Dysmenorrhoea, dyspareunia

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Dysmenorrhoea, dyspareunia PMS

• Dr hashmi hajrasi
• Consultant in OBS GYN
• MBBCh, DGO, MRCOG, DMAS

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Learning objectives

• By the end of the lecture the student is expected
  to
• understand the definition, possible causes of
  dysmenorrhoea, dyspareunia and impact on womens
  life
• Know how to investigate and come up with a
  diagnosis
• Treatment options and effectiveness

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• Have a basic knowledge on PMS in term of the
  common symptoms, possible theories behind its
  occurrence
• Know how to reach a diagnosis using symptom chart
  and exclusion
• Know the commonly suggested treatment options and
  their efficacy

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Dysmenorrhoea

• Defined as painful menstruation.
• Although some pain during period is normal,
  pain that is sever enough to limit normal
  activity or requires medication is abnormal and
  requires evaluation.
• Affects about 50 of menstruating women and
  regarded as sever in 10 of sufferers
• Dysmenorrhoea is the leading cause for absence
  from school or work

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classification

• Primary dysmenorrhoea occurs in otherwise
  healthy women with no organic cause
• Secondary dysmenorrhoea due to an underlying
  disease or structural uterine abnormality

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Primary dysmenorrhoea

• Onset a few years after menarche
• Cycles are regular
• Pain for less than 2 days
• Cramping pain radiating to the thighs
• Nausea and other GI symptoms
• relieved after childbirth
• Prostaglandins leukotrins play a major role

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Secodary dysmenorrhoea

• Causes
• endometriosis
• adenomyosis
• chronic pelvic inflammatory disease
• Pelvic congestion syndrome
• pelvic adhesions
• IUD
• fibroids

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Dysmenorrhoea evaluation

• History
• Physical examination
• Is pelvic examination needed?
• Recommended in all cases except if not sexually
  active with typical primary dysmenorrhoea

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Dysmenorrhoea

• Investigations needed ?
• Pelvic Ultrasound if
• clinical pelvic examination abnormal
• symptoms suggestive of secondary dysmenorrhoea
  but PV not conclusive or not possible
• Laparoscopy
• Sometimes needed

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Primary dysmenorrhoea ..Treatment

• Simple analgesics paracetamol, NSAID
• Hormonal therapy as a second line when simple
  analgesia fails. COCP are 90 effective

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Secondary dysmenorrhoea...treatment

• Treat the underlying cause
• NSAIDs
• Hormonal contraceptives
• Pre-sacral neurectomy in selected cases

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Dyspareunia

• Defined as pain during or after intercourse
• It is not a disease ,but rather a symptom of an
  underlying physical or psychological disorder
• Could be superficial at entrance of the vagina or
  deep in the pelvis on deep penetration

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Causes

• Superficial dyspareunia
• Vaginismus
• Vaginal infection
• Episiotomy scars narrowed vagina
• Insufficient vaginal lubrication
• Atrophic vagina due to menopause

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Vaginismus

• Recurrent or persistent involuntary spasm of
  the musculature of the outer third of the vagina
  that interferes with intercourse
• Etiological background
• lack of sex education/information
• negative attitudes about sexuality
• sexual abuse or trauma

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• Deep dyspareunia
• PID
• Endometriosis
• Ovarian cysts
• Ectopic pregnancy
• Pelvic congestion

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Dyspareunia .....management

• Aimed at identifying properly treating the
  underlying cause
• Adequate foreplay or k-y gel for vaginal dryness
• Topical oestrogen for atrophic vagina
• surgery may sometimes be required for vaginal
  prolapse or inadequate vagina

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Vaginismus .....treatment

• Insertion of a graduated set of dilators in the
  vagina
• psychotherapy

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Premenstrual syndrome
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Premenstrual Syndrome Modern Definition

• Distressing physical, psychological and
  behavioural symptoms, not caused by organic
  disease, which regularly recur during the same
  phase of the menstrual (ovarian) cycle and which
  significantly regress or disappear during the
  remainder of the cycle
• Magos Studd (1984)

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• Affects 30-40 of women of child bearing age but
  in 10 the symptoms are so sever and disabling
  (premenstrual Dysphoric dysorders (PMDD)
• Over 150 symptoms have been documented but the
  three most prominent are , irritability, tension
  dysphoria (unhappiness)

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aetiology

• Is poorly understood but a major role played by
• Cyclical ovarian activity
• Estradiol
• Progesterone
• Neurotransmitters serotonin GABA

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PMS vs PMDD

• PMDD may be viewed as a more severe form of PMS

Rapkin A. Psychoneuroendocrinology. 2003.
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Premenstrual Symptoms
Disorders
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Prevalence of Premenstrual Symptoms in Women (USA)
Percent Estimated (in millions)
Minor PM symptoms 70 90 43 55
PMS 20 40 12 25
PMDD 3 8 2 5
Ginsberg KA, et al. 2000.
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Signs and Symptoms of PMS/PMDD
Symptoms occur
Ovulation
Follicular Phase
Luteal Phase
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28
Days of Menstrual Cycle
more
Malone DC. Am J Manag Care. 2005 Dickerson LM et
al. Am Fam Physician. 2003.
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Signs and Symptoms of PMS/PMDD (continued)

• More than 150 symptoms associated with PMS

Malone DC. Am J Manag Care. 2005 Dickerson LM et
al. Am Fam Physician. 2003.
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Diagnosis of PMS/PMDD
Occur in luteal phase
Resolves near the start of menstruation
Creates problems or impairment
Not better explained by another diagnosis
Johnson SR. Obstet Gynecol. 2004 Rapkin AJ. Am J
Manag Care. 2005 ACOG. ACOG Practice Bulletin
No. 15. 2000 Dickerson LM et al. Am Fam
Physician. 2003.
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Menstrual Symptoms Chart for Diagnosis of PMS/PMDD

• List the symptoms you have in the left column.
  Circle the dates of your menstrual period. Fill
  in the boxes on the days your symptoms occur.
  Indicate severity by filling in the boxes as
  shown Mild, Moderate, Severe

Symptoms Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month Day of the month
Symptoms 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 27 29 30 31






Download from www.arhp.org/menstrualsymptomschart
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Multiple Visit Diagnostic Approach for PMS/PMDD
more
Kaur G, et al. Cleve Clin Med. 2004. Johnson SR.
Obstet Gynecol. 2004.
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Multiple Visit Diagnostic Approach for PMS/PMDD
(continued)
Kaur G, et al. Cleve Clin Med. 2004. Johnson SR.
Obstet Gynecol. 2004.
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PMS/PMDD Treatment Considerations
no single intervention is effective for all
women.
Dimmock PW et al Lancet 2000
Dimmock PW et al. Lancet. 2000. Steiner M. Am Fam
Physician. 2003.
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Treatment stratiges

• General advice about diet, exercise stress
  reduction should be considered before starting
  specific treatment
• Women with marked underlying psychopatology
  should see a psychiatrist
• Symptom diary should be used to assess the effect
  of treatment

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Treatment of PMS Dietary Changes
Johnson SR. Obstet Gynecol. 2004.
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Treatment of PMS Nutritional Supplementation
Medications
Vitamin B6, up to 100 mg per day
Vitamin E, up to 600 IU per day
Calcium carbonate with vitamin D
Magnesium, up to 500 mg per day
NSAIDS
limited benefit
Bhatia SC et al. Am Fam Physician.2002 Bowman
MA. 2000. Freeman EW, Sondheimer SJ. J Clin
Psychiatry. 2003 Endicott J et al. Patient Care.
1996 Johnson WG et al. Psychosom Med. 1995
Rapkin AJ. Am J Manag Care. 2005.
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Treatment of PMS Behavioral Changes

• Aerobic exercise/Yoga
• Relaxation and stress management
• Anger management
• Self-help support groups
• Therapy (individual, couples, cognitive-behavioral
  , )
• Smoking cessation
• Regular sleep

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pharmacological

• Selective serotonin re-uptake inhibitors (SSRI)
  ....e.g Fluoxetine significantly reduces tension,
  irritability dysphoria (4-6 times better )
• Progestogens
• COCP
• Diuretics
• Antidepressants
• danazole
• GnRH A

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surgical

• Hysterectomy BSO

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conclusion

• Dysmenorrhoea is not uncommon complaint. Detailed
  history gynae examination together with pelvic
  USS and sometimes laparoscopy enables diagnosis
  appropriate treatment
• Dyspareunia can be very distressing and a cause
  for broken sexual life. It may be confused with
  vaginismus though this is largely due to fear of
  pain .previous H/O sexual abuse or trauma must be
  sought but an organic must be excluded

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• PMS can be confused with so many other conditions
  and diagnosis sometimes by exclusion. PMS diary
  helps to establish diagnosis and assess severity
  of symptoms
• Treatment requires multidisciplinary team
  approach involving gynaecologist,
  psychotherapist, social worker, self-support
  groups and husband support
• Pharmacological agents help to alleviate symptoms
  but eventually oophorectomy may be required