Dysmonorrhea is characterized by painful menstruation and can be primary or secondary. Primary dysmonorrhea is caused by increased uterine contractions without underlying pathology, while secondary dysmonorrhea has an identifiable cause like endometriosis. NSAIDs are first-line treatment for primary dysmonorrhea, while secondary dysmonorrhea requires treating the underlying condition through medical, surgical or alternative approaches.

1. By
Dr .Nadia Sabeen
SHL

2. Introduction
 The term dysmonorrhea is derived from Greek word
 Dys meaning difficult,painful meno means month
and rhea means flow
 Dysmonorrhea is a medical condition characterized by
severe uterine pain during mensturation manifestating
as cyclical lower abdominal pain.

3. Types of dysmonorrhea
 Primary dysmonorrhea
 It is defined as pain during menses in the absence of co
existentent pathology.
 Symptoms of primary dysmonorrhea begin few hours
before the start of menses and relived during the few days
of menses.
 Onset is usually shortly after menarche,when ovulatory
cycles are established.
 Secondary dysmonorrhea
It is caused by underlying pathology such as
endometriosis,adenomyosis,PID,IUD and polyp.

4. EPIDEMIOLOGY
 The reported prevalance is age related as
40% in girls aged 12 yrs
70% in girls aged 17yrs
decreases with advancing age.
 Ranges from 60-93% in adolosence group
 5-20% with severe dysmonorrhea

5. Pathophysiology
 Primary dysmonorrhea
 The most important physiological event reported with
dysmonorrhea is increased myometrial contractility with
accompanying uterine ischemia which stimulate the type C
afferent pain neurons.
 During mensturation when there is withdrawl of progesterone,
shedding of endometrium occurs and during its destruction
release of inflamatory cytokines most commonl]y PGF2alpha
which is myometrial stimulant and vasoconstrictor leading to
pain.
 The utrine contractions due to leukotrienes causing ischemia
due to reduced blood supply result in uterine pain.

8.  Secondary dysmonorrhea
it is cused by underlying pelvic pathology such as
Gynaecological disorders
 Endometriosis
 Adenomyosis
 PID
 Endometrial polyp
 Submucous fibroid
 IUDs
 Ovarian cyst
 Ashermans syndrome
 Pelvic congestive syndrome
 Cervical stenosis

9.  Non-gynaecological disorders
Inflammatory bowel disease
Irritable bowel syndrome
Urogenital disease
Psychological diosorders

10. Charactericstics
 Primary dysmonorrhea
 Age of onset is 16-25yrs
 Spasmodic pain start just prior or with the onset of
mensturation lasting 1 to 2 days
 Occurs due to excess production of prostaglandins,
vasopressin and leukotrienes
 It usually respond to COCPs and NSAIDs
 Periods remain normal in flow
 Associated symptoms including Malaise and fatigue
85%,irritability 72%,dizziness 28%,headache 45%,lower
backache 60%,diarrhea 60%,nausea,vomiting 89%
 Signs are unremarkable

11.  Secondary dysmonorrhea
Age of onset is 30-45 yrs
Congestive Pain often progress throughout the late
luteal phase and peaking with the onset of menses.
Occur due to underlying pathology and coincide with
other gynaecological symptoms.
Usually resistant to OCPs and NSAIDs
Signs depend upon the cause but usually include
tender,enlarged,fixed retroverted uterus with adenexal
tenderness or a mass.

12. Evaluation and diagnosis
 History
 Examination
 Investigations including
CBC,ESR,C-Reactive protein
Microscopy and culture of vaginal swabs
TVS
Hysteroscopy
Laproscopy

13. Management

14.  Treatment of primary dysmonorrhea is tackling the
etiology with cyclooxygenase inhibitors and
inhibiting the ovulation.
 Treatment of secondary dysmonorrhea targets the
cause.
 The treatment strategy is based on grading the
dysmonorrhea according to severity of pain and
limitation of daily activities.

15. Evidence based treatment options
for dysmonorrhea
 Grade A NSAIDs(other than aspirin)
 Grade B&C Aspirin,Paracetamol and compound analgesics
Magnesium,Thiamine,Vit B1,B6,E,Fish oil,
High frequency TENS,Topical heat(39c)
Exercise,Japanese & chinese herbal medicines
 Unknown Mirena,Surgical interruption of pelvic nerve
pathway,Acupuncture, Behavioural interventions
Magnet therapy,Vasopressin antagonists
Low frequency TENS
 No benefit Spinal manipulation

16. Medical treatment

17. Tretment of primary dysmonorrhea
1-NSAIDs 1st line- 80% effective
Propionic acid derivatives including
Ibuprofen and Naproxen
Fenamates including mefanamic acid
2-Oral Contraceptives – 90% effective
if NSAIDs are not effective or contraindicated
3-Follow up
some patients may require combining both drugs
Consider secondary dysmonorrhea if no improvement
with therapy

18. Mechanism of action
1-NSAIDs
 inhibits prostaglandins production
 Antagonistic action at the receptor by inhibiting the
cyclooxygenase
2- Oral Contraceptives
 Decrease endometrial thickness
 Decrease prostaglandins through inhibition of
ovulation& change the hormonal status to that of early
proliferative phase(which has the lower level of PGs)

19. NSAIDs

20. Side effects of dysmonorrhea
 Gastric irritation
 Nausea
 GIT ulceration
 Increase bleeding time
 Nephrotoxicity
 Fenamates cause blurring of vision,headach and dizziness
 Bronchospasm in patients with bronchial asthma
 Hypersensitivity reactions
 Autoimmune hemolytic anemia

21.  Recommended doses of NSAIDs
 Naproxen (250-275mg) 4 to 8 hourly
 ibuprofen 400mg 3,4 or 6 times daily
 Diclofenac 200mg/day in divided doses
 Mefanamic acid 250mg 8 hourly
 Nimesulide 50-100mg twice daily
 Meloxicam 7.5-15mg daily

22. Other hormonal therapies
 Progestrone (depomedroxyprogestrone acetate and
levonorgestrol)
 Danazol
 GnRH Analogues
 About 20% of women who fail to respond PG
synthetase inhibitors or COCPs ,have secondary
dysmonorrhea

23. Surgical treatment
 There is insufficient evidence to support the routine
use of surgical treatment but procedures such as
laproscopic uterine nerve ablation and presacral
neurectomy performed in refractory cases of
dysmonorrhea.
 LUNA(laproscopically uterosacral nerve ablation )
 Presacral neurectomy block presacral nerve plexus

24. Treatment of secondary
dysmonorrhea
 Treat the cause
Cervical stenosis-
 Congenital
 Secondary to cervical injury such as
electocutery,cryocautery,conization, infection
• Pt presented with scanty menstural flow and severe
cramping throughout the menstural cycle
 Diagnosis – internal os scarred & impossible to pass uterine
sound
 Treatment –D&C

25.  Endometriosis – ectopic endometrial tissues
 Adenomyosis – endometrial tissue in the myometrium
 History – severe dysmonorrhea, infertility, dyspreunia
 Pelvic examination- uterine tenderness, cervical
excitation, adenexal fullness
 Diagnosis- laroscopy or laprotomy
 Direct biopsy of vagina or cervix lesions
 Treatment – medical Rx
 Cauterization of endometiotic spots
 Surgical removal of endometriotic cysts

26. Pelvic infections and adhesions
 PID & Pelvic abscess- adhesions- pelvic pain
 History of acute episodes of pain begins with menses and
continues
 Pain may involve the entire abdomen
 On examination- severe tenderness on palpation of uterus
and cx motion(cx excitation), purulent cx discharge
 Associted findings – fever and raise WBCs count & ESR
 Pain due to congestion,edema and adhesions occur due to
inflammatory response
 treatment - appropiate antibiotics
 Surgical- release of adhesions, TAH&BSO

27. PELVIC CONGESTION SYNDROME
 Engorgement of pelvic vasculature
 Pain- burning or throbbiong, worst at night, and after
standing for long time
 On examination-vasocongestion of vagina &
cervix,uterine tenderness and increase size
 Diagnosis by laproscopy- congestion of uterus
Varicosities of broad ligament and pelvic side wall
veins
 Treatment – medroxyprogesterone acetate
TAH&BSO

28. Conservative treatment
 Herbal products and dietry supplements
 Magnesium
 Pyridoxine
 Omega-3 fatty acid
 Vitamine B1/Thiamine(100mg daily for 2 months-87%
cure rate in a study)
 Vitamin E- 500 units/day or 200 units twice/day
 Japenese herbal medicines

29. Alternative remedies
 Exercise
 Topical heat treatment – 40c for 8 hours
 Transcutaneous electric nerve stimulation (TENS)-
altering the body ability to receive or perceive pain signals
 It has 2 effects
1- raise the threshold for pain signals, lower the perception of
painful uterine signals
2-it stimulates the release of endorphins from peripheral
nerve and spinal cord.
Behavioural intrventions including hypnotherapy, imagery
, coping strategies, modification of her response to pain (
biofeedback, electromyographic training, relaxation traing)

31.  Acupuncture
 Spinal manipulation – improves spinal mobility and
pelvic blood flow.
 Other non hormonal therapies including
 Alverine citrate – anticholinergic, antispasmodic
 Transdermal glyceryl trinitrate- modulator of uterine
contractiliy
 Beta 2 adrenoreceptor antagonists limited due to side
effects

32. Take home message
 Dysmonorrhea effects 40-70% women of reproductive
age.
 Proper history and examination is necessary for
diagnosis
 NSAIDs are the first line therapy for primary
dysmonorrhea
 20% of patients not respond to NSAIDs and COCPs
have secondayr dysmonorrhea
 For secondary dysmonorrhea treat the cause