Premenstrual syndrome Dysmenorrhea

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Premenstrual syndromeDysmenorrhea

• Dr.Roaa H. Gadeer
• MD

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PMS/PMDD

• The presence of physical and/or behavioral
  symptoms that occur repetitively in the second
  half of the menstrual cycle and often the first
  few days of menses.

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Incidence

• 70 - 80
• Only 20 are clinically significant.
• PMDD affect only 5-6
• Relatively high rates
• Mediterranean countries, the Middle East,
  Iceland, Kenya, and New Zealand

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• Premenstrual syndrome
• 1. The presence by self report of at least one of
  the following somatic and affective symptoms
  during the five days prior to menses in each of
  the three menstrual cycles
• Affective Depression, Angry, outbursts,
  Irritability Confusion, Social withdrawal,
  Fatigue.
• Somatic Breast tenderness, Abdominal bloating
  ,Headache, Swollen extremities.
• 2. Relief of the above symptoms within four days
  of the onset of menses, without recurrence until
  at least cycle day 13.

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• 3.The symptoms are present in the absence of any
  pharmacologic therapy, hormone , drug or alcohol
  use.
• 4. Identifiable dysfunction in social or economic
  performance by one of the following criteria
• Marital or relationship discord.
• Difficulties in parenting.
• Poor work or school performance.
• Tiredness/Increased social isolation.
• Legal difficulties.
• Suicidal ideation.
• Seeking medical attention for a somatic symptom.

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PATHOGENESIS

• interaction of cyclic changes in ovarian steroids
  with central neurotransmitters.
• Serotonin.
• Beta-endorphin.
• Gamma-aminobutyric acid (GABA).
• Autonomic nervous system.
• Peripheral mechanisms.

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• Symptom
• Fatigue 92
• Irritability 91
• Bloating 90
• Anxiety/tension 89
• Breast tenderness 85
• Mood liability 81
• Depression 80
• Food cravings 78
• Acne 71
• Increased appetite 70
• Over sensitivity 69
• Swelling 67
• Expressed anger 67
• Crying easily 65
• Feeling of isolation 65
• Headache 60
• Forgetfulness 56
• Gastrointestinal symptoms 48

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• Diagnostic criteria are
• The American Psychiatric Association DSM-IV
  criteria for PMDD
• The University of California, San Diego (UCSD)
  criteria for PMS

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• DSM-IV criteria (PMDD)
• Documentation of physical and behavioral symptoms
  being present for most of the preceding year.
• Five or more of the following symptoms must have
  been present during the week prior to menses.
• Resolving within a few days after menses starts.
• At least one of the five symptoms must be one of
  the first four on this list
• Feeling sad, hopeless, or self- deprecating
• Feeling tense, anxious
• Marked liability of mood / tearfulness
• Persistent irritability, anger, and increased
  interpersonal conflicts
• Decreased interest in usual activities /
  withdrawal from social relationships
• Difficulty concentrating
• Feeling fatigued, lethargic, or lacking in energy
  
• Marked changes in appetite, which may be
  associated with binge eating or craving certain
  foods
• Hypersomnia or insomnia
• Being overwhelmed or out of control
• Breast tenderness or swelling, headaches, joint
  or muscle pain, a sensation of bloating, weight
  gain

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• UCSD criteria (PMS)
• In whom coexisting medical conditions or
  psychiatric disturbance were excluded by history,
  physical examination and psychometric testing.
• The presence of at least one of the following six
  Behavioral symptoms
• - Fatigue, irritability, depression, expressed
  anger, poor concentration, and social withdrawal.
• at least one of the following four Somatic
  symptoms
• - Breast tenderness, abdominal bloating,
  headache, or swollen extremities

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Therapies for the premenstrual syndrome

• Treatments with demonstrated efficacy
• Serotonin reuptake inhibitors (NOT Anti
  depressant)
• Alprazolam
• Agents that suppress ovulation
• GnRH agonists
• Danazol
• Treatments with possible efficacy
• Oral contraceptives
• Diuretics
• Exercise
• Ineffective treatments
• Progesterone
• Vitamin supplements/Dietary restrictions

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Dysmenorrhea
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• Dysmenorrhea painful menstruation.
• Primary Dysmenorrhea (PD) The presence of
  recurrent, crampy, lower abdominal pain that
  occurs during menses in the absence of
  demonstrable pelvic disease.
• Secondary Dysmenorrhea The occurrence of painful
  menstruation in the presence of a pelvic
  pathology, such as endometriosis, adenomyosis,
  uterine leiomyomata, or chronic pelvic
  inflammatory disease

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Incidence

•  PD typically begins during adolescence
• Not until ovulatory menstrual cycles are
  established.
• At two years postmenarche (18 to 45) teens have
  ovulatory cycles.
• 80 are ovulatory by four to five years
  postmenarche.
• The prevalence of dysmenorrhea among adolescent
  females ranges from 60 to 93 percent, but
  decreases with advancing age

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RISK FACTORS

• Presentation at age less than 30 years.
• Body mass index less than 20.
• Menarche before age 12.
• Longer cycles/duration of bleeding.
• Irregular or heavy menstrual flow.
• Premenstrual symptoms.
• Pelvic inflammatory disease.
• Sterilization.
• History of sexual assault.
• Heavy smoking.

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Reduced risk of dysmenorrhea in

• Use of oral contraceptives.
• Fish intake.
• Physical exercise.
• Being married or in a stable relationship.
• Higher parity.

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• Major causes of secondary dysmenorrhea
• Gynecologic disorders
• Endometriosis
• Adenomyosis
• Ovarian cysts
• Pelvic adhesions
• Pelvic inflammatory disease
• Uterine polyps
• Congenital obstructive müllerian malformations
• Cervical stenosis
• Nongynecologic disorders
• Inflammatory bowel disease
• Irritable bowel syndrome
• Uteropelvic junction obstruction
• Psychogenic disorders

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PATHOGENESIS 

• PD is caused by frequent and prolonged uterine
  contractions that decrease blood flow to the
  myometrium resulting in ischemia (uterine
  "angina").
• Stimulation of the endometrium by estrogen
  (follicular and proliferative phase) followed by
  progesterone (luteal and secretory phase)
  increases endometrial stores of arachidonic acid.
• AA is a precursor to prostaglandin (PGF2),(PGE2)
  and leukotrienes.
• Cyclooxygenase inhibitors decrease menstrual
  fluid prostaglandin levels and decrease pain.

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CLINICAL MANIFESTATIONS

• Occurs during ovulatory cycles.
• The pain begins just before or with the onset of
  menstrual bleeding.
• Gradually diminishes over 12 to 72 hours.
• The cramps are confined to the lower abdomen
  (suprapubic).
• Pain is strongest in the midline (back and thigh
  pain).
• Nausea, diarrhea, fatigue, headache, and a
  general sense of malaise accompany the pain.
• By comparison, women with secondary dysmenorrhea
  often have symptoms and physical findings that
  alert the physician to the presence of pelvic
  pathology (Endometriosis).

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Treatment

• Nonpharmacological interventions
•   Heat
•   Dietary, vitamin, and herbal treatments
•   Exercise

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• Pharmacologic interventions
• A placebo
• Nonsteroidal antiinflammatory agents (NSAIDs)
• Hormonal contraceptives.
• Levonorgestrel intrauterine contraception IUD

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VAGINITIS

• NORMAL VAGINAL PHYSIOLOGY AND FLORA 
• Normal vaginal discharge consists of 1 to 4 mL
  fluid (per 24 hours).
• White or transparent, thick, and mostly odorless.
• Is formed by mucoid endocervical secretions in
  combination with sloughing epithelial cells,
  normal bacteria, and vaginal transudate.
• The discharge may become more noticeable (
  during pregnancy, use of estrogen-progestin
  contraceptives, midmenstrual cycle close to the
  time of ovulation.
• The pH of the normal vaginal secretions is 4.0
  to 4.5.
• Dozens of different bacterial isolates.
• Lactobacillus
• Diphtheroids
• S. epidermidis

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Causes of vaginitis

• Infectious vaginitis
• Common causes
• Bacterial vaginosis (40 to 50 percent of cases)
• Vulvovaginal candidiasis (20 to 25 percent of
  cases)
• Trichomoniasis (15 to 20 percent of cases)
• Less common causes
• Foreign body with secondary infection
• Desquamative inflammatory vaginitis
• Streptococcal vaginitis (group A)
• Ulcerative vaginitis associated with
  Staphylococcus aureus and toxic shock syndrome
• Idiopathic vulvovaginal ulceration associated
  with HIV.

• Noninfectious vaginitis
• Chemical or other irritant
• Allergic, hypersensitivity, and contact
  dermatitis (lichen simplex)
• Traumatic vaginitis
• Atrophic vaginitis
• Postpuerperal atrophic vaginitis
• Desquamative inflammatory vaginitis
  (steroid-responsive)
• Erosive lichen planus
• Collagen vascular disease, Behcet's syndrome,
• Idiopathic vaginitis

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GENERAL DIAGNOSTIC APPROACH

• History  Symptoms of vaginitis include abnormal
  vaginal discharge, pruritus, irritation, burning,
  soreness, odor, and, less commonly, dyspareunia
• Physical examination Appearance, cervical
  motion tenderness. The vulva usually appears
  normal in bacterial vaginosis. Erythema, edema,
  or fissure formation suggest candidiasis,
  trichomoniasis, or dermatitis.

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Diagnostic studies

• Vaginal pH
• Vaginal pH is the single most important finding.
• A strip of pH paper is applied to the vaginal
  sidewall.
• A pH above 4.5 in a premenopausal woman suggests
  infections such as bacterial vaginosis or
  trichomoniasis (pH 5 to 6), and helps to exclude
  candida vulvovaginitis (pH 4 to 4.5).
• Vaginal pH may be altered (usually to a higher
  pH) by contamination with lubricating gels,
  semen, douches, and intravaginal medications.
• Microscopy
• Candidal buds or hyphae
• Motile Trichomonas
• Epithelial cells studded with adherent
  coccobacilli (clue cells)
• Polymorphonuclear cells (PMNs).
• The saline should be at room temperature and
  microscopy should be performed within 10 to 20
  minutes.

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• Vaginal discharge processing
• is generally sampled with a cotton-tipped swab.
  The sample of vaginal discharge is mixed with one
  to two drops of 0.9 percent normal saline
  solution on a glass slide. Cover slips are placed
  on the slides, which are examined under a
  microscope at low and high power.
• The addition of 10 percent potassium hydroxide
  (KOH) to the wet mount of vaginal discharge
  destroys cellular elements (Candida vaginitis).
• Smelling ("whiffing") the slide immediately after
  applying KOH is useful for detecting the fishy
  (amine) odor of Bacterial Vaginosis.
• Excess WBCs without evidence of yeast,
  trichomonads, or clue cells suggests cervicitis.
• If microscopy is not available, diagnostic
  testing cards are an alternative rapid test for
  confirming the clinical suspicion.

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•  Vaginal culture
• For Candida or Trichomonas , if microscopy is
  negative because microscopy is not sufficiently
  sensitive to exclude these diagnoses in
  symptomatic patients.
• Cervical culture
• For cervicitis, typically due to Neisseria
  gonorrhoeae or Chlamydia trachomatis, if you see
  a purulent vaginal discharge, fever, or lower
  abdominal pain (PID).
• Sexual behaviors that result in STD-related
  vulvovaginitis (eg, trichomoniasis, herpes
  simplex virus) increase the odds of acquiring
  other STDs. The presence of high risk behavior or
  any sexually transmitted disease requires
  screening for HIV, hepatitis B, and other STDs.

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Candida Albicans
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Trichomonas
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Clue Cell (BV) Bacteroides species anaerobic
Peptostreptococcus species Fusobacterium sp. and
Atopobium vaginae
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Treatment

• Candida
• A-non complicated
• Butoconazole (Femstat)
• (Femstat) 2 percent cream 5 g/day for 3 days or
  1 day for sustained release formulation
• (Gynazole) 2 percent cream 5 g/day for a single
  dose
• Clotrimazole (Gyne- lotrimin, Mycelex) 1 percent
  cream 5 g/day for 7 to 14 days
• 100 mg vaginal tablet 1/day for 7 days
• Miconazole (Monistat) 2 percent cream 5 g/day for
  7 days
• 100 mg vaginal suppository 1/day for 7 days
• 200 mg vaginal suppository 1/day for 3 days
• 1200 mg vaginal suppository 1 suppository
• Tioconazole (Vagistat) 6.5 percent cream 5 g in a
  single dose
• Terconazole (Terazol) 0.4 percent cream 5 g/day
  for 7 days
• 80 mg vaginal suppository 1/day for 3 days
• Nystatin (Mycostatin) 100,000 U vaginal tablet
  1/day for 14 days
• Fluconazole (Diflucan)
• B- complicated
• Boric Acid

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Trichomonas / BV

• Metronidazole
• PO 500 mg bid x 7 days OR 2 gms single dose.
• PV
• Clindamycin 300 mg po bid x 5 days for BV.
• Treat the partner in Trichomoniasis

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Atrophic vaginitis

• Lubricating /moisturizing gel.
• Low dose Estrogen
• Systemic
• Local

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• Thanks