Dysmenorrhea

Definition: cyclic pain related to menstruation up to provoke the female seeks medical advice.
Classification: *1ry (spasmodic) dysmenorrhea.
*2ry (congestive) dysmenorrhea.

Spasmodic dysmenorrhea

Definition: pain related to menstruation in the absence of organic pelvic lesion.
Incidence:
♦ Occurs in virgins and improves after childbirth (WHY?!!)
♦ It usually occurs with the onset of ovulatory cycles (2 – 3 years after puberty).

Aetiology:
A. Abnormal anatomy;
* Cervical obstruction: due to:
a) Cervical stenosis :
– Congenital pin hole os with elongated cervix.
– Acquired after amputation.
b) Acute anteflexion: cochleate uterus.
* Uterine anomalies:
a) Underdevelopment: hypoplasia (can’t expel the menstrual blood).
b) Maldevelopment: bicornuate and septate uterus.
c) Position: congenital RVF & acute AVF.
B. Abnormal physiology;
1) Prostaglandins theory (the most accepted) why?
a) PGf2α concentration is higher in females with spasmodic dysmenorrhea.
b) Progesterone stimulates PGs production, (anovulatory cycles are painless).
c) Presence of other PGs effects e.g. nausea and vomiting.
d) Anti-PGs relieve the problem.
2) Hormonal imbalance:
a) Progesterone in excess increase endometrial thickness and predispose for
contraction of the isthmus.
3) Myometrial ischemia: Ischemic pain similar to angina pectoris.
4) Clotting of menstrual blood: difficult to be expelled.
5) Reversed polarity: the isthmus contracts instead of relaxing during menses.
6) Abnormal sensory nerve endings with high sensitivity.
C. General factors;
♦ Physiological factors: more in females with positive family history.
♦ Low pain threshold: such women have low endorphins level.
Clinical picture: (pain)
•Onset: start at the 1st day of menses then ↓ gradually when the flow established.
•Site: lower abdomen.
•Radiation: inner aspects of the thighs.
•Character: colicky.
•Association: nausea + vomiting.
D.D.:
A. From congestive dysmenorrhea (see later).
B. From other types of spasmodic dysmenorrhea.
1) Membranous dysmenorrhea:
• Def.: rare variant of primary dysmenorrhea with big membranous cast shedding.
• C/P: pain: * very severe.
* Relieved during the 4th day of menses (after passage of the cast).
• Treatment:
I. Anti prostaglandins as spasmodic dysmenorrhea.
II. Repeated curettage: Remove the unhealthy endometrium and provoke growth
of new healthy endometrium.
III. Oral contraceptive pills.
2) Dysmenorrhea with: * passage of blood clots (menorrhagia). * IUD.
3) Unilateral dysmenorrhea:
I. Rudimentary horn.
II. Unilateral endometriosis.
III. Unilateral cornual fibroid.
Treatment:
A. General measures
1) Reassurance and psychic support.
2) Avoid sedentary life i.e. encourage physical exercise.
3) Improve general condition e.g. correct anemia.
B. Medical measures
* Hormonal: – Oral contraceptive pills, anovulatory cycles are painless.
* Non-hormonal:
Anti-PGs (the best):
Type 1:↓PGs synthesis only (moderately effective) e.g. acetyl salicylic acid.
Type 2:↓PGs synthesis and antagonize its effects on tissues (more effective).
e.g. mefenamic acid (ponstan).
Other drugs:
a) Anti-spasmodic. b) Anti-histaminic. c) Analgesic.
d) Calcium channel blockers: tried in resistant cases.
C. Surgical treatment
* Indications: only in resistant cases, so rarely needed.
* Procedures:
1) Cervical dilatation up to Hegar 14:
Idea: cutting of paracervical sympathetic fibers which transmit pain.
Disadvantages:
a) Used only in married nullipara.
b) Recurrence of pain after 6-9 months (regeneration of nerve fibers).
c) Habitual abortion due to incompetent isthmus.
2) Pre-sacral neurectomy (Cott’s operation):
Idea: removal of pre-sacral plexus (the sensory nerve supply of the uterus).
3) LUNA (Laser Uterine Nerve Ablation):
Laparoscopic division of uterosacral ligament containing uterine nerve supply. ￠￠￠￠

Congestive dysmenorrhea

Definition: pain related to menstruation due to local pelvic lesion.
Incidence: common in multipara after many years of relatively painless cycles.
Aetiology:
1) Inflammatory: *chronic cervicitis.
* Chronic endometritis.
*Chronic salpingitis.
2) Tumor: fibroid.
3) Simple congestion: * sedentary life.
* Coitus interruptus.
* Chronic constipation.
4) Displacement: * Genital prolapse. * RVF. * IUD.
5) Miscellaneous: *endometriosis. *varicose veins in broad ligament.
Clinical picture: (pain):
Onset: – start 3-5 days before menses,
– Then ↑ gradually then relieved by the onset of menstrual flow
Except in crescendo dysmenorrhea of endometriosis which ↑ sharply
with the onset of menses due to distension of ectopic endometrium by blood
then ↓ gradually after the end of menses due to absorption of blood.
Site: lower abdomen.
Radiation: to the back.
Character: dull aching pain.
Association: menorrhagia and leucorrhea.
D.D.:
1) From spasmodic dysmenorrhea.
2) From ovarian dysmenorrhea:
• Def.: rare type of congestive dysmenorrhea due to ovarian congestion.
• C/P: premenstrual dull aching pain which can be reproduced by pressure on ovaries
during bimanual examination.
• Treatment: 1) as congestive dysmenorrhea.
2) Ovarian sympathectomy is done in severe and resistant cases.
Treatment:
1. Treatment of the cause.
2. Glycerin icthyol pessaries : have hydroscopic and soothing properties.

Ovulatory pain (Mittleschmerz pain)

Def.: midcyclic pain in one iliac fossa at time of ovulation lasting few hours.
Causes:
a. Pre-ovulatory: ↑tension inside ovary (thickened tunica albuginea).
b. Ovulatory: irritation of the peritoneum by fluid of ruptured follicle.
c. Post-ovulatory: active contraction of the tube caused by PGs.

Dysmenorrhea Videos:

Dysmenorrhea – Painful Menstruation Relief

Obstetrics and Gynecology – Dysmenorrhea: By Paul Davies M.D.

Dysmenorrhea is the medical term for painful cramping associated with menstruation. It is classified as “primary” if not associated with pelvic pathology, or “secondary” if associated with pelvic disease. Primary dysmenorrhea can be attributed to endogenous prostaglandins and most commonly presents in younger women. There are no abnormal physical exam findings, laboratory values, or imaging studies. It is effectively treated with NSAIDs. Secondary dysmenorrhea is usually due one of these three pelvic diseases:

Endometriosis, which is the growth of endometrial tissue outside of the uterine cavity. Depending on its location it can be associated with such things as dyspareunia, bowel or bladder symptoms or infertility.Pelvic exam findings might reveal nodularity of the uterosacral ligaments or enlarged ovaries suggestive of endometriomas (ovarian endometriosis). Definitive diagnosis is made via laparoscopy at which time endometrial implants are visualized or biopsied. Treatment can include surgical resection, NSAIDs or hormonal therapy.

Dysmenorrhea – CRASH! Medical Review Series

Dysmenorrhea power point presentations:

Dysmenorrhoea by Presented by: Dr. Rozhan Yassin khalil FICOG,CABOG,HDOG,MBChB

DYSMENORRHOEA Aboubakr Elnashar Benha university, Egypt ABOUBAKR ELNASHAR

Types 1°: pain has no obvious organic cause. 2ndry: an underlying condition. Pain highly subjective and varies greatly between women. However, if a woman describes her periods as unacceptably painful, then they are!