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SALWA NEYAZI
COSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST
DYSMENORRHEA
HA S DYSMENORRHEA? ainful menstruation HA S 50-75 % S N DEN E?
HA ARE HE O MA N A E OR ES? 1- rimary >painful menstruation without associated pelvic disease 2-Secndary > painful menstruation caused by pelvic pathology
DYSMENORRHEA
HOW TO EVALUATE A PATIENT WITH DYSMENORRHEA 1-Hist r -P si l x i ti > s l l t l N r s , v ri v l t ri i Pt it 1r t i t r s & x ill il l t r si l 3-I v sti ti s > t r q ir i Hx & x i ti r sist t it 1r s *U/S *HSG r s *L *H str s *D& All s t ir si i r s lvi t r is
1RY DYSMENORRHEA
PRIMARY DYSMENORRHEA
Us i s rs r r it t s t str ti t r ll r s +v il Hx T i is r / li k , i t l r st i t s i t i li l sts r 1 r St rt it v l t r l s 6-1 M t r r Ass i t s t s rt i s 6 -B k i & i i t -N s /v itti 9 -Di rr 6 -F ti / l is 8 -H (t si r i r i ) 4 -Dizzi ss, rv s ss, i ti >i s v r s s ll
1r DYSMENORRHEA
WHAT IS THE CAUSE OF 1RY DYSMEN -Pr st l i (PG F ) r l s r tri l lls > t ri s t s l tr ti , i r s i tr t ri r ss r & s r t ri is i -PG r ti during the 1st 48-72 hrs of menses -PG may also cause hypersensitization of pain terminals to physical & chemical stimuli -B vi r l, lt r l & s l i l t rs i l ti t i t Pt r
1r DYSMENORRHEA
WHAT IS THE TREATMENT OF 1RY DYSMEN 1-NSAID > 1st li *Pr i i *F >8 tiv riv tiv s > I r N r x t s>M i i P st tiv tr i i
i i i r v
s t it
1r DYSMENORRHEA
WHAT IS THE MECHANISM OF ACTION OF THESE DRUGS 1- NSAID i r ti I i its r st l A t isti ti tt r t r P st S l s it t st rt i r l rl r -3 s - ORAL CONTRACEPTIVES endometri l t i kness PG t rough inhi ition of ovul tion & hange the hormonal status to that of the earl roliferative hase ( hi h has the lowest level of PG)
1r DYSMENORRHEA
WHAT ARE THE SIDE EFFECTS OF NSAID Gastri irritation Nausea GIT ul eration Bleeding time Nephrotoxi it Fenamates > blurred vision, headache & dizziness Bronchospasm in Pt with bronchial asthma H persensitivit reaction Autoimmune hemol tic anemia
1ry DYSMENORRHEA
HOW TO MANAGE A PT WHO CONTINUES TO HAVE PROBLEM Investigations to R/O ry dysmenorrhea If results are normal - Codeine may be helpful under close supervision to avoid addiction -Acupuncture
SECONDARY DYSMENORRHEA
2RY DYSMENORRHEA
Hx -Older patients with onset of symptoms several years after menarche -Recurrent pelvic infections -IUCD -Recent pelvic surgery -Heavy periods -Irregular cycles Physical examination May help in Dx by finding abnormalities that point to a pelvic disease
2RY DYSMENORRHEA
HOW TO EVALUATE PT WITH 2RY DYSMEN CBC ESR Cultures for std U/S HSG > if intruterine scarring or fibroid is suspected Laparoscopy Hysteroscopy D&C TREATMENT OF 2RY DYSMENORRHEA Treat the cause
2RY DYSMENORRHEA
CX STENOSIS
Cx stenosis > I tr t ri s s r r ss r str ti ri >
Cx st
S t t r
CX STENOSIS
Dx Internal os scarred & impossible to pass uterine sound or even very thin probe Rx -D&C -The problem frequently recurs > repeat procedure -Vaginal delivery afford morelasting cure Pt with large endocervical polyp will have the same presentation
ENDOMETRIOSIS
Endometriosis > Ectopic endometrial tissue Adenomyosis >Endometrial tissue in the myometrium Hx > Sever dysmenorrhea Infertility Dysparunea Pelvic examination Evidence of endometriosis in vagina or cx Tenderness Thickening / nodules of rectovaginal septum or uterosacral ligament Ovarian (chocolate) cyst
ENDOMETRIOSIS
Dx -Laparoscopy or laparotomy -Direct biopsy of vaginal or cx lesion Rx To supress menstruation by medication Cauterization of endometriotic spots Analgesics
PREMENSTRUAL SYNDROME
PMS
WHAT IS PMS A group of physical, emotional & behavioral symptoms that occur in the 2nd half (luteal phase) of the menstrual cycle often interfere with work & personal relationships followed by a period entirely free of symptoms starting with menstruation WHAT THE INCIDENCE OF PMS 4 >Significantly affected at one time or another 2-3 > Sever symptoms with impact on their work & lifestyle 5% by the American psychiatric association definition
PMS
WHAT SYMPTOMS ARE ASSOCIATED WITH PMS PHYSICAL SYMPTOMS -Bloated feeling -Wt gain -Breast pain & tenderness -Skin disorders acne -Hot flushes -Headache -Pelvic pain -Changes in bowel habits -Joint or muscle pain -edema
ETIOLOGY
DO WE KNOW WHAT CAUSES PMS No, many theories have been postulated, most of them have to-do with various hormonal alterations Vit B6 deficiency Multifactorial psychoendocrine disoreder Alterations in the serotoninergic neuronal mechanism in the CNS (serotonin deficiency) Ovulation / progestrone production are important in this syndrome > Drugs that inhibit ovulation > relief of PMS symptoms Antiprogestrone RU486 > No relief
ETIOLOGY
Abnormal response of the CNS to the normal fluctuations of estrogen & progestrone during the menstrual cycle Administration of estrogen & progestrone to women with PMS whose ovaries were suppressed with GnRH agonist analogues > development of PMS symptoms
BIOPYCHOSOCIAL MODEL
Hormonal changes of the luteal phase of the menstrual cycle, that is the estradiol & progestrone act as a trigger to stimulate the development of PMS symptoms in women who are biologically, socially & psychologically predisposed to develop PMS Biological explanation > abnormal response of the CNS to the hormonal changes could be related to serotonin or -aminobutyric acid Social explanation > mimicking the behavior of other important females in her life, social expectations or pressure from others Psychological explanation > rejection of the female role or that PMS could be a variation of other common affective disorder
EVALUATION
Pt should keep a diary of her symptoms throughout 2-3 menstrual cycles > then the physician should review these symptoms with the Pt to determine what seems to be causing her the most difficulty Complete Hx & physical examination to R/O any medical problem
DX
DIAGNOSTIC CRITERIA FOR THE PMDD (PreMenstrual Dysphoric Disorder) in the Diagnostic Statistical Manual for Mental Disorders Requires 5 of the following -Depressed mode -Anexiety -Labile mode -Irritability -Change in appetite - Lethargy -Sleep disturbance -Out of control -Lack of interest -Physical sympt *Occur in the week before menses in most menstrual cycles *Disappear few days after the onset of menses *Impair social, occupational function or the ability to interact with others
TREATMENT
1- SUPPORTIVE Counseling & education > the physician should reassure the Pt that her symptoms are real & can be treated The goal is to provide the Pt with greater control over her life Life style changes such as exercise & dietary modifications 2-MEDICATIONS The selection of medications should be tailored to the Pt main symptoms
MEDICAL THERAPY
SYMPTOMATIC Rx 1- Bloating & feeling of fluid retention > Diuretics (spironolactone) 2-Cramping, back pain, heat intolerance > Antiprostaglandines 3-Breast tenderness > Bromocriptine 4-Depression, anxiety, irritability > Alprazolam 0.25 mg bd SSRI >Fluoxetine (Prozac) 5-20 mg/D (D20-28)
MEDICAL THERAPY
SUPPRESSION OF OVULATION 1-Danazol 200 mg QID D 20-28 2-Oral Contraceptives 3-Medroxyprogestrone acetate 10 mg BID/TID contiuously MISCILANEOUS Rx 1-Micronized progestrone 100mg AM 200mg PM D 20-28 2-Multiple Vitamines 3-Pyridoxine B6 > 50 mg/ day or B-complex 4-Ca Carbonate 1200mg/D 5-Prime rose oil > linolenic acid