 months after menarche  Usually begins few hrs before or with the onset of menstruation  The pain is crampy/ colicky in the lower abdomen and suprapubic area associated with nausea, vomitting, diarrhea, headache and fatigue.
  5. 5. Treatment of 1ry dysmenorrhea 1- NSAIDs are 1st line treatment *Propionic acid derivatives (Ibuprofen, naproxen) *Fenamates (mefenamic acid) 2- Oral contraceptives * If NSAID are not effective or contraindicated * 90% effective within 3-4 months of use 3- Some Pt may require combining both drugs 4- Consider 2ry dysmenorrhea if no improvement with therapy
  6. 6. Causes of 2ry dysmenorrhea         Endometriosis Adenomyosis Endometrial polyp Fibroid Cx stenosis Pelvic inflammatory disease Presence of an IUD Adhesions
  7. 7. Evaluating pt with 2ry dysmenorrhea 1- History - Onset of symptoms : several years after menarche - Recurrent pelvic infections (PID) - Fever and vaginal discharge (PID) - IUCD - Recent pelvic surgery (adhesions) - Heavy periods (adenomyosis, endometrial polyp, fibroid) - Infertility and dysparunea (endometriosis) 2- Physical examination: may help in Dx by finding abnormalities that point to a pelvic disease
  8. 8. Evaluating pt with 2ry dysmenorrhea 3- Investigations  CBC: anaemia related to chronic menorrhagia, infection (PID)  Cervical/vaginal swabs for cultures: PID  Transvaginal ultrasound: pelvic masses, uterine fibroids and polyps, pelvic abscess, adenomyosis.  Laparoscopy: both diagnostic and therapeutic, particularly in the management of endometriosis and where pain is of uncertain origin  Hysteroscopy: defines intrauterine pathology and provides an endometrial tissue sample for histology
  9. 9. CX STENOSIS  Causes: - Congenital - 2ry to cervical injury (electrocautery, cryocautery, conization, infection)  Presentation: Scanty menstrual flow & sever cramping through out the menstrual cycle  Diagnosis: Internal os scarred & impossible to pass uterine sound or even very thin probe  Treatment - D&C - Vaginal delivery afford more lasting cure
  10. 10. ENDOMETRIOSIS  Endometriosis: an ectopic endometrial tissue in extra-uterine sites (ovaries, fallopian tubes or uterosacral ligaments)  History: Sever dysmenorrhea, infertility and dysparunea  Pelvic examination - Evidence of endometriosis in vagina or cx - Rectovaginal examination reveals tenderness and nodularity along the uterosacral ligaments
  11. 11. ENDOMETRIOSIS  Diagnosis -Laparoscopy or laparotomy -Direct biopsy of vaginal or cx lesion  Treatment - Suppress menstruation (OCP, GnRG agonists, danazol) - Cauterization of endometriotic spots
  12. 12. Pelvic inflammatory disease  PID adhesions  pelvic pain  History - Acute episodes of abdominal pain begins with menses & continues - Fever - Vaginal discharge  Examination - Sever tenderness on palpation of the uterus & cx motion - Purulent cx discharge
  13. 13. Pelvic inflammatory disease  Investigations: ↑WBC, ↑ESR, ↑CRP  Treatment - Appropriate antibiotics - Surgical  release of adhesions
  14. 14. Thank you