بسم الله الرحمن الرحيم 1Module 6 - ppt 5 Dr. Maysoon Al-Amoud.
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Transcript of بسم الله الرحمن الرحيم 1Module 6 - ppt 5 Dr. Maysoon Al-Amoud.
بسم الله بسم الله الرحمن الرحمن الرحيمالرحيم
1Module 6 - ppt 5 Dr. Maysoon Al-Amoud
Dysmenorrhea
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
Introduction to Primary Care
a course of the Center of Post Graduate Studies in FM
Objectives• General considerations.• Classification of dysmenorrhea• Causes of dysmenorrhea• Clinical picture of dysmenorrhea• Management of dysmenorrhea
3Module 6 - ppt 5 Dr. Maysoon Al-Amoud
Introduction
4Module 6 - ppt 5 Dr. Maysoon Al-Amoud
Dysmenorrhoea - painful menstruation- is one of the most common gynaecologic problems seen by the family physician.
It affects 50% of all women and between 20% & 90% of all adolescent women.
~ 1% of all adult & 15% of adolescent women describe their dysmenorrhoea as severe.
It is the leading cause of morbidity in female high school students, resulting in absence from school and nonparticipation in sports.
Classification
5Module 6 - ppt 5 Dr. Maysoon Al-Amoud
1. Primary : The presence of painful menses in the
absence of disease 2. Secondary : The occurrence of painful menstruation
caused by pelvic disease.
Risk factors of dysmenorrhea
Age < 20 years Attempts to lose weight Depression/Anxiety Heavy menses Nulliparity Smoking Disruption of social network
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No underlying pelvic pathology.
Caused by release of prostaglandin F2 from
tendometrium at time of ovulatory menstruation
uterine hypercontactility .
Ischemia of uterine wall during a contraction causes
pain.
Causes of dysmenorrhoea Primary dysmenorrhea
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Prostaglandins induce smooth muscle contraction in the uterus, as well as in intestine, bronchi, & vasculature,
Account for the systemic symptoms of diarrhea, asthma exacerbation, hypertension, & headache experienced by women with 1o dysmenorrhea.
As contractions cause the pressure within uterus to exceed that of the systemic circulation, ischemia ensues, causing an anginal epuivalent in uterus.
Primary dysmenorrhea ... continue
Causes of dysmenorrhoea
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•Underlying pelvic pathology with variable severity : •Adenomyosis, myomas, polyps, •Infections – chronic pelvic, endometriosis, •Tumors, dhesions, leiomyomas, •Intrauterine devices, •Anatomic causes, •Bladder pathology & GI pathology•Psychosexual problems•Blind uterine horn(rare).
Secondary dysmenorrhea
Causes of dysmenorrhoea
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Clinical findings Symptoms: History of : • Pain at menses onset for 12-72 hrs• Pain is : crampy & intermittent in nature• Pain most intense in lower abdomen, ± to back or
upper thighs.• Headache, nausea, vomiting, diarrhea & fatigue• Worst on 1st day of menses then gradually resolve• Onset: gradual with 1st yr then worsen as menses
become regular.• If 2ry: onset >20 yrs old, for 5-7 ds & worsen
progressively. ± pelvic pain not with menses.
Painful MenstruationPainful Menstruation
Dysmenorrhea
SpasmodicSpasmodicCyclic Cyclic Radiate to back, inner aspect of Radiate to back, inner aspect of thighsthighs
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Clinical findings
Physical examination:
•Pelvic examination + cervical smear pain not with menses & culture should be for all married pts presenting with a chief complaint of dysmenorrhea
•If find cul-de-sac induration & uterosacal ligament nodularity on pelvic examination endometriosis.•Uterine abnormalities or tenderness raise index of suspicion for underlying pathology as a cause.
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Management
•Medical therapy•Physical modalities•Alternative & complementary therapy•Behavioral modification•Surgical intervention
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Medical therapy
Drug groups:• NSAIDs – diclofenac, ibuprofen,• Danzol • Leuprolide• Depo-methroxyprogesteron-terone acetate• CC :oral & intravaginal• COX-2 inhibitors• Levonorgestrel IUD• Nifedipine• Transdermal CC patch
Aim: endometrial prostaglandin production; ± CC
Inhibition of ovulationDesire contraceptionNo relief or cannot tolerate NSAIDsNo contraindication
Oral Contraceptive PillsOral Contraceptive Pills
OCsOCsMinipillMinipillDMPADMPAGnRHaGnRHa
Agents used in the treatment of dysmenorrhea
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Physical modalities
Utilize :1. Heat 2. Acupuncture or acupressure3. Spinal manipulation• A heated abdominal patch was demonstrated to
have efficacy similar to ibuprofen (400 mg) quicker - not greater relief of heat + ibuprofen• Acupuncture : in91% relief as compared 36% of
control.
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Alternative & complementary therapy
• Numerous supplements & herbal formulations.
• Few are backed by solid evidence.Example:
Vitamin E 200mg units bd daily, beginning 2 days
before menses & continuing through 1st 3 days of
bleeding shorter duration & lower intensity of
pain than in placebo.
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Behavioral modification
• Life-style: strenuous Ex. & caffeine intake can modulate prostaglandin-induced uterine
contractions.• Strenuous Ex. : uterine tone uterine
“angina” periods + prostaglandins ......• strenuous Ex. In 1st few days of menses
± dysmenorrhea.• Caffeine : controversial effect, it uterine tone
by uterine cyclic adenosine monophosphote level.
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Surgical intervention
• Continues to have significant dysmenorrhea + preceding treatment testing for secondary dysmenorrhea .
• Chronic pelvic pain not responding to supportive therapy adhesions, endometriosis or chronic PID discovered on diagnostic laparoscopy.
• Hysterectomy is an option for refractory 1o amenorrhea.
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Treatment at PHC centres
• primary dysmenorrhea: try previously mentioned methods.
• Secondary dysmenorrhea: refer to investigate (e.g. laparoscopy) & treat underlying cause
Have patience and empathy.
Tips for general practitioners
Adolescents are unlikely to have underlying disease and so do not usually require a pelvic examination
First line treatment for dysmenorrhoea should be oral contraceptives and/or non-steroidal anti-inflammatory drugs
Specialist referral is indicated if oral contraceptives and non-steroidal anti-inflammatory drugs fail
The levonorgestrel intrauterine system is useful in managing secondary dysmenorrhoea
When to refer
Referral for laparoscopy is indicated if initial measures, such as oral contraceptives and NSAIDs, have not improved symptoms.
Referral is also indicated if secondary dysmenorrhoea is suspected (for example, associated menstrual symptoms
Menorrhagia, Intermenstrual or postcoital bleeding Dyspareunia Abnormal pelvic examination If the patient has pain management problems with
disruption to daily living.
Summary
Dysmenorrhoea is a common gynaecological condition that is underdiagnosed and undertreated
Simple analgesics and non-steroidal anti-inflammatories are effective in up to 70% of women
Oral contraceptives can be considered for women who wish to avoid pregnancy
For women seeking alternative therapies heat, thiamine, magnesium, and vitamin E may be effective
تم بحمد تم بحمد ThankاللهاللهyouDr. Maysoon Al-Amoud
31Module 6 - ppt 5 Dr. Maysoon Al-Amoud