DYSMENORRHOEA

1. DYSMENORRHOEA
Aboubakr Elnashar
Benha university, Egypt
ABOUBAKR ELNASHAR

2. Types
1°: pain has no obvious organic cause.
2ndry: an underlying condition.
Pain
highly subjective and varies greatly between
women.
However, if a woman describes her periods as
unacceptably painful, then they are!
ABOUBAKR ELNASHAR

3. 1º dysmenorrhoea
Pain in the menstrual cycle:
Feature of ovulatory cycles
AE:
1. uterine vasospasm and ischaemia,
2. nervous sensitization due to PGs and other
inflammatory mediators
3. uterine contractions.
Maternal or sibling history: very common
Problem usually starts soon after menarche.
ABOUBAKR ELNASHAR

4. Theories
1. Abnormal PG ratios or sensitivity.
2. Neuropathic dysregulation.
3. Venous pelvic congestion.
4. Psychological causes.
ABOUBAKR ELNASHAR

5. 2° dysmenorrhoea
Causes:
1. Endometriosis.
2. Adenomyosis.
3. PID.
4. Pelvic adhesions.
5. Fibroids (though not always causal).
6. Cervical stenosis (iatrogenic post-LLETZ or
instrumentation).
7. Asherman's syndrome.
8. Congenital abnormalities: genital tract
obstruction, e.g. non-communicating cornua
ABOUBAKR ELNASHAR

6. Diagnosis
I. History
Present:
1. Timing and severity of pain (induding degree of
functional loss): commonly premenstrual pain inc
in the first 1-2 days of bleeding, then eases.
2. Pelvic pain and deep dyspareunia (may signify
pelvic pathology).
Past:
1. PID or STI.
2. Abdominal or genital tract surgery (may cause
adhesions).
ABOUBAKR ELNASHAR

7. II. Examination
1. Abdominal
exclude pelvic masses.
2. Pelvic
cervical excitation
adnexal tenderness
mobility
masses.
ABOUBAKR ELNASHAR

8. III. Investigations
1. STI screen
(including Chlamydia swab).
2. USS:
Endometriomata
PID sequelae
Fibrolds
congenital abnormalities.
3. Laparoscopy:
A. USS abnormalities
B. medical treatment failures
C. concomitant subfertility.
ABOUBAKR ELNASHAR

9. Management
Reassurance and analgesia may be
all that is required.
I. Symptom control:
1. Mefenamic acid: 500 mg tds with
each period is effective
2. COCP to abolish ovulation
3. Mirena IUCD demonstrate benefit
4. Paracetamol, hot-water bottles
may be helpful
5. TENS, vitamin B1. and
magnesium may be of benefit
ABOUBAKR ELNASHAR

10. II. Treat any underlying causes
1. Endometriosis
COCP, progestagens, GnRH analogues
2. PID:
antibiotics
3. obstruction (usually surgical).
III. Therapeutic laparoscopy
-for above indications: gold standard for diagnosis
+ management of
endometriosis/adhesions/complicated PID.
Hysterectomy
is now rare for this indication alone.
Laparoscopic uterine nerve ablation (LUNA)
not currently recommended.
ABOUBAKR ELNASHAR

11. IV. When no disease is identified
1. ovulation suppression
• tricycling COCP or
• GnRH analogues
for up to 6-12mths will limit the number of 'periods'
and therefore pain.
This is an empirical trial of hormonal therapy.
2. psychological support
3. Pain clinic
ABOUBAKR ELNASHAR

12. ABOUBAKR ELNASHAR