DYSMENORRHOEA Definition Cramps or painful menstruation Sharp, intermittent pain or dull aching pain, in the pelvis or lower abdomen Classified as - Primary dysmenorrhoea Secondary dysmenorrhoea

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D.G.F CME on 16th
April 2018
at Wood apple residency
DYSMENORRHOEA
PART
2
Contributors
Dr. Vandana Gupta & DGF expert's team

2. DYSMENORRHOEA
Dr. Vandana Gupta

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Dysmenorrhoea
During / Before
Interview
During
Touring
During JobDuring Exams

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Definition
• Cramps or painful menstruation
• Sharp, intermittent pain or dull aching
pain, in the pelvis or lower abdomen
• Classified as -
– Primary dysmenorrhoea
– Secondary dysmenorrhoea

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Primary & Secondary
Primary dysmenorrhoea (PD)
– Otherwise healthy women
– No disease of uterus or other pelvic organs
Secondary dysmenorrhoea (SD)
– Underlying disease present (PID, fibroids,
endometriosis, adhesions, adenomyosis,
retroverted uterus)

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Incidence
• Primary dysmenorrhoea – 40-50% in reproductive
age group
• Severe - absenteeism work or school – 15%
• Highest in adolescent up to 90%
• Decreases with increasing age
• Increases with smoking
• More in unmarried than married
• ? relation with parity

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Burden of monthly pain
Absenteeism in
school/work
Health worries
Unable to enjoy
life
Anxiety
QOL

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Symptoms - PD
• With or shortly (6 months) after
menarche
• Fluctuating, spasmodic cramps
• “Labour-like”
• Begins few hours before or with menses
• Most intense first 24-36 hours
• Lasts 2-3 days

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Symptoms - PD
• Suprapubic
• Radiating to thighs & back
• Nausea, vomiting, dizziness
• Diarrhoea
• No pelvic pathology

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Symptoms - SD
• Later age of onset
• Starts 2 or more years after menarche
• Begins more than few hours before menses
• Dysmenorrhoea with anovulatory cycles
• H/O IUCD, recurrent PID
• F/H/O endometriosis
• Pelvic pathology on examination

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Risk factors
• Age > 20 years
• Attempts to lose weight
• Depression/anxiety
• Heavy menses
• Smoking

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Diagnosis
Primary
dysmenorrhoea
•History
•Beginning in
adolescence
•With menstrual
periods
Secondary
dysmenorrhoea
•Inconsistent history
•Physical findings of a
– pelvic mass
– abnormal vaginal
discharge
– pelvic tenderness (not
limited to the time of
the menstrual period)

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Diagnosis
• Abdominal examination
• Pelvic examination
• Pelvic USG
• HSG
• Vaginal swab culture
• MRI
• Diagnostic laproscopy/hysteroscopy
• D & C

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Treatment

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Lifestyle modification
• Low-fat vegetarian diet
• Decreased consumption of foods
like caffeine, salt & sugar
• Exercise - walking, swimming,
running, bicycling, aerobic dance
• Smoking cessation
• Hot fomentation

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Case 1
• A 20 y.o. woman presents to her
gynecologist with a 4 year history of
increasing lower abdominal pain with
her menses. The pain begins on the first
day of her menses and lasts 2-3 days.
She also complains of lower back pain
and nausea. Menarche occurred at
the age of 13 and her menses occur
every 28 days and last 5 days. Physical
and pelvic exam are normal.

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Complaints
• Lower abdominal pain
• Vomiting
• Nausea
• Dizziness
• Increased salivation

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The diagnosis is
Primary
Dysmenorrhea

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Differential Diagnosis
• Primary Dysmenorrhea
• Endometriosis
• Inflammatory Bowel Disease
• Irritable Bowel Syndrome
• Fibroids
• Pelvic Inflammatory Disease
• Urinary Tract Infections

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Rule out D/D

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• RBC – 3.7 x 10^12
• Hb – 13.2 g
• WBC – 5 x 10^9 cell/L
• Thrombocytes – 179 x 10^9
• ESR -8 mm/hr
Interpretation – Normal without significant
changes
General Blood Analysis

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• The diagnosis of dysmenorrhea was
made simply on the medical history of
menstrual pain that interferes with daily
activities.
How was dysmenorrhea
diagnosed ?

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Management
• General measures
• Drugs
• Diet

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General Measures
• Improvement of general health and
simple psychotherapy
• Usual activities such as sports to be
continued

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Drugs – NSAIDs
to reduce pain
• Prostaglandin synthetase inhibitors
• Mefanamic acid 250-500 mg 8 hourly
• Ibuprofen 400 mg 8 hourly or Naproxen
250mg 6 hourly
• Indomethacin 25mg 8 hourly

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• Combined oral contraceptive pills for 3-
6 months
• Monophasic COC prepatations
containing 30-35µg of ethinyestradiol
nad norethisterone
• Yasmin(Drospirenone 3mg; Ethinyl
oestradiol 30µg)
• Mala-D (Desogestrel 0.15mg; Ethinyl
oestradiol 20µg)
Combined Oral
Contraceptives

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• Antiemetics
To relieve vomiting and
nausea

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Diet
• Calcium, Magnesium, Vitamin B1 and
the essential fatty acods are helpful for
treating acute menstrual pain; increase
consumption of whole grains, green
vegetables , legumes, and seaweeds.
• Cold or sour foods should be avoided,
especially one week prior to or during
menstruation.

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Dysmenorrhea
• Dysmenorrhea – severe, painful
cramping sensation in the lower
abdomen often accompanied by other
symptoms – sweating, tachycardia,
headaches, n/v, diarrhea,
tremulousness, all occurring just before
or during menses
- Primary: no obvious pathologic
condition, onset < 20 years old
- Secondary: associated with pelvic
conditions or pathology

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Primary Dysmenorrhea
• Pathogenesis: elevated PG F2α in
secretory endometrium (increased
uterine contractility)
• Treatment: NSAIDs – PG synthetase
inhibitors – 1st
line treatment of choice
• Other treatment options: OCPs, other
analgesics

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• Etiologies
- Cervical Stenosis
- Endometriosis and Adenomyosis
- Pelvic Infection
- Adhesions
- Pelvic Congestion
- Stress and Tension
Secondary Dysmenorrhea

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• Cervical Stenosis
- Severe narrowing of cervical canal
may impede menstrual outflow –
congenital or iatrogenic
- can cause an increase in intrauterine
pressure during menses
- can lead to endometriosis
Secondary Dysmenorrhea

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• Cervical Stenosis
- Hx – scant menstrual flow, severe
cramping throughout menses
- Dx – inability to pass a thin probe
through the internal os OR HSG
demonstrates thin cx canal
- Tx – cervical dilation via D&C or
laminaria placement
Secondary Dysmenorrhea

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• Pelvic Congestion
- Due to engorgement of pelvic
vasculature
- Hx – burning or throbbing pain, worse
at night and after standing
- Dx – Laparoscopic visualization of
engorgement/varicosities of broad
ligament and pelvic sidewall veins
Secondary Dysmenorrhea

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Case 2
• At the age of 30, the patient presents
with a 2 year history of infertility. Her
menses are still regular but she has 2-3
days of spotting before her menses are
due. She also complains of pain with
intercourse and pelvic pain. In
reviewing the patient’s history, the
gynecologist notes that over the past
year the patient was repeatedly treated
by her internist with antibiotics for
recurrent microscopic hematuria.

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Case 2
• What is the most likely diagnosis?
• What are the main theories regarding
the pathogenesis in this case?
• How would you evaluate and treat this
patient?

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Diagnosis
• Secondary dysmenorrhea
Investigations
• Complete blood counts
• Ultrasounds
• MRI if required
• Laproscopy if required

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• Variable and unpredictable
- asymptomatic
- dysmenorrhea
- CPP
- deep dyspareunia
- sacral backache w/ menses
- dysuria +/- hematuria (bladder
involvement)
- dyschezia/hematochezia (bowel
involvement)
Endometriosis - Symptoms

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• Uterosacral nodularity
• Adnexal mass (endometrioma)
• Normal exam
Endometriosis – Physical
Exam

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• 7-10% of general population
• 20-50% of infertile women
• 70-85% in women w/ CPP
• No racial predisposition
• +Familial association with almost 10x
increased risk of endometriosis if
affected 1st
degree relative
Endometriosis - Incidence

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Take Home Message
• Recommendations for diagnosis, D/D, Investigations
– Adolescents with dysmenorrhea at menarche and in an
anovulatory patient the diagnosis of obstructing
malformation of genital tract is to be considered.
– Secondary dysmenorrhea is considered when symptoms
appear after many years of painless periods.
– Specific questions should be included regarding
menstrual pain.
– Adolescent who is not sexually active, a pelvic exam is
not necessary in cases of mild to moderate
dysmenorrhea.
– Pelvic exam is for all patients not responding to
conventional therapy or when an organic pathology is
suspected

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Differential Diagnosis of Dysmenorrhea
•Primary dysmenorrhea
•Secondary dysmenorrhea
– Endometriosis
– Adenomyosis
– Uterine myomas
– Endometrial polyps
– Cervical stenosis
– Obstructive malformations of the genital tract
•Other causes of pain
– Chronic pelvic inflammatory disease
– Pelvic adhesions Irritable bowel syndrome
– Inflammatory bowel disease
– Interstitial cystitis
•Sudden onset of dysmenorrhea
– Pelvic inflammatory disease
– Unrecognized ectopic pregnancy or spontaneous abortion
Take Home Message

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INVESTIGATIONS
•For Primary Dysmenorrhea usually history taking is important
•Lab investigations
•Imaging –
– Ultrasound
• Patients refractory to 1st
line therapy.
• Patients who have clinical abnormality on pelvic exam to identify causes of
secondary dysmenorrhea
– MRI
• Important diagnostic tool for adenomyosis
•Hysteroscopy and Saline sonohysterography for endometrial
polyps and sub mucosal fibroids
•Laproscopy for diagnosis of
– Endometriosis
– PID
– Pelvic Adhesions
Take Home Message

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Medical treatment
Dysmenorrhoea
PD SD
Rx of underlying disease
NSAIDS OCPs Vit E
Other
Acupuncture & Acupressure
Vit B

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Thank You

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