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Dysmenorrhoea and premenstrual syndrome

The document discusses dysmenorrhea, its definitions, types (primary and secondary), and associated conditions such as endometriosis and adenomyosis. It outlines symptoms, diagnosis methods like laparoscopy, treatment options including medication and surgery, as well as the management of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Recommendations for lifestyle modifications and dietary changes to alleviate symptoms are also covered.

Health & Medicine◦
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
DEFINITION • Painful menstruation 45-95%
•Primary dysmenorrhea •Secondary dysmenorrhoea
PRIMARY DYSMENORRHOEA •Increased prostaglandin •Increased vasopressin
SECONDARY DYSMENORRHOEA •Endometriosis and adenomyosis •Fibroid uterus •Endometrial polyp •Pelvic inflammatory disease •Cervical stenosis •Congenital malformation of uterus
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
COMPLICATIONS •Formation of adhesions •Chocolate ovarian cyst •Infertility
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
HISTORY AND EXAMINATION
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
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)
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
• 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
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
• 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
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
MANAGEMENT
SELECTION OF TREATMEJNT •PATIENT PREFERENCE OF TREATMENT •RISKS/BENEFIT OF EACH OPTION •CONTRACEPTIVE REQUIREME •PAST MEDICAL HISTORY • ANY CONTRAINDICATIONS TO MEDICAL THERAPIES
NON HORMONAL NSAIDS COX-2 INHIBITOR TRANS DERMAL GLYCERYL TRINATE HORMONAL OCPS PROGESTOGEN SURGICAL NON MEDICAL TENS,EXERCISE,HEAT ALTERNATIVES
•NSAIDS •ORAL CONTRACEPTIVES •LNG-IUS •GnRH ANALOUES •LIFE STYLE CHANGES •HEAT
DYSPAREUNEA
PAIN DURING SEXUAL INTERCOURSE TYPES SUPERFICIAL DEEP CAUSES ENDOMETRIOSIS PELVIC INFLAMMATORY DISEASE ON MANY OCCASION NO CAUSE FOUND AND PSYCHOLOGICAL SUPPORT IS OFFERED
PREMENSTRUAL SYNDROME
OCCURRENCE OF CYCLICAL,PSYCHOLOGICAL AND EMOTIONAL SYMPTOMS THAT OCCUR IN LUTEAL PHASE AND CEASE BY THE TIME MENSTRUATION CEASES
•Occur in women of reproductive age •3-60%
What Causes PMS? CYCLICAL OVARIAN ACTIVITY AND EFFECTS OF ESTRADIOL AND PROGESTERONE ON CERTAIN NEUROTRANSMITTO R LIKE SEROTONIN ?? ? ??? ??? ??? ???
SYMPTOMS • Mood swings • Bloating • Cyclical weight gain • Mastalgia • Abdominal cramps • Fatigue • Headache • Depression • Irritability • Food cravings
No objective test can confirm PMS the diagnosis is made on the basis of prospective daily symptoms recording using various rating scales
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
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?
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
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
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
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
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
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. .
Dysmenorrhoea and premenstrual syndrome