بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم Module 6 - ppt 5 Dr. Maysoon Al-Amoud

2. Dysmenorrhea Introduction to Primary Care a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

3. Objectives • General considerations. • Classification of dysmenorrhea • Causes of dysmenorrhea • Clinical picture of dysmenorrhea • Management of dysmenorrhea Module 6 - ppt 5 Dr. Maysoon Al-Amoud

4. Introduction • Dysmenorrhoea - painful menstruation- is one of the most common gynaecologic problems seen by the family physician. • It affects 50% of all women and between 20% & 90% of all adolescent women. • ~ 1% of all adult & 15% of adolescent women describe their dysmenorrhoea as severe. • It is the leading cause of morbidity in female high school students, resulting in absence from school and nonparticipation in sports. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

5. Classification Primary : The presence of painful menses in the absence of disease Secondary : The occurrence of painful menstruation caused by pelvic disease. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

6. Risk factors of dysmenorrhea • Age < 20 years • Attempts to lose weight • Depression/Anxiety • Heavy menses • Nulliparity • Smoking • Disruption of social network

7. Causes of dysmenorrhoea Primary dysmenorrhea • No underlying pelvic pathology. • Caused by release of prostaglandin F2from tendometrium at time of ovulatory menstruation •  uterine hypercontactility . • Ischemia of uterine wall during a contraction causes pain. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

8. Causes of dysmenorrhoea Primary dysmenorrhea ... continue • Prostaglandins induce smooth muscle contraction in the uterus, as well as in intestine, bronchi, & vasculature, • Account for the systemic symptoms of diarrhea, asthma exacerbation, hypertension, & headache experienced by women with 1o dysmenorrhea. • As contractions cause the pressure within uterus to exceed that of the systemic circulation, ischemia ensues, causing an anginal epuivalent in uterus. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

9. Causes of dysmenorrhoea Secondary dysmenorrhea • Underlying pelvic pathology with variable severity : • Adenomyosis, myomas, polyps, • Infections – chronic pelvic, endometriosis, • Tumors, dhesions, leiomyomas, • Intrauterine devices, • Anatomic causes, • Bladder pathology & GI pathology • Psychosexual problems • Blind uterine horn(rare). Module 6 - ppt 5 Dr. Maysoon Al-Amoud

12. Clinical findings Symptoms: • History of : • Pain at menses onset for 12-72 hrs • Pain is : crampy & intermittent in nature • Pain most intense in lower abdomen, ± to back or upper thighs. • Headache, nausea, vomiting, diarrhea & fatigue • Worst on 1st day of menses then gradually resolve • Onset: gradual with 1st yr then worsen as menses become regular. • If 2ry: onset >20 yrs old, for 5-7 ds & worsen progressively. ± pelvic pain not with menses. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

14. Dysmenorrhea Painful Menstruation Spasmodic Cyclic Radiate to back, inner aspect of thighs

15. Clinical findings Physical examination: • Pelvic examination + cervical smear pain not with menses & culture should be for all married pts presenting with a chief complaint of dysmenorrhea • If find cul-de-sac induration & uterosacal ligament nodularity on pelvic examination  endometriosis. • Uterine abnormalities or tenderness  raise index of suspicion for underlying pathology as a cause. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

17. Management • Medical therapy • Physical modalities • Alternative & complementary therapy • Behavioral modification • Surgical intervention Module 6 - ppt 5 Dr. Maysoon Al-Amoud

19. Medical therapy Aim:  endometrial prostaglandin production; ± CC • Drug groups: • NSAIDs – diclofenac, ibuprofen, • Danzol • Leuprolide • Depo-methroxyprogesteron-terone acetate • CC :oral & intravaginal • COX-2 inhibitors • Levonorgestrel IUD • Nifedipine • Transdermal CC patch Module 6 - ppt 5 Dr. Maysoon Al-Amoud

20. Oral Contraceptive Pills • Inhibition of ovulation • Desire contraception • No relief or cannot tolerate NSAIDs • No contraindication OCs Minipill DMPA GnRHa

22. Agents used in the treatment of dysmenorrhea

23. Physical modalities • Utilize : • Heat • Acupuncture or acupressure • Spinal manipulation • A heated abdominal patch was demonstrated to have efficacy similar to ibuprofen (400 mg) • quicker - not greater relief of heat + ibuprofen • Acupuncture : in91% relief as compared 36% of control. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

24. Alternative & complementary therapy • Numerous supplements & herbal formulations. • Few are backed by solid evidence. • Example: • Vitamin E 200mg units bd daily, beginning 2 days before menses & continuing through 1st 3 days of bleeding  shorter duration & lower intensity of pain than in placebo. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

25. Behavioral modification • Life-style: strenuous Ex. & caffeine intake • can modulate prostaglandin-induced uterine contractions. • Strenuous Ex. :  uterine tone uterine “angina” periods +  prostaglandins ...... •  strenuous Ex. In 1st few days of menses  ± dysmenorrhea. • Caffeine : controversial effect, it  uterine tone by  uterine cyclic adenosine monophosphote level. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

26. Surgical intervention • Continues to have significant dysmenorrhea + preceding treatment testing for secondary dysmenorrhea . • Chronic pelvic pain not responding to supportive therapy  adhesions, endometriosis or chronic PID discovered on diagnostic laparoscopy. • Hysterectomy is an option for refractory 1o amenorrhea. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

27. Treatment at PHC centres • primary dysmenorrhea: try previously mentioned methods. • Secondary dysmenorrhea: refer to investigate (e.g. laparoscopy) & treat underlying cause Have patience and empathy. Module 6 - ppt 5 Dr. Maysoon Al-Amoud

28. Tips for general practitioners • Adolescents are unlikely to have underlying disease and so do not usually require a pelvic examination • First line treatment for dysmenorrhoea should be oral contraceptives and/or non-steroidal anti-inflammatory drugs • Specialist referral is indicated if oral contraceptives and non-steroidal anti-inflammatory drugs fail • The levonorgestrel intrauterine system is useful in managing secondary dysmenorrhoea

29. When to refer • Referral for laparoscopy is indicated if initial measures, such as oral contraceptives and NSAIDs, have not improved symptoms. • Referral is also indicated if secondary dysmenorrhoea is suspected (for example, associated menstrual symptoms • Menorrhagia, • Intermenstrual or postcoital bleeding • Dyspareunia • Abnormal pelvic examination • If the patient has pain management problems with disruption to daily living.

30. Summary • Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated • Simple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of women • Oral contraceptives can be considered for women who wish to avoid pregnancy • For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective

31. تم بحمد الله Thank you Dr. Maysoon Al-Amoud Module 6 - ppt 5 Dr. Maysoon Al-Amoud