this is a new blog for gynaecology and obstetric, i found out that many of our fellow students can not get books, this site will be giving information about diseases related to gynaecology and obstetric, topic will depend on my preparation for that day, welcome aboad
Wednesday, August 1, 2012
Dysmenorrhea
Dysmenorrhea, or painful menstruation, is one of the most
common complaints of gynecologic patients. Many women experience mild
discomfort during menstruation, but the term dysmenorrhea is reserved
for women whose pain prevents normal activity and requires medication, whether
an over-the-counter or a prescription drug.
There are 3 types of dysmenorrhea: (1)
primary (no organic cause), (2) secondary (pathologic cause), and (3)
membranous (cast of endometrial cavity shed as a single entity). This
discussion focuses mainly on primary dysmenorrhea. Secondary dysmenorrhea is
discussed elsewhere in this book in association with specific diseases and
disorders (eg, endometriosis, adenomyosis, pelvic inflammatory disease,
cervical stenosis, fibroids, and endometrial polyps). Membranous dysmenorrhea
is rare; it causes intense cramping pain due to passage of a cast of the
endometrium through an undilated cervix. Another cause of dysmenorrhea that should
be considered is cramping due to the presence of an intrauterine device (IUD).
Pain during menstruation has long been
known to be associated with ovulatory cycles. The mechanism of pain has been
attributed to prostaglandin activity. Prostaglandins are present in much higher
concentrations in women with dysmenorrhea than in those with mild or no pain.
Other studies have confirmed increased
leukotriene levels as a contributing factor. Vasopressin was thought to be an
aggravating agent, but atosiban, a vasopressin antagonist, has shown no effect
on menstrual pain.
Psychologic factors may be involved,
including attitudes passed from mother to daughter. Girls should receive
accurate information about menstruation before menarche; this can be provided
by parents, teachers, physicians, or counselors. Emotional anxiety due to
academic or social demands may be a cofactor.
Reactions to pain are subjective, and
questioning by the physician should not lead the patient to exaggerate or minimize
her discomfort. History taking is most important and should include the
following questions: When does the pain occur? What does the patient do about
the pain? Are there other symptoms? Do oral contraceptives relieve or intensify
the pain? Does the pain become more severe over time?
Because dysmenorrhea almost always is
associated with ovulatory cycles, it does not usually occur at menarche but
rather later in adolescence. As many as 14–26% of adolescents miss school or
work as a result of pain. Typically, pain occurs on the first day of the
menses, usually about the time the flow begins, but it may not be present until
the second day. Nausea and vomiting, diarrhea, and headache may occur. The
specific symptoms associated with endometriosis are not present.
The physical examination does not
reveal any significant pelvic disease. When the patient is symptomatic, she has
generalized pelvic tenderness, perhaps more so in the area of the uterus than
in the adnexa. Occasionally, ultrasonography or laparoscopy is necessary to
rule out pelvic abnormalities such as endometriosis, pelvic inflammatory
disease, or an accident in an ovarian cyst.
The most common misdiagnosis of
primary dysmenorrhea is secondary dysmenorrhea due to endometriosis. With
endometriosis, the pain usually begins 1–2 weeks before the menses, reaches a
peak 1–2 days before, and is relieved at the onset of flow or shortly
thereafter. Severe pain during sexual intercourse or findings of adnexal
tenderness or mass or cul-de-sac nodularity, particularly in the premenstrual
interval, help to confirm the diagnosis (see Chapter 43). A similar pain
pattern occurs with adenomyosis, although in an older age group and in the
absence of extrauterine clinical findings.
NSAIDs or acetaminophen may relieve
mild discomfort. Addition of continuous heat to the abdomen in addition to
NSAIDs decreases pain significantly. For severe pain, codeine or other stronger
analgesics may be needed, and bed rest may be desirable. Occasionally,
emergency treatment with parenteral medication is necessary. Analgesics may
cause drowsiness at the dosages required.
Antiprostaglandins are now used for
treatment of dysmenorrhea. The newer, stronger, faster-acting drugs appear to be
more useful than aspirin. Ibuprofen, an NSAID that is available over the
counter and in prescription strength, has been extremely effective in reducing
menstrual prostaglandin and relieving dysmenorrhea. Less frequently dosed
naproxen (550 mg/day) also is effective. Cyclooxygenase-2 (COX-2) inhibitors
such as valdecoxib (20–40 mg/day) is equally effective and has fewer
gastrointestinal side effects, but it is more costly. The drug must be used at
the earliest onset of symptoms, usually at the onset of, and sometimes 1–2 days
prior to, bleeding or cramping.
Antiprostaglandins work by blocking
prostaglandin synthesis and metabolism. Once the pain has been established,
antiprostaglandins are not nearly as effective as with early use.
Cyclic administration of oral
contraceptives, usually in the lowest dosage but occasionally with increased
estrogen, prevents pain in most patients who do not obtain relief from
antiprostaglandins or cannot tolerate them. The mechanism of pain relief may be
related to absence of ovulation or to altered endometrium resulting in
decreased prostaglandin production. In women who do not require contraception,
oral contraceptives are given for 6–12 months. Many women continue to be free
of pain after treatment has been discontinued. NSAIDs act synergistically with
oral contraceptive pills to improve dysmenorrhea.
In a few women, no medication controls
dysmenorrhea. Cervical dilatation is of little use. Laparoscopic uterosacral
ligament division and presacral neurectomy are infrequently performed, although
some physicians consider these procedures to be important adjuncts to
conservative operation for endometriosis.
Adenomyosis, endometriosis, or
residual pelvic infection unresponsive to medical therapy or conservative
surgical therapy eventually may require hysterectomy with or without ovarian
removal in extreme cases. Rarely a patient with no organic source of pain
eventually requires hysterectomy to relieve symptoms.
Continuous low-level topical heat
therapy has been shown to be as effective as ibuprofen in treating
dysmenorrhea, although its practicality in daily life may be questionable. Many
studies have indicated that exercise decreases the prevalence and/or improves
the symptomatology of dysmenorrhea, although solid evidence is lacking.
Diets low in fat and meat products
have been shown to decrease serum sex-binding globulin and decrease the
duration and intensity of dysmenorrhea.
Subscribe to:
Posts (Atom)