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Dysmenorrhea and Premenstrual syndrome (PMS)
Dysmenorrhea refers to the symptom of painful menstruation . it can
be divided into 2 broad categories : primary (occurring in the absence of
pelvic pathology ) and secondary ( resulting from identifiable organic
diseases ) .
Secondary dysmenorrhea may be a symptom of
1- Endometriosis
2- Pelvic inflammatory diseases
3- Adenomyosis
4- Asherman syndrome
5- Cervical stenosis (rarely)
Clinical features of primary dysmenorrhea include the following
. onset shortly after menarche (< 6 months)
. usual duration of 45-72 hours ( often starting several hours
before or just after the menstrual flow )
. cramping or labor like pain .
. constant lower abdominal pain , radiate to the back and thigh .
. often unremarkable pelvic examination (including rectal
examination).
The followings may indicate secondary dysmenorrhea
. dysmenorrhea beginning in the 20s or 30s after previous
relatively painless cycle .
. heavy menstrual flow or irregular bleeding
. pelvic abnormality with physical examination .
. poor response to NSAIDs or oral contraceptive pill .
. infertility
. dyspareunia
. vaginal discharge .
Complete physical examination should be performed . pelvic
examination is crucial for excluding uterine irregularity ,
tenderness , nodularity
Diagnosis
No tests are specific to diagnose primary dysm. , the following
may be performed to identify organic cause of secondary dysm.
Endocervical swab and high vaginal swab , abd. or trans vag. U/S
, hystrosalpengography ,CT , MRI ,diagnostic laparoscopy ,
hysteroscopy and diagnostic D &C .
Management
Pharmacotherapy is the most reliable and effective treatment for
relieving dysm. , treatment of secondary dysm. Involve correction
of underlining organic cause .
NSAIDs such as Diclofenac , Ibuprofen , Mefenamic acid
Oral combined pills (OCP).
Levonorgestrel intrauterine device.
Depot medroxyprogesterone acetate .
In addition to lifestyle modification ,smoking cessation and
exercise .
Surgical treatment aimed at interruption the nerve pathway from
the uterus have been employed .
Premenstrual syndrome (PMS)
Premenstrual syndrome (PMS) is a recurrent luteal-phase
condition characterized by physical, psychological, and behavioral
changes of sufficient severity to result in deterioration of
interpersonal relationships and normal activity. Premenstrual
dysphoric disorder (PMDD) is considered a severe form of PMS.
PMDD is listed as a mental disorder.
Pathophysiology and Etiology
The definitive cause of PMS is unknown.Current research provides
some evidence supporting the following etiologies:
- Serotonin deficiency is postulated because patients who are
most affected by PMS have differences in serotonin levels; the
symptoms of PMS can respond to selective serotonin reuptake
inhibitors (SSRIs), which increase the amount of circulating
serotonin
- Magnesium and calcium deficiencies are postulated as
nutritional causes of PMS; studies evaluating supplementation
show improvement in physical and emotional symptoms
- Women with PMS often have an exaggerated response to
normal hormonal changes; although their levels of estrogen and
progesterone are similar to those of women without PMS, rapid
shifts in levels of these hormones promote pronounced
emotional and physical responses
- Other theories under investigation include increased endorphins,
alterations in the gamma-aminobutyric acid (GABA) system,
and hypoprolactinemia.
To establish the diagnosis, instruct patients to chart symptoms
daily for two cycles. This usually demonstrates symptoms
clustering around the luteal phase of ovulation, with resolution
when menses begins. Advise the patient to use a numeric scoring
system to specify severity (1 for mild, 2 for moderate, 3 for severe)
when recording symptoms. Ask the patient to bring her lists to the
next appointment. The categories of PMS symptoms may be
divided into five basic categories—A, C, D, H, and O—as follow
PMS-A (anxiety) symptoms include the following:
Difficulty sleeping
Tense feelings
Irritability
Clumsiness
Mood swings
PMS-C (craving) symptoms include the following:
Headache
Cravings for sweet foods
Cravings for salty foods
Cravings for other types of food
PMS-D (depression) symptoms include the following [19] :
Depression
Angry feelings for no reason
Feelings that are easily upset
Poor concentration or memory
Feelings of low self-worth
Violent feelings
PMS-H (hydration) symptoms include the following:
Weight gain
Abdominal bloating
Breast tenderness
Swelling of extremities
PMS-O (other) symptoms include the following:
Dysmenorrhea
Change in bowel habits
Frequent urination
Hot flashes or cold sweats
General aches or pains
Nausea
Acne
Allergic reactions
Upper respiratory tract infections
Physical Examination
Usually, no physical findings are specifically helpful in
establishing the diagnosis of PMS. If the adolescent presents
during the luteal phase, she may have mastalgia or edema of the
breasts or legs.
Treatments and drugs
For many women, lifestyle changes can help relieve PMS
symptoms. But depending on the severity of symptoms.
Antidepressants , Selective serotonin reuptake inhibitors (SSRIs)
— which include fluoxetine , paroxetine , sertralin and others —
have been successful in reducing mood symptoms. SSRIs are the
first line treatment for severe PMS or PMDD. These drugs are
generally taken daily. But for some women with PMS, use of
antidepressants may be limited to the two weeks before
menstruation begins.
Nonsteroidal anti-inflammatory drugs (NSAIDs). Taken before
or at the onset of your period, NSAIDs such as ibuprofen or
naproxen can ease cramping and breast discomfort .
Diuretics, Spironolactone (Aldactone) is a diuretic that can help
ease some of the symptoms of PMS.
Hormonal contraceptives, danazol and GnRH agonist stop
ovulation, which may bring relief from PMS symptoms.