Gynecology 5th year, 3rd lecture (Dr. Sindus)


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The lecture has been given on Dec. 6th, 2010 by Dr. Sindus.

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Gynecology 5th year, 3rd lecture (Dr. Sindus)

  2. 2. <ul><li>Definition : </li></ul><ul><li>Painful menstruation. It is a very common complaint with at least 50 % of post menarchial women experience some degree of dysmenorrhea. In at least 10 % of women it is severe enough to interfere with daily activities. </li></ul><ul><li>Classification : into either : </li></ul><ul><li>1 – Primary dysmenorrhoea. </li></ul><ul><li>2 – Secondary dysmenorrhoea. </li></ul><ul><li>3 – membranous ( cast of endometrial cavity shed as a single entity ). It is a rare type and it causes entense cramping pain due to passage of a cast of endometrium through an undilated cervix. </li></ul>
  3. 3. <ul><li>Primary dysmenorrhoea : </li></ul><ul><li>Refers to the presence of painful menses where there is no underlying pathology. </li></ul><ul><li>Aetiology : a number of factors claimed to have a role in the presence of primary dysmenorrhoea : </li></ul><ul><li>1 – Endocrine : </li></ul><ul><li>by definition ovulatory cycle are necessory for the development of primary dysmenorrhoea which implicates a role for oestrogen and progesteron and backed up by the fact that oral CCP may allivate the dysmenorrhoea to some extent. </li></ul><ul><li>2 – Abnormal uterine activity : </li></ul><ul><li>Some studies shown that women with primary dysmenorrhoe may have an elevated 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 effect on menstrual pain ) while the pain is often improved with the use of anti PG . </li></ul><ul><li>Other studies have confirmed increased leukotriene levels as a contributing factor. </li></ul><ul><li>. </li></ul>
  4. 4. <ul><li>3 – Psuchological : </li></ul><ul><li>unlikely to be the primary cause of dysmenorrhoe but may influence individual perception to painful stimuli, including attitude passed from mother to daughter. Girls should receive accurate informations about menstruation before menarche. Emotional anxiety due to academic or social demands may also be a cofactor. </li></ul><ul><li>Diagnosis : </li></ul><ul><li>Primary dysmrnorrhoe usually begins prior to or during menses and last for the duration of the flow only. Because dysmenorrhoe is almost always associated with ovulatory cycles it does is not usually occur at menarche but rather later in adolescence. Usually described as crampy in nature, and is most intense in the suprapubic region. It may occur in association with other symptoms such as nausea, vomiting , diarrhea, fatigue and headache . </li></ul><ul><li>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 pathology ( secondary dysmenohrrea. </li></ul>
  5. 5. <ul><li>Management : </li></ul><ul><li>A sympathetic approach to the patient, including consideration of psychological and behavioral element will enhance the likelihood of a positive outcome for the patient . </li></ul><ul><li>1 – Anti prostaglandin ( Non steroidal anti inflammatory drugs ) : </li></ul><ul><li>act via suppression of menstrual fluid PG. usually taken during the first few days of menstruation and may be used in conjunction with oral CCP for example ibuprofin or mefenamic acid. The drug must be used at the earliest onset of symptoms, usually at the onset of, and sometimes 1 -2 days prior to , bleeding or cramping. </li></ul><ul><li>2 – Oral contraceptives : </li></ul><ul><li>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. </li></ul>
  6. 6. <ul><li>3 – Surgical treatment : </li></ul><ul><li>In a few women, no medication will control dysmenorrheal. Cervical dilatation is of little use. Laparoscopic uterosacral ligament division and pre sacral neurectomy are infrequently performed. Similarly ablation of the uterine nerve is rarely used , especially in patient resistant to treatment . </li></ul><ul><li>patient who remain unresponsive to medical therapy should be investigated for a pathological cause . In general laparoscopy is the diagnostic procedure of choice . </li></ul><ul><li>4-adjuvant treatment : </li></ul><ul><li>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. </li></ul><ul><li>analgensics such as codine and bed rest can be used also. </li></ul>
  7. 7. <ul><li>Secondary dysmenohrroea </li></ul><ul><li>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. </li></ul><ul><li>Aetiology : </li></ul><ul><li>1 – Endometrosis : </li></ul><ul><li>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. </li></ul><ul><li>2 – Adenomyosis : </li></ul><ul><li>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. </li></ul><ul><li>at least one third of hysterectomy specimens show evidence of adenomyosis classically associated with severe dysmenohhreoa </li></ul>
  8. 8. <ul><li>3 – Pelvic inflammatory disease : </li></ul><ul><li>Particularly in patient with residue of pelvic infection. </li></ul><ul><li>4 – intrauterine adhesions ( Asherman's syndrome ) : </li></ul><ul><li>it can develop after uterine instrumentation or infection. </li></ul><ul><li>5 - Cervical stenosis : </li></ul><ul><li>Narrowing of endocervial canal may result from conization of chronic infection. Painful mense is a common association with this condition. </li></ul><ul><li>6 - Uterine fibroid : </li></ul><ul><li>Especially fibroid polyps. </li></ul><ul><li>7 – Intrauterine contraceptive device : </li></ul><ul><li>8 – Uterine retroversion especially with fixation. </li></ul>
  9. 9. <ul><li>Management : </li></ul><ul><li>Secondary dysmenohrroea easily diagnosed from the history but the underlying cause may not be readily identified from clinical examination. Important investigations include : </li></ul><ul><li>1 – Laparoscopy : generally the single most useful diagnostic procedure that can also provide an opportunity to treat certain condition. </li></ul><ul><li>2 – Pelvic ultrasound : show ovarian endometriosis and may demonstrate the fixity of the ovaries in PID. </li></ul><ul><li>3 – Hysterosalpingogram : useful in identifying intrauterine adhesions. </li></ul><ul><li>4 – Microbiological cultures : from endocervix, form peritoneal cavity if PID is suspected. </li></ul><ul><li>Treatment : </li></ul><ul><li>1 – Treat underlying cause. </li></ul><ul><li>2 – Supportive measures such as analgesics and NSAID in a similar manner to that used in primary dysmenohroea. </li></ul><ul><li>3 – in patients with intractable dysmenohrroea, hysterectomy often with bilateral oophorectomy may be the ultimate end result. </li></ul>
  10. 10. Premenstrual syndrome
  11. 11. <ul><li>Symptoms : </li></ul><ul><li>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 ). </li></ul><ul><li>The most common symptoms include : </li></ul><ul><li>1 – Bloating. </li></ul><ul><li>2 – Cyclical weight gain. </li></ul><ul><li>3 – Mastalgia ( breast tenderness ) </li></ul><ul><li>4 – Abdominal cramps </li></ul><ul><li>5 – Fatigue. </li></ul><ul><li>6 – Headache. </li></ul><ul><li>7 – Depression. </li></ul><ul><li>8 – Irritability. </li></ul><ul><li>9 – Lack of energy. </li></ul><ul><li>10 – Sleep changes and mode swings. </li></ul>
  12. 12. <ul><li>PMS is a psyconeuroendocrine disorder. Defined as cyclical presence of somatic, psycological and emotional symptoms that worsen as menses approach and ameliorated by the onset of the menstrual flow. Nearly all women with regular menses do experience some form of symptomatology in the premenstrual phase, 20 – 40 % are mentally or physically incapacitated to some degree and 5 % experience severe and debilitating disease. </li></ul><ul><li>The highest incidence is in women in their late twenties to early thirties. PMS is rarely encountered in adolescent. </li></ul><ul><li>Aetiology : </li></ul><ul><li>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. </li></ul>
  13. 13. <ul><li>Diagnosis : </li></ul><ul><li>By definition PMS is a clinical diagnosis in order to confirm the diagnosis a number of certain criteria that need to be met : </li></ul><ul><li>1 – Symptoms are cyclic and occur only during the luteal phase. </li></ul><ul><li>2 – Symptoms increase in severity on the cyclic progress. </li></ul><ul><li>3 – Symptoms are releived with the onset of menses and are absent by day 3 of flow. </li></ul><ul><li>4 – There must be a post menstrual symptom – free period of at least 7 days. </li></ul><ul><li>5 – Symptom must be present for at least 3 consecutive cycle. </li></ul><ul><li>6 – Symptoms should be of a severity to interfere with daily activity. </li></ul><ul><li>It is important that PMS is distinguished from any underlying psychiatric conditions such as depression. </li></ul>
  14. 14. <ul><li>Treatment : </li></ul><ul><li>Many pharmacological preparations have been used for the treatment of PMS but very few have been tested by appropriate clinical trials. </li></ul><ul><li>1 – Vit B6 ( Pyridoxine ) widely prescribed but its efficacy and safety not been adequately studied. </li></ul><ul><li>2 – Psychotherapy involving both behavioral and congnitive methods. </li></ul><ul><li>3 – Suppression of ovulation using oral CCP, danazol, GnRH analogue. </li></ul><ul><li>4 – Selective serotonin inhibitors i.e fluoxetin. </li></ul><ul><li>in addition factors such as diet alteration or modification, exercise or stress relaxative technique may improve many individual symptoms. </li></ul><ul><li>In situations where PMS is refractory to pharmacological treatment, hysterectomy and oopherectomy may be considered as a last option and is generally curative. </li></ul>