Dysmenorrhoea In Adult Women

Dysmenorrhoea in Adult Women Dys: difficult/painful/abnormal Meno: month Rrhoea: flow By Vanessa Ting Ching Ching

The Menstrual Cycle

Primary Dysmenorrhoea • ‘Spasmodic’: menstrual pain in the absence of pelvic disease • Starts in the first few years after menarche • Risk factors: ▫ ▫ ▫ ▫ ▫ ▫

Earlier age at menarche (<12 years) Nulliparity Heavy or prolonged menstrual flow Smoking Positive family history Obesity & alcohol consumption

Pathophysiology

• Destruction of endometrial cells release prostaglandins ▫ PGE2 & PGF2α - potent myometrial stimulants and vasoconstrictors ▫ increases intrauterine pressure, vessel constriction and decreases uterine blood flow ▫ Results in tissue ischemia, endometrial disintegration, bleeding and pain

• Other mediators are also thought to be involved ▫ Leukotrienes, vasopressin, type C neurons

Secondary Dysmenorrhoea • ‘Congestive’: menstrual pain resulting from underlying disease, disorder or structural abnormality either within or outside the uterus ▫ ▫ ▫ ▫ ▫ ▫ ▫

Endometriosis Adenomyosis Pelvic inflammatory disease Ovarian cysts and tumours Fibroids and uterine polyps Intrauterine adhesions Intrauterine contraceptive device

• Commonly affects women in 20’s or 30’s

Symptoms Primary

Secondary

• Onset within 6-12 months after menarche • Lower abdominal/pelvic pain (begins with onset of menses and lasts 8-72 hours) • Low back pain • Medial/anterior thigh pain • Headache • Diarrhoea • Nausea/vomiting

• Onset in 20s or 30s (previously painless menstrual cycles) • Infertility • Heavy menstrual flow or irregular bleeding • Dyspareunia • Vaginal discharge • Lower abdominal or pelvic pain during times other than menses • Pain unrelieved by NSAIDS

Diagnosis • Medical history • Laboratory tests ▫ WBC, UFEME, ESR, cervical swab, HCG level

• Ultrasound

▫ Abdominal, transvaginal, pelvic

• Invasive studies

▫ Laparascopy, hysteroscopy, dilatation & curretage

• Differential diagnosis

▫ Abortion, ectopic pregnancy, UTI, PID, IBS, peritonitis, uterine neoplasm

NSAIDS • Best-established first line treatment ▫ Inhibits prostaglandin synthesis & decreases intrauterine pressure & menstrual blood flow

• Traditional NSAIDS are more effective than paracetamol ▫ Diclofenac, naproxen, mefenamic acid & ibuprofen

• Small studies show that selective COX-2 inhibitors are not superior to traditional NSAIDS for pain relief

28-day Menstrual Cycle

Oral Contraception • Off-label treatment of dysmenorrhoea ▫ Reduces secretion of LH and FSH from pituitary & therefore prevents ovulation & prostaglandin production ▫ May also reduce the number of menstrual cycles  Long-term use of active pills and avoiding the pillfree week or with extended-cycle formulations (eg: 12 weeks active hormones & 1 week placebo)

Other Hormonal Methods • Depo-medroxyprogesterone acetate (Depo-Provera) ▫ Inhibits secretion of gonadotropins, thereby inhibiting ovulation and decreasing thickness of endometrium

• Levonorgesterol intrauterine device (Mirena) ▫ Similar to Depo-Provera

• Intravaginal administration of OCs ▫ 30 mcg of ethinyl estradiol and 150 mg of levonorgestrel daily ▫ Less systemic side effects

Other Pharmacologic Methods • Hyoscine ▫ Blocks Ach & therefore decreases motility in GI & urogenitary areas, leading to less spasms

• Transdermal glyceryl trinitrate ▫ Nitric oxide reduces uterine contractions ▫ less effective than diclofenac ▫ associated with a high incidence of headache

• Danazol or leuprolide acetate ▫ Suppresses the menstrual cycle ▫ Indicated for treatment of endometriosis

• Oral nifedipine • Intravenous terbutaline

Surgery • Mostly for the treatment of secondary dysmenorrhoea ▫ Laparoscopic uterine nerve ablation (LUNA) destruction of a small segment of ligament that carries nerve fibres within the pelvis

▫ Hysterectomy (removal of the uterus) ▫ Ovary removal ▫ Presacral neurectomy

Diet & Lifestyle • Low fat vegetarian diet • Smoking cessation or reduction of passive smoking • Exercise ▫ Strenuous or aerobic exercise produce endorphins

• Heat application

▫ warm bath or heating pad /hot water bottle on the abdomen

• Sleep

▫ Lying in the supine position

• Sexual intercourse

▫ Orgasms produce endorphins

• Relaxation

▫ Meditation/yoga ▫ Abdominal/back massage

Supplements & Complementary Medicine • • • • • • • •

Fish oil supplements Vitamin E Vitamin B1 Magnesium & calcium Japanese herb toki-shakuyaku-san Ginger Acupuncture or acupressure transcutaneous electric nerve stimulation (TENS)

References • Dawood MY. Dysmenorrhea. J Reprod Med. Mar 1985;30(3):154-67 • Calis KA, Dang DK, Popat V, Kalantaridou SN. General Gynaecology: Dysmenorrhea. Emedicine. Last updated 28/01/2009 • French L. Dysmenorrhea. American Academy of Family Physicians. Last updated 15/01/2005 • Dawood MY, Khan-Dawood FS. Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2alpha in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea. Am J Obstet Gynecol. Jan 2007;196(1):35.e1-5 • Wilson ML, Murphy PA; Herbal and dietary therapies for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2001; (3):CD002124. • Proctor ML, Roberts H, Farquhar CM; Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea. Cochrane Database Syst Rev. 2001;(4):CD002120. • Samuels LA. Pharmacotherapy Update: Hyoscine Butylbromide • in the Treatment of Abdominal Spasms. Clinical Medicine: Therapeutics 2009:1