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L4 Dysmenorrhea D. Wsn

Definition is painful menstruation

Classification: 1. P rimary dysmenorrhea

2. Secondary dysmenorrhea

Epidemiology

 The age and parity are inversely related to the incidence of dysmenorrhea
 Family history
 Stress increase incidence
 Smoking . low body mass index
 Early menarche . heavy menstrual loss
 Exercise and high intake of fruit and v egetables reduce incidence
 Psychological morbidity . sexual abuse

Causes

Primary dysmenorrhea

 Uterine myometrium hyperactivity
 Excess prostaglandin production during menstruation –increase myometrium
contraction –reduction uterine blood flow –increase ischemia and pain
 Physiological
 Ovulatory cycle is essential for development

Secondary dysmenorrhea

Underlying pathological causes
Causes gynecological
 . Endometriosis . adenomyosis. Uterine fibroid
 . Cervical stenosis and other obstructive causes
 . Pelvic venous congestion
 . Residual \trapped ovary syndrome
o . Pelvic adhesion . Pe lvic inflammatory disease

Gastrointestinal: irritable bowel syndrome

Chronic constipation

Urinary tract: bladder pain syndrome (interstitial cystitis)

Musculoskeletal: pelvic floor myalg ia
Myofascial pain
Neurology: nerve entrapment

2

Symptoms and sign

Primary spasmodic dysmenorrhea:

 Is colicky cramping suprapubic pain that may radiate to the back and thigh

 Associated with gastrointestinal and systemic symptoms
 Is usually begin few hours before or within the onset of menstruation
 Continue for 8 to 72 hour
 Typically , in young female
 Onset within 6 - 12 months after menarche
 Cause significant morbidity and negative pelvic pathology

Secondary dysmenorrhea

 Pain associated with identifiable pelvic pathology
 is more sever before menstruation
 Exacerbated by menstruation and continue throughout the cycle
 Usually associated with deep dyspareunia
 Usually more common in older woman

Investigation

Investigation of primary dysmenorrhea is unnecessary unless there are atypical symptoms or
abnormal finding on pelvic examination

 Ultrasound : endometr iomata, PID sequelae, fibroid, congenital abnormalities

 STI screan including chlamydia swab
 Laparoscopy is usually reserved for woman with ultrasound abnormalities, medical
treatment failure or those with concomitant subfertility
 hystrosalpingog ram useful to identify intrauterine adhesion
 MRI

T reatment

In the majority nothing more than general advice, reassurance and empirical relief of pain
The girl should realize that her complaint is likely to be short lived

NSAIDs: produce moderate or excellent pain relief

More effective than paracetamol
Selection according to cost and patient preference ( naproxen, mefenamic acid,
diclofenac …)
Limited by its side effect
May be used in combination with another drug like codeine and paracetamol
Calcium channel blocker
Oral contraception
For inhibition of ovulation
LNG -IUS
Effective for pain and as contraception

GnRH analogues

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Act through induce hypo estrogen state

Limited use
Relive the symptom if waiting for hysterectomy or as a form of assessment as to the benefits
of hysterectomy

Heat: effective as NSIAD in relieving pain

Life style changes
.low fat, vegetable diet may improve the symptoms
.ex ercise may improve symptoms by improving blood flow to the pelvis
Vitamin B1 and magnesium

Treatment of underlying pathology in case of secondary dysmenorrhea

Therapeutic laparoscopy :diagnosis and management of endometriosis adhesion and PID
.hysterectomy is now rare
. laproscopic uterine nerve ablation is not currently recommended
.injection of pelvic plexus with anesthetic agent
.dilation of the cervix

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Self -assessment

Q1: how can you clinically differentiate between p rimary and secondary dysmenorrhea

Q2 : what types of birth control methods help control dysmenorrhea?

Q3: what is the surgery done to treat dysmenorrhea?

Q4: what alternative treatment help ease dysmenorrhea ( non -medical )

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رفعت المحاضرة من قبل: Mubark Wilkins
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