causes ,aetiology of pain during menstrual cycle and treatment. causes and treatment for anxiety before menstrual cycle non pharmacological treatment of anxiety before periods different gynaecological problems pscycological aspects of the dysmenorrhoea pharmacological management of dysmenorrhoea

1. DYSMENORRHOEA
D R K I S H W A R N A H E E D
A S S I S T P R O F G Y N A E / O B S

2. DEFINITION
• Painful menstruation
45-95%

3. •Primary dysmenorrhea
•Secondary dysmenorrhoea

4. PRIMARY DYSMENORRHOEA
•Increased prostaglandin
•Increased vasopressin

5. SECONDARY DYSMENORRHOEA
•Endometriosis and adenomyosis
•Fibroid uterus
•Endometrial polyp
•Pelvic inflammatory disease
•Cervical stenosis
•Congenital malformation of uterus

6. ENDOMETRIOSIS
• Presence of endometrial tissue outside the uterine cavity
including ovary,pelvic wall,pouch of douglas,uterosacral
ligament and bowel
• These tissues are under hormonal control
• So symptoms are exacerbated at the time of menstruation
• Laproscopy is gold standard diagnostic tool
• Treatment
• Combined pill
• Mirena IUS
• Surgical approach with laser,diathermy or excision of
endometriotic tissue

7. COMPLICATIONS
•Formation of adhesions
•Chocolate ovarian cyst
•Infertility

8. ADENOMYOSIS
•Presence of ectopic endometrial tissue within
endometrium
•It is associated with previous procedures which
may break the barrier between the
endometrium and myometrium
•eg caesarean section and suction termination of
pregnancy

9. HISTORY AND
EXAMINATION

10. HISTORY
• A complete history should include the following[26] :
• Age at menarche
• Menstrual frequency, length of period, estimated menstrual flow, and
presence or absence of intermenstrual bleeding
• Associated symptoms
• Onset, duration, type, and severity of pain, as well as its relation to the
menstrual cycle
• External factors affecting the pain
• Impact of dysmenorrhea on physical and social activity
• Progression of symptom severity
• Sexual and obstetric history

11. CHARACTER OF PAIN IN PRIMARY
DYSMENORRHOEA• Onset shortly after menarche (typically within
• 6 months)
• Usual duration of 48-72 hours (often
• starting several hours before or just after
• the menstrual flow)
• Cramping or laborlike pain
• Background of constant lower abdominal pain
• , radiating to the back or the anterior or
• medial thigh
• Often unremarkable pelvic examination
findings (including rectal)

12. CHARACTER OF PAIN IN SECONDARY
DYSMENORRHOEA
• A different pattern of pain is observed with secondary dysmenorrhea
that is not limited to the onset of menses; this is usually associated with
abdominal bloating, pelvic heaviness, and back pain. Typically, the pain
progressively increases during the luteal phase until it peaks around the
onset of menstruation.
• The following may indicate secondary dysmenorrhea[1, 2] :
• Dysmenorrhea beginning in the 20s or 30s, after relatively painless
menstrual cycles in the past
• Heavy menstrual flow or irregular bleeding
• Dysmenorrhea occurring during the first or second cycles after
menarche, which may indicate congenital outflow obstruction

13. • Pelvic abnormality with physical examination (consider
endometriosis, pelvic inflammatory disease [PID], pelvic
adhesions, and adenomyosis)
• Little or no response to nonsteroidal anti-inflammatory drugs
(NSAIDs) or OCs
• Infertility
• Dyspareunia
• Vaginal discharge

14. SEVERITY OF PAIN
• Do you need to take pain killer for this pain?
• Have you needed to take any time off work/school
due to pain?
•EXAMINATION
• ABDMINAL EXAMINATION
• For any mass

15. • PELVIC EXAMINATION
• Inspection of the external genitalia for rashes, swelling, or
discoloration
• Inspection of the vaginal vault for discharge, blood, or foreign
bodies
• Inspection of the cervix for the above, plus any masses or
signs of infection
• BIMANUAL EXAMINATION
• To assess cervical motion tenderness, uterine or adnexal
tenderness, or any masses in the pelvis
• Fixed uterus
• Endometriotic nodules

16. INVESTIGATIONS
• PELVIC ULTRASOUND TO RULE OUT ENDOMETRIOMAS AND ADENOMYOSIS
• HIGH VAGINAL AND ENDOCERVICAL SWAB
• DIAGNOSTIC LAPROSCOPY
• INDICATIONS
• HISTORY SDUGGESTIVE OF ENDOMETRIOSIS
• WHEN SWAB AND USG ARE NORMAL
• WHEN PT WANTS DEFINITE DIAGNOSIS
• WHEN PT WANTS TO KNOW HER PELVIS IS OK
• DISCUSSION
• RISKS OF PROCEDURE
• ANAESTHESIA AND DAMAGE TO BOWEL AND BLADDER

17. MANAGEMENT

18. SELECTION OF TREATMEJNT
•PATIENT PREFERENCE OF TREATMENT
•RISKS/BENEFIT OF EACH OPTION
•CONTRACEPTIVE REQUIREME
•PAST MEDICAL HISTORY
• ANY CONTRAINDICATIONS TO MEDICAL
THERAPIES

19. NON HORMONAL
NSAIDS
COX-2 INHIBITOR
TRANS DERMAL GLYCERYL TRINATE
HORMONAL
OCPS
PROGESTOGEN
SURGICAL
NON MEDICAL TENS,EXERCISE,HEAT
ALTERNATIVES

20. •NSAIDS
•ORAL CONTRACEPTIVES
•LNG-IUS
•GnRH ANALOUES
•LIFE STYLE CHANGES
•HEAT

21. DYSPAREUNEA

22. PAIN DURING SEXUAL INTERCOURSE
TYPES
SUPERFICIAL
DEEP
CAUSES
ENDOMETRIOSIS
PELVIC INFLAMMATORY DISEASE
ON MANY OCCASION NO CAUSE FOUND AND PSYCHOLOGICAL
SUPPORT IS OFFERED

23. PREMENSTRUAL
SYNDROME

25. OCCURRENCE OF CYCLICAL,PSYCHOLOGICAL
AND EMOTIONAL SYMPTOMS THAT OCCUR IN
LUTEAL PHASE AND CEASE BY THE TIME
MENSTRUATION CEASES

26. •Occur in women of reproductive age
•3-60%

27. What Causes PMS?
CYCLICAL OVARIAN
ACTIVITY AND
EFFECTS OF
ESTRADIOL AND
PROGESTERONE ON
CERTAIN
NEUROTRANSMITTO
R LIKE SEROTONIN
??
?
???
???
???
???

28. SYMPTOMS
• Mood swings
• Bloating
• Cyclical weight gain
• Mastalgia
• Abdominal cramps
• Fatigue
• Headache
• Depression
• Irritability
• Food cravings

30. No objective test can confirm
PMS the diagnosis is made on the
basis of prospective daily
symptoms recording using various
rating scales

31. MONTH________________ (provided by http://www.pms-relief.org)
Chart your PMS symptoms according to the following criteria.
Colour the boxes according to your symptoms: NONE = leave blank. MILD = GREEN. MODERATE = YELLOW. SEVERE = RED
PMS SYMPTOMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Abdominal Pain
Acne
Anger, Aggression
Anxiety
Back Pain
Breast Swelling
Breast Tenderness
Cervical Fluid
Constipation
Cramps
Diarrhea
Difficulty Concentrating
Fatigue
Food Cravings & Binges
Headache
Irritability
Joint Pain
Libido (Decreased)
Libido (Increased)
Moody
Muscle Pain
Nausea
Ovarian Pain
Sadness
Sleep (Decreased)
Sleep (Increased)
Tension
Urinary difficulties
Water Retention
Weight Gain

32. The symptoms of PMS can be
similar to or overlap with other
conditions, including:
Perimenopause
Depression or anxiety
Chronic fatigue syndrome
Thyroid disease
The key difference is that PMS
symptoms come and go in a
distinct pattern, month after
PMS or
Somethin
g Else?

33. Diagnosing PMS: Symptom Tracker
To figure out whether you have
PMS, record your symptoms on
a tracking form. You may have
PMS if:
Symptoms occur during the five
days before your period.
Once your period starts,
symptoms end within four days.
Symptoms return for at least
three menstrual cycles.
It is important to keep a
daily diary or log to
record the type of
symptoms you have,
how severe they are,
and how long they last.
You should keep this
"symptom diary" for at
least 3 months. It will
help your doctor make
an accurate PMS
diagnosis and

34. Premenstrual Dysphoric Disorder
Premenstrual dysphoric
disorder (PMDD) follows the
same pPremenstrual dysphoric
disorder (PMDD) follows the
same pattern as PMS, but the
symptoms are more disruptive.
Women with PMDD may
experience panic attacks,
crying spells, suicidal thoughts,
insomnia, or other problems
than interfere with daily life.
Fortunately, many of the same
strategies that relieve PMS can
be effective against PMDD.
Risk factors for PMDD include
a personal or family history of

35. MANAGEMENT
FIRST
LINE
• LIFE STYLE MODIFICATION
• COCP
• SSRI
• COGNITIVE BEHAVIOURAL THERAPYSECON
D LINE
• OESTRADIOL PATCHES PLUS ORAL PROGESTOGEN OR LNG-IUS
• SSRIS..HIGH DOSE ,CONTINUOUS OR LUTEAL PHASE
THIRD
LINE
• GnRH Analogues+add-back HRT{CONTINUOUS COMBINED
ESTROGEN AND PROGESTOGEN OR TIBOLONE}
FOURTH
LINE
• TOTAL ABDOMINAL HYSTERECTOMY AND BILATERAL OOPHRECTOMY+HRT {INCLUDING TESTOSTERONE

36. PMS
Remedy
(a) Exercise
Exercise can help boost
your mood and fight
fatigue. To get the
benefits, you need to
exercise regularly --
not just when PMS
symptoms appear. Aim
for 30 minutes of
moderate physical
activity on most days
of the week. Vigorous
exercise on fewer days
can also be effective.
(b)Diet Rich in B VitaminsThere's evidence that foods rich in B
vitamins may help ward off PMS. In
one study, researchers followed more
than 2,000 women for 10 years. They
found that women who ate foods
high in thiamine and riboflavin (eggs,
dairy products) were far less likely to
develop PMS. Taking supplements
did not have the same effect

37. You may be able to
reduce PMS symptoms
by cutting back on
these foods:
Salt, which can increase
bloating
Caffeine, which can
cause irritability
Sugar, which can make
cravings worse
Alcohol, which can
affect mood
(d) Foods to Avoid

38. Prevention Some of the lifestyles changes
often recommended for treating
PMS may help prevent
symptoms or keep them from
getting worse.
Getting regular
exercise and eating
a balanced diet
(with increased
whole grains,
vegetables, fruit,
and decreased or
no salt, sugar,
alcohol, and
caffeine) may prove
beneficial.
.