DYSMENORRHOEA AND PREMENSTRUAL SYNDROME

DYSMENORRHOEA means cramping pain accompanying menstruation.

CLINICAL VARITIES OF DYSMENORRHOEA:

1. SPASMODIC DYSMENORRHOEA: most prevalent; manifest with craping pain usually on starting two days of menstruation.
2. CONGESTIVE DYSMENORRHOEA: manifest as pelvic discomfort and pelvic pain a few days before menstruation begins. And symptoms begin to resolve as patient approaches menstruation; this variety is commonly seen in pelvic inflammatory disease, IUCD users, pelvic endometriosis and fibroids. Also seen in case of females with varicose pelvic veins.
3. MEMBRANOUS DYSMENORRHOEA: here the endometrium is shed as cast at the time of menstruation. As the cast passes the female experiences discomfort and pain along with uterine cramping. This is usually very rare.

CAUSE OF PAIN:

Spasmodic pain is due to myocardial contractions due to increases PGF2α secreted under the effect of progesterone.

CLINICAL FEATURES:

PRIMARY DYSMENORRHOEA:  type of dysmenorrhea that is not associated with any pelvic pathology

• Onset is within 2 years of menarche
• Cramping usually present at hypogastrium, back and inner thigh.
• The patient experiences nausea, vomiting, diarrhea, headache and fatigue.
• Pelvic findings on ultrasound and Doppler are normal.
• The symptoms are attributed to excess myocardial contraction, ischemia, and excess prostaglandin production.

SECONDARY DYSMENORRHOEA: refers to the one associated with the presence of organic pelvic pathology.

• Onset is at the age of 20-30 years.
• It can be premenstrual and postmenstrual.
• Patient experiences variable dull ache.
• Symptoms include: dyspareunia, infertility, menstrual disorders.
• Pelvic findings are variable and depend on the cause.
• The causes include endometriosis, PID, adenomyosis, fibroids, pelvic vein congestion.

INVESTIGATIONS:

• Pelvic sonography followed by CT scan or MRI
• Hysterosalpingogram or sonosalpingography
• Endoscopy – diagnostic hysteroscopy or laparoscopy

TREATMENT

MEDICAL MEASURES:

Therapy for primary dysmenorrhea:

• Analgesic like paracetamol t.i.d 500mg
• Antispasmodic like hyoscine compounds t.i.d
• Camylofin t.i.d / drotaverine t.i.d
• Prostaglandin synthase inhibitors
• Mefenamic acid 200mg -500mg q.i.d
• Indomethacine 25mg 3 to 6 times a day
• Naproxen 275mg t.i.d. /ketoprofen 50mg t.i.d
• Ibuprofen 400 mg  is also effective
• Nitroglicerine relaxes uterine smooth muscles
• IUCDs like mirena, progestasert relives pain , provide contraception and reduces bleeding

SURGERY

            Indicated when the medical measures fail to provide relief to the patient also done in case of secondary dysmenorrhea to treat underlying pelvic pathology.

Surgical intervention includes the following:

• Diagnostic hysteroscopy followed by dilation and curettage ,excision of polyp or uterine septum
• Diagnostic laparoscopy followed by lysis of pelvic adhesion , myomectomy ,drainage of chocolate cyst ,cautery ,laser vaporization  of island of endometriosis ,excision of adnexal masses, laser assisted uterosecral nerve ablation for spasmodic dysmenorrhoea
• Laparotomy followed by excision of chocolate cyst ,eradication of endometriosis ,myomectomy ,excision of localized adenomyoma ,presacral neurectomy (cottes operation)
• Hysterectomy in elderly female to be considered last
• Trancutaneous electrical nerve stimulation is effective in half of the cases .

PREMENSTRUAL SYNDROME

Premenstrual syndrome also called premenstrual tension is a symptom complex recognized by cyclic changes associated with ovulatory cycles

It occurs 7 to 14 days before start of menstruation and resolves after menses

CAUSES

The exact cause is unknown

The following reasons have been implicated.

1. Estrogen excess or progesterone deficiency in luteal phase
2. Increased carbohydrate intolerance in luteal phase
3. Pyridoxine deficiency
4. Increased production of vasopressin, aldosterone, prolactin and systemic prostaglandins.

SYMPTOMS:

1. PAIN: headache ,breast pain , abdominal carps ,muscle stiffness ,generalized body pain
2. Water retention : breast pain , bloating and weight gain
3. Behavioral changes :low concentration , low performance, irritability ,depression ,anxiety ,loneliness and feels like crying
4. Autonomic changes: dizziness, nausea, vomiting and hot flushes.

MANAGEMENT:

Diagnosis is based on careful history and clinical examination, the presenting symptoms of the patient and family history.

TREATMENT:

• Psychosomatic: Vitamin B1, B6, E. selective serotonin reuptake inhibitor, sertraline, citalopram, anxiolytics.
• Breast pain: danazol, bromocryptine GnRH.
• Pelvic pain and bloatedness: prostaglandin, primrose, mirena IUCD, oral contraceptives, yasmin.

Reassurance, counseling, psychotherapy and selective use of medications help to control the symptoms.

Contributor- Dr. Yagika Pareek