1. DYSMENORRHEA
By Dr Faisal Al Hadad
Consultant of Family Medicine, PSMMC

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. 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. 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. 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. Causes of 2ry dysmenorrhea








Endometriosis
Adenomyosis
Endometrial polyp
Fibroid
Cx stenosis
Pelvic inflammatory disease
Presence of an IUD
Adhesions

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. 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. 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. 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. ENDOMETRIOSIS

Diagnosis
-Laparoscopy or laparotomy
-Direct biopsy of vaginal or cx lesion

Treatment
- Suppress menstruation (OCP, GnRG agonists, danazol)
- Cauterization of endometriotic spots

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. Pelvic inflammatory disease

Investigations: ↑WBC, ↑ESR, ↑CRP

Treatment
- Appropriate antibiotics
- Surgical  release of adhesions

14. Thank you