Dysmenorrhea

1. Dysmenorrhea Valerie Robinson D.O.

2. Definition • Dysmenorrhea – painful menstruation • Symptoms – Recurrent episodes of uterine cramps and lower abdominal pain during menstrual cycle. • Primary dysmenorrhea – occurs in the absence of a disease process. Common in adolescents and nulliparous women • Secondary dysmenorrhea – occurs with a disorder causing the symptoms. More common in women in their 30s-40s

3. Primary dysmenorrhea • Protective factors may include • Young age at first childbirth • High parity • Advancing age • Multiple risk factors may include • Age less than 30 • BMI less than 20 • Smoking • Menarche before age 12 • Longer menstrual cycles/bleeding • Irregular or heavy cycles • History of sexual assault • Family history of dysmenorrhea

4. Primary dysmenorrheasymptoms • Recurrent episodes of uterine cramps, lower abdominal pain, nausea, vomiting, diarrhea, headache, backache during menstrual cycle. • Usually begins in adolescence after ovulatory cycles begin. (Usually 2-5 years after menarche) • Prevalence is 60-93% in adolescents • The defining symptom is crampy pelvic pain that is intermittently intense and may range from mild to severe pain. • Pain occurs with most or all menstrual cycles and may begin 1-2 days before bleeding starts. • Pain occurs midline and may radiate to back or thighs.

5. Primary dysmenorrheapathogenesis • At the beginning of the menstrual cycle, the sloughing endometrial lining releases prostaglandins, specifically E2 and F2-alpha • The prostaglandins stimulate uterine contractions • Prostaglandins also stimulate the GI tract, causing nausea, vomiting, diarrhea • Contractions are frequent and uncoordinated and result in high intrauterine pressures • When the intrauterine pressure exceeds the arterial pressure, uterine ischemia develops • Ischemia of uterine tissue causes it to form anaerobic metabolites that in turn stimulate pain fibers.

6. Primary dysmenorrheadiagnosis • Rule out likely causes of secondary dysmenorrhea (PID, endometriosis, adenomyosis, fibroids) • Does it respond to treatment? If no relief after 3 months of tx, start thinking secondary.

7. Primary dysmenorrheatreatment • NSAIDs – are prostaglandin synthetase inhibitors • Patients with severe symptoms should take NSAIDs prior to menses • Hormonal contraceptives – suppress ovulation, thin endometrium, and thereby decrease prostaglandin production • Copper IUDs may increase dysmenorrhea • Adjunct tx – heat packs, exercise, relaxation techniques, TENS unit • Nitrates, calcium channel blockers and magnesium are under study d/t tocolysis

8. Secondary dysmenorrheasymptoms • May occur well after menarche • Abnormal uterine bleeding • Pain may not be midline • Absence of nausea, vomiting, diarrhea, and back pain • Dyspareunia • Dyschezia • Progression of symptoms

9. Secondary dysmenorrheacauses • PID • Endometriosis • Adenomyosis • Fibroids • Ovarian cysts • Adhesions • Obstructive endometrial polyps • Obstructive congenital malformation • Cervical stenosis • IUD • Pelvic congestion • IBS • IBD • Psychogenic

10. Secondary Dysmenorrheadiagnosis • PID: pelvic pain, occurs during or shortly after menses, dyspareunia, AUB, vaginal or urethral discharge, cervical motion tenderness, adnexal tenderness • Endometriosis: premenstrual spotting, dyspareunia, dyschezia, progressive course. Uterosacral ligament nodularity, thickening, or tenderness, cervical stenosis, adnexal mass • Adenomyosis: typically after age 35, may be related or unrelated to cycle, bulky, mildly tender uterus • Fibroids: more common in women >30. Dyspareunia, noncyclic pain, menorrhagia, enlarged and irregularly shaped uterus, usually nontender • Testing is based on suspicion • Urine HCG if new-onset • Culture for GC/CT • Pelvic ultrasound • Rarely, diagnostic laparoscopy

11. Secondary dysmenorrheatreatment • PID – tx the STD. May need laproscopiclysis of adhesions • Endometriosis – Progesterone IUD, GnRH agonist (nafarelin or leuprolide) • Adenomyosis –progesterone IUD, GnRH agonist, aromatase inhibitors, hysterectomy • Fibroids – watch and wait, NSAIDs, hormonal contraception, GnRH agonists, antiprogestin (mifepristone), myomectomy, hysterectomy • Ovarian cysts, Adhesions, Obstructive endometrial polyps, IUD – Remove • IBS/IBD – treat the cause • Psychogenic - psychotherapy

12. References • Banikarim, Chantay, MD, MPH. “Primary dysmenorrhea in adolescents.” UpToDate. Updated August 28, 2012 • Smith, Roger P., MD and Andrew M. Kaunitz MD. “Primary dysmenorrhea in adult women: Clinical features and diagnosis.” UpToDate. Updated March 1, 2012. • Smith, Roger P., MD and Andrew M. Kaunitz MD. “Treatment of primary dysmenorrhea in adult women.” UpToDate. Updated April 24, 2012. • Stewart, Elizabeth A., MD. “Overview of treatment of uterine leiomyomas (fibroids).” UpToDate. Updated February 27, 2012. • Stewart, Elizabeth A., MD. “Uterine adenomyosis.” UpToDate. Updated September 6 2011.

13. Colloquialisms • The curse • Aunt Flo coming for a visit • That time of month • Having the painters in • Checking into the Red Roof Inn • Lady days • Monthlies • Mother Nature’s gift • Planting cotton • Red letter day