Dysmenorrhea

1. SHERHAIFA S. ALIH

2. Acute Pelvic Pain Chronic Pelvic Pain
• Rapid, short course, sudden onset More than 6 months
• intense Severe - functional disability or
necessitating medical care
Assoc with autonomic reflex
responses (nausea, emesis,
diaphoresis, and apprehension
Not associated
affiliated with signs of inflame or
infx (fever and leukocytosis)
Absent
Etiology: mediators of infl present in
high conc as a result of infection,
ischemia and chemical irritation
Etiology: changes in modulation or
“up-regulation” of normally
nonpainful stimuli
-cause tissue damage
-genetic predispo, adverse envt
pressure

7. • date and character of the previous and last menstrual period
• presence of abnormal bleeding or discharge
• menstrual, sexual, contraceptive, gynecologic hx, STD hx,
• How and when pain started, pregnancy related symptoms, GI
symptoms, urinary symptoms, signs if infection, symptoms
attributable to a hemoperitoneum.

8. 1. Ectopic pregnancy
2. Leaking or rupture of an ovarian cyst
3. Adnexal torsion
4. Acute salphingo-oophoritis and pelvic inflammatory disease
5. Tubo-ovarian abscess
6. Uterine leiomyomas
7. Endometriosis-related acute pain

9. -implantation of the fetus in a site other than the uterine cavity.
-Implantation of the fetus in fallopian tube produces pain with
acute dilation of the tube. If tubal rupture occurs, localized abd
pain tends to be temporarily relieved and is replaced by
generalized pelvic and abdominal pain and dizziness with
development of hemoperitoneum
-triad: amenorrhea, followed by irregular bleeding and acute onset
of pain
Signs:
VS reveals orthostatic changes in the case of ruptured ectopic:

10. Functional cysts are the most common ovarian cysts, more likely to
rupture than benign or malignant neoplasms.
Mittelschmerz- pain assoc with rupture of the ovarian follicle at the
time of ovulation
Midcycle pelvic pain is caused by the amount of blood leaking into the
peritoneal cavity and high concentration of follicular fluid
prostaglandins
Signs:
Abdominal tenderness, assoc with localized or generalized lower
quadrant rebound tenderness because of peritoneal irritation
Abdomen can be moderately distended with decreased bowel sound

11. Diagnosis:
Blood test and transvaginal ultrasound
Culdocentesis reveal the nature of intraperitoneal fluid
helpful in determining the cause of peritonitis
Fresh blood: corpus luteum
Chocolate “old blood”: endometrioma
Oily sebaceous fluid: benign teratoma’
Purulent fluid: Pelvic inflammatory disease or tubo-ovarian
abscess
Mgt:
Surgical laparotomy or laparoscopy

12. Torsion (twisting) of the vascular pedicle of an ovary, ovary with cyst, fallopian
tube, paratubal cyst, or rarely pedunculated uterine myoma results in
ischemia of the structure distal to the twisted pedicle and acute onset of pain
-benign cystic teratoma most common
83% occurred in ovaries that were 5 cm or ;larger
Symptoms:
Pain is Severe and constant
If partial and intermit, pain can wax and wane
Onset of torsion and abd pain coincides with activity (exercise, lifting,
intercourse
Presence of autonomic reflex response (nausea, emesis, tachycardia)

13. • Mild temp elevation, tachycardia, leukocytosis may accompany necrosis of
the tissue
• Localized direct and rebound tenderness in the lower quadrants
• Presence of large pelvic mass on bimanual exam
Management:
• Surgical
SIGNS:

14. All cases of PID are microbial
PID initiated by Neisseria gonococcus or chlamydia is manifested by the acute
onset of pelvic pain that increases with movement, fever, purulent vaginal
discharge, nausea and emesis.
Signs:
-elevated temperature, tachycardia, abdominal distention and decreased bowel
sounds
Direct and rebound abdominal tenderness
Cervical motion tenderness and bilateral adnexal tenderness: Acute salpingo-
oophoritis
Lack of a discrete mass or masses

15. Complication of acute salpingo-oophoritis, usually unilateral and multilocular.
Signs:
-fever, tachycardia and low blood pressure if the patient is septic
-palpated on bimanual exam as firm, exquisitely tender, bilateral fixed masses.
Diagnosis:
UTZ – diagnostic imaging of choice
CT with or without contrast
Management:
Drainage along with intravenous antibiotics is considered first line

16. • Leiomyomas (fibroids), are uterine smooth muscle tumors
• Discomfort is noncyclic pressure or pain symptoms.
• Acute Pelvic pain is rare but can develop if the myoma undergoes degeneration
or torsion.
Signs:
VS usually normal
With degeneration - Low grade fever and mild tachy can be present
abdominal tenderness in palpation and mild localized rebound tenderness
Irregular solid mass from the uterus- UTZ

17. Acute pain is usually premenstrual and menstrual; if nonmenstrual acute
generalized pain occurs, a ruptured endometrioma (chocolate endometriotic
cyst within the ovary) should be considered.
Diagnosis:
Bimanual and rectovaginal exam reveal a fixed, retroverted uterus with
tender nodules in the uterosacral region or thickening of cul-de-sac
Definitive dx is made by laparoscopy or laparotomy.

18. Appendicitis Acute Diverticulitis
Symptoms: Diffuse abdominal pain,
periumbilical pain followed by
anorexia, n/v
Pain shifts to right lower quadrant
Fever, chills, obstipation
Severe, LLQ pain
Less likely to lead to perforation
and peritonitis
(+)Fever, chills and constipation
Anorexia and vomiting are
uncommon
Signs: Low grade fever to normal temp
RLQ tenderness (McBurney point)
Severe gen muscle guarding,
abdominal rigidity, rebound
tenderness,right sided mass,
tenderness on rectal exam, (+)psoas
sign (+)obturator sign
Hypoactive bowel sounds
Distended abdomen
LLQ tenderness and localized
rebound tenderness
(+)poorly mobile doughy
inflammatory mass in the LLQ

19. Diagnosis Normal WBC to left
shift
Abnormal appendix on
UTZ or CT with
contrast
Ct with or without
contrast: swollen
edematous bowel
Barium enema is
contraindicated
Management IVF
Strict restriction of any
oral intake and
preoperative antibiotics
Surgery
IVF
Strict restriction of oral
intake
Broad spectrum
antibiotics

20. Intestinal obstruction
Causes Postsurgical adhesions,hernia formation, inflammatory bowel
disease, carcinoma of the bowel or ovary
Symptoms Colicky abdominal pain abdominal distention, vomiting,
constipation, and obstipation
Signs Fever late stages
Onset of mechanical obstruction: high pitched and maximal
Obstruction progresses: bowel sounds decrease
Absent BS: ischemic bowel
Diagnosis
and Mgt
Upright Abd xray: gas pattern, distended loops of bowel and air
fluid levels
Complete obstruction: Surgical
Partial: IVFm bowel rest, nasogastric suction

21. Ureteral colic due to ureteral lithiasis
Cystitis and pyelonephritis
Pain is severe and crampy, it can radiate from the costovertebral angle to the
groin
(+) Hematuria
Cystitis Pyelonephritis
Dull suprapubic pain, urinary
frequency, urgency, dysuria,
occasionally hematuria
Flank, costovertebral angle pain
although lateralizing lower
abdominal pain occasionally is
present

23. How is it controlled?

26. Primary Secondary
Menstrual pain without pelvic
pathology
Painful menses with underlying
pathology
Appears within 1 to 2 yrs after
menarche
Younger women, but may persists int
40s
Appears years after menarche
Occur with anovulatory cycle
Etiology: excessive or imbalanced
amount of prostanoids secreted into the
endometrium during menstruation
Prostanoid increased uterine
contractions w/ dysrhythmic pattern, in
basal tone and inc active pressure
Uterine hypercontractility, dec uterine
bld flow and inc nerve hypersensitivity
= pain

29. Pain begins a few hours before or just after the onset of a menstrual period
and last 48 to 72 hours.
-similar to labor w/ suprapubic cramping, maybe accompanied by
lumbosacral backache,pain radiating down to the anterior thigh, n/v,
diarrhea, and rarely syncopal episodes.
-colicky in nature
-relieved by abdominal massage, counter pressure, or movt of the body
Signs:
-suprapubic region may be tender to palpation
-Bimanual examination at the time of the dysmenorrheic episode often
reveals uterine tenderness
-severe pain does not occur w/ movt of the cervix or palpation of the adnexal
structures.

30. -rule out first underlying pelvic pathology and confirm the cylic natire of the
pain
-CBC and ESR to rule out endometritis and subacute PID
-Pelvic UTZ if symptoms do not resolve with NSAIDs
Management:
• NSAIDs or Prostaglandin synthase inhibitors
-taken upto 1-3 days before menses or if irregular at the first onset of even minimal pain or
bleeding
• Hormonal Contraceptives (combines estrogen and progestin)
-progesterone only oral contraceptives, transdermal patch, vaginal ring, injectable progestin
preparation or levonorgestrel-releasing IUD

31. -heat
-acupuncture
-transcutaneous electrical nerve stimulation

32. -pain begins 1-2 weeks before menstrual flow and persists until a few days
after the cessation of bleeding.
Causes: Endometriosis, adenomyosis and non hormonal IUD

33. -presence of endometriomal stroma and glands within the myometrium, at
least one low-power field from the basis of the endometrium.
Risk Factors:
-increasing parity, early menarche, shorter menstrual cycles
Symptoms: (begin upto 2 weeks before the onset of menstrual flow anf may
not resolve until after cessation of menses)
Excessively heavy or prolonged menstrual bleeding
Dyspareunia
Dysmenorrhea
-

34. Enlarged uterus, soft and tender
Mobility of the uterus is not restricted, No associated adnexal pathology
DIAGNOSIS
Clinical diagnosis
The pathologic confirmation of suspected adenomyosis can be made only at the time of
hysterectomy
Management:
Depends on patient’s age and desire for future fertility

35. Endometrial glands and stroma are found outside the uterine cavity
Symptoms:
Severe dysmenorrhea, cyclic pelvic pain that starts upto 2 weeks prior to
menses
Pain can be sharp or pressurelike, localized to midline or involving the lower
abdomen, back and rectum
Dyspareunia, subfertility, irregular bleeding
Signs:
Bimanual and rectovaginal exam reveal uterosacral nodularity and focal
tenderness

36. Homogenous hemorrhagic appearing cysts that fail to resolve after one to two
menstrual cycles are suspicious
Definitive diagnosis: direct operative visualization either laparoscopically or
laparotomy
Early disease: Active red flame or colorless vesicles or petechial lesions
Long standing lesion: powder-burn, fibrotic lesion

37. First line: Trial of NSAIDs with or without combined estrogen-progestin
formulations.
Second line: High dose progestins or gonadotropin-releasing hormone (GnRH)
analogues
Management: SURGICAL
Laparoscopy and laparotomy (if unresponsive to hormonal treartment)
Hysterectomy with bilateral salpingo-oophorectomy and removal of endometriosis lesion- for
women who no longer desire fertility

38. Pain that persists in the same location for greater than 6 months’ duration
causing functional disability or requiring treatment
Differential Diagnosis
1. Gynecological
2. Genitourinary
3. Neurologic
4. Musculoskeletal
5. Gastrointestinal
6. Systemic

41. Multidisciplinary Approach
-therapeutic, optimistic, supportive, and sympathetic
The patient should be instructed to complete a daily pain
ratings from after her first visit.