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Dysmenorrhea and Pre-menstrual syndrome ( PMS )

Dysmenorrhea and Pre-menstrual syndrome ( PMS ). Primary Spasmodic Dysmenorrhea. Painful menstruation without underlying pathology Commonest in teens/early twenties Onset 1 or more years after menarche Associated vomiting and faintness. Secondary Dysmenorrhea.

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Dysmenorrhea and Pre-menstrual syndrome ( PMS )

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  1. Dysmenorrhea and Pre-menstrual syndrome(PMS)

  2. Primary Spasmodic Dysmenorrhea Painful menstruation without underlying pathology Commonest in teens/early twenties Onset 1 or more years after menarche Associated vomiting and faintness

  3. Secondary Dysmenorrhea Painful menses secondary to pathology Pain may begin before bleeding and may last for entire duration Commoner 30s and 40s

  4. Secondary Dysmenorrhea Endometriosis Fibroids Adenomyosis Pelvic Inflammatory Disease Uterine anomalies

  5. Nerves around Uterus, Cervix and Ovaries

  6. Nerve around Endometriosis(in peritoneum, not in endometrioma) Peritoneal endometriosis innervated by sensory Aδ & C, cholinergic & adrenergic nerve fibers (IHC study) (Tokushige et al, Hum Reprod, 2006) Nerve fibers not found in ovarian endometrioma (IHC study) (Al-Fozan et al, Fertil Steril, 2004)

  7. Deep Infiltrating Rectovaginal Endometriosis

  8. Hematosalpinx Bicornuate uterus Cervical orifices Hematocolpos Vaginal Stenosis Vagina

  9. History Taking Timing Severity Disruption in life-style Previous gyn history Contraceptive needs Wish for fertility

  10. Examination Vaginal exam not essential in young female with Primary dysmenorrhea Vagina -septum/ tenderness Uterus- size / mobility/ position/tenderness Adnexa –tenderness/ enlargement

  11. Investigations Transabdominal ultrasound with full bladder Transvaginal ultrasound –increased sensitivity Laparoscopy –gold standard for endometriosis Risks versus benefits

  12. Management Primary Spasmodic Dysmenorrhea Education Prostaglandin synthetase inhibitors Combined oral contraceptive pill-choose a progestagen dominant pill “Bicycle” or “Tricycle” pill Failure to respond to Pill increases likelihood of underlying pathology

  13. Adolescent Endometriosis • 症狀: Dysmenorrhea, acyclic pain (or both), dyspareunia, G-I pain • 診斷：超音波 (不必然要內診，測serum CA-125?) • 藥物治療: OCP, NSAID。無效則腹腔鏡手術 • 病灶: (1)外觀: clear, red and white。(2) 80% 屬minimal to mild stage • 術後: GnRH-a (!), add-back • 長期追蹤 (ACOG, committee opinion, 2005)

  14. Premenstrual Syndrome Physiological premenstrual change All but 3-5% of ovulating females experience one or more symptom Remitting completely inn the postmenstrual week (Berek & Novak’s Gynecology)

  15. Symptoms Physical –bloating/breast tenderness/headache Psychological-aggression/agitation/crying bouts/depression/irritability • Depressed mood, hopelessness, self-deprecation • Anxiety, tension • Affective liability • Anger, irritability, interpersonal conflict • Decreased interest in usual activities • Difficulty concentrating • Decreased energy • Appetite changes or cravings • Changes in sleep • Feeling overwhelmed or out of control • Physical symptoms such as breast tenderness, headache, bloating

  16. Measurement and Diagnosis Cyclical symptoms –character, timing, severity Degree of underlying psychological dysfunction Degree of disruption of lifestyle Usually self documented using diary/calendar

  17. Aetiology No measurable abnormality in female sex hormones or prolactin Oophorectomy abolishes symptoms Cyclical HRT reproduces symptoms ? Abnormal endorphins ? Change in serotonin metabolism

  18. Treatment 15 RCTs SSRIs vs placebo SSRIs improve physical and psychological symptoms Both intermittent and continuous therapy beneficial (Dimmock et al Lancet 2000) Lifestyle modification: (some benefits for some women) Elimination of caffeine from the diet Smoking cessation Regular exercise Regular meals and a nutritious diet Adequate sleep Stress reduction

  19. Treatment Temporary or permanent abolition of hormonal cycle GnRH analogue Hysterectomy and Oophorectomy Progesterone/progestagens shown to be ineffective

  20. Non-contraceptive Benefits of Oral Contraceptive Pills • Dysmenorrhea Mittelschmerz Metrorrhagia Premenstrual syndrome Hirsutism Ovarian and endometrial cancer Functional ovarian cysts Benign breast cysts Ectopic pregnancy Acne Endometriosis • Amenorrhea • Dual suppression in IVF program

  21. 成份：Estrogen & Progestin Low-dose : ＜30~35μg EE Higher dose: 50 μg EE

  22. World Health Organization Precautions for the Use of OCs(世界衛生組織對使用避孕藥的提醒) • Category 4 (refrain from use)Venous thromboembolism*Cerebrovascular or coronary artery disease*Structural heart diseaseDiabetes with complicationsBreast cancer*Pregnancy*Lactation (<6 weeks postpartum)Liver diseaseHeadaches with focal neurologic symptomsMajor surgery with prolonged immobilizationAge >35 years and smoke 20 cigarettes or more per dayHypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease) • Category 3 (exercise caution)Postpartum <21 daysLactation (6 weeks to 6 months)Undiagnosed vaginal or uterine bleeding*Age >35 years and smoke fewer than 20 cigarettes per dayHistory of breast cancer but no recurrence in past 5 yearsInteracting drugsGallbladder disease • Category 2 (advantages outweigh risks) • Category 1 (no restrictions)

  23. 謝謝 高雄長庚醫院婦產部, 2008

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