Dysmenorrhoea and pelvic pain
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Dysmenorrhoea: derived from the Greek meaning difficult monthly flow
it's classified into
Primary dysmenorrhoea when there is no pelvic pathology, prevalence
(45-95%)
Secondary dysmenorrhoea when there is underlying pathology which
leads to painful menstruation
Primary dysmenorrhoea:
Highly prevalent condition is associated with uterine hypercontractility,
characterized by excessive amplitude and frequency of contractions and
a high resting tone between contractions, during contractions
endometrial blood flow is reduced this suggesting ischemic nature of
pain.
Prostaglandin and leukotriene levels are elevated in menstrual fluid and
uterine tissue as are systemic levels of vasopressin.
Clinical features:
It appears 6-12 mo. After menarche, when ovulatory cycles are
established.
There is lower abdominal cramps and backache, which may be
associated with GI disturbances such as diarrhea and vomiting
Diagnosis is of exclusion, therapeutic trial may be tried before any
examination and investigation especially in adolescents. If clinical
evaluation raise the suspicion of secondary dysmenorrhoea eg
cryptomenorrhoea in an accessory uterine horn, investigations are
required eg. high vaginal swab, endocervical swab, TVS, MRI,
hysteroscopy, laparoscopy is considered.
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Management:
Non steroidal anti-inflammatory drugs:
COX-1 inhibitor such as mefenamic acid, naproxen, ibuprofen, and
aspirin are all effective.
Hormonal treatment:
COCP combined oral contraceptive pills,
Are thought to act by inhibiting ovulation,
Decreasing endometrial production of prostaglandins, and leukotriens
by inducing endometrial atrophy.
Other hormonal methods LNG-IUS, in women aged 25-47 years,
levonoregestrel intrauterine systems were associated with reduced
menstrual pain from 60- 29% after 36 mo. Of device- use.
High dose progesterone only pills (inhibit ovulation)
Other methods:
Vasopressin receptor antagonist
Beta adrenergic agonists
Transdermal glyceryltrinitrates
Vitamin E
Omega 3 poly unsaturated fatty acids
Surgical treatment: aimed at interrupting the nerve pathways from the
uterus, there is some evidence of their efficacy, it should only be done in
special centers for treatment of women who's condition is unresponsive
to medical therapy.
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Secondary dysmenorrhoea:
May be symptom of
Endometriosis
fibroids
Pelvic inflammatory disease
Adenomysis
Asherman's syndrome
Rarely cervical stenosis
Clinically, patient spent part of her reproductive age with normal menses
then she start to develop dysmenorrhoea with or without altered
menstrual pattern.
Investigations and management are directed according to underlying
pelvic pathology.
Pelvic pain:
Acute pelvic pain can be due to life threatening conditions which require
urgent diagnosis and treatment.
Chronic pelvic pain syndrome is estimated to account for 10% of all visits
to gynecologists.
It refers to continuous lower abdominal, pelvic pain that markedly
hinders their daily activities, with devastating impact on quality of life, in
the lack of physical finding psychological effects may be considered:
Major depression, sexual dysfunction, and substance abuse
Sexual abuse
Acute pelvic pain
Differential diagnosis:
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1- ectopic pregnancy: the pain is due to distension of tube by growing
pregnancy, is usually unilateral
2-rupture ovarian cyst: midcycle pain or Mittleschmerz, lower abdominal
pain noticed at time of ovulation, is believed to be secondary to
chemical irritation of the peritoneum from ovarian follicular cyst after
ovulation, pain lasts from few hours- 2days, diagnosis is by ultrasound
3-ovarian torsion, clinical presentation with pain which's proportional
with ischemia, diagnosis is with color Doppler, laparoscopy, if necrotic
ovary must be removed, if viable it may be untwisted and cystectomy
performed.
4-pelvic inflammatory disease (PID)
5-gastrointestinal disorders: appendicitis, diverticulitis
6-urological causes: cystitis, renal stones.
Chronic recurrent pelvic pain: either cyclic or constant
1-dysmenorrhoea
2-pelvic adhesions: 70% is due to operative procedures, other causes are
endometriosis, or infection, foreign body granuloma caused by gauze,
suture material, and diagnosis is by history of previous surgery, physical
exam, laporoscopy-laporoscopic lysis of adhesion results in
improvement of symptoms
3-endometriosis: is prevalent in 25-40% of patients with chronic pelvic
pain.
4-adenomyosis: can also presents will chronic pelvic pain and severe
dysmenorrhoea. The diagnosis is by MRI, histopathological study of
excised uteri.
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