Dysmenorrhea and PMS

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Dysmenorrhea and PMS

• Nazila Karamy-MD
• Obstetric and Gynecology Specialist
• www.doctorkaramy.ir

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Primary Dysmenorrhea

• Painful menstruation without underlying pathology
• Commonest in teens(13-19),early twenties
• Onset 1 or Max 2 years after menarche(cos of it
  occurs only in ovulation cycle tht it happens 1
  year after menarche)
• If it occurs 2 y after menarch almost always its
  not primary dysmenorhea

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Clinical characteristics

• painhappaens with mense onset
• it takes long Max 2-3 days
• The kindcolic or cramp
• Locationusually Midline in suprapubic,
• sth in back ,flunk,thigh
• Associated vomiting and faintness,loss of
  appetite,diarhea,headache
• Reduce with increasing age _at_after NVD

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Etiology (primary dysmenorhea)

• Decrease of progestrone in the end of luteal
  phase(near to next mense)gtlysosome rupture gt
  phospholipase A2 gt
• Increase PG E2,PF2_at_gtContraction of uterus
  ,vasoconstrictor

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Secondary Dysmenorrhea

• Painful menses secondary to pathology
• Onset gtalways after 20 y
• Pain may begin before bleeding and may last
  for entire duration
• Commoner 30s and 40s

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Secondary Dysmenorrhea

• Endometriosis
• Polyp(sourcegtendometer)
• Fibroidce (sourcegtmyometer)
• Pelvic Inflammatory Disease(PID)
• Uterine anomalies(Bicorn uterus,...)
• Ovarian cysts _at_tumors

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History Taking so according tht treat

• Timing
• Severity
• Disruption in life-style
• Previous gynae history
• Contraceptive needs
• Wish for fertility

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Examination

• Vaginal exam not essential in young female with ?
  Primary dysmenorrhea
• Vagina ?septum/ tenderness in BME
• Uterus? size / mobility/ position/tenderness
• Adnexa ?tenderness/ enlargement

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Investigations

• Transabdominal ultrasound with full bladder
• Transvaginal ultrasound increased sensitivity
• Laparoscopy gold standard for endometriosis
• Risks versus benefits
• _at_U CANT FIND ANY PATHOLOGY

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Management Primary Spasmodic Dysmenorrhea

• Education esp husband
• Nutritiondecrease taking sweet ,fatty
  ,alchohol,coffeine,choclate,salt,red meat
• Increase sea food,vegetable,fruit
• Exerciseaerobic(Min 30 minutes, 4times/weeks
• Calcium supplementgtdecrease mood disorders

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MEDICAL THERAPY

• Prostaglandin synthetase inhibitors(NSAIDS)gtMefen
  amic acid or Ibuprofen(Advil) taking regular from
  first day till 3 days(No need taking before
  mestural cycle)

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• Combined oral contraceptive pill-choose a
  progestagen dominant pill Such as Tricycle pill
• IN RESISTANT CASES
• Presacral neurectomy
• hystrectomy

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• In Failure to respond to Pillgtgt Regard
  secondary dysmenorhea
• increases likelihood of underlying
• pathology tht treatment is due to the
  patology

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PMS(Premenstrual Syndrome)

• Physiological premenstrual change
• About 95 of females experience one or more
  symptom

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Symptoms

• Physical bloating/breast tenderness/headache/flus
  hing
• Psychologicalagression/agitation/crying
  bouts/depression/irritability

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Etiology

• PMS exists only in ovulation cycle SO its not in
  menapause ,oophorectomy,non ovulatory cycles
• It happens in luteal phase not in follicular
  phase

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Etiology

• SO Endocrine changes gtdecrease
  endocrine,serotonin in PG metabolism, IN LUTEAL
  PHASE,change

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Treatment

• Control nutrition _at_exercise as dysmenorhea
• Psychologic treatment by relaxation or medical
  therapy if needed
• SSRI inhibitorsFloxetin( both continuous
  ,intermittant are effective)
• Nortriptilin in severe deppression)(25 mg /day
  through the cycle)
• Alprazolam in severe anxiety

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• Bromocriptin in breast congestion
• (2.5 mg from the Day 10 to 26 of the cycle)
• In severe breast congestion gtdanazole is OK
• Spirinolactone in severe weight gain ,edema
  ,abdomen bloating

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If no response to usual Treatment???

• Temporary or permanent abolition of ovulation by
• GnRH analogue plus Add back regimen
• OCP,High dose of progestrone (Depo provera 150 mg
  every 3 months)
• Hysterectomy and Oophorectomy if not response to
  other treatment _at_not want to be pregnant