DYSMENORRHOEA

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DYSMENORRHOEA
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• Dysmenorrhea
• is defined as severe, cramping pain in the
  lower abdomen that occurs just before or during
  menses.
• (primary or secondary)
• Primary dysmenorrhoea occurs in the absence of
  significant pelvic pathoIogy. usually develops
  within the first 2 years of the menarche

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Characteristics of primary dysmenorrhoea

• The pain is often intense, cramping, crippling
  and severely incapacitating so that it causes a
  major disruption of social activities.
• It is usually associated with the onset of
  menstrual blood loss but may begin on the day
  preceding menstruation.
• The pain only occurs in ovulatory cycles, is
  lower abdominal in nature but sometime radiates
  down the anterior aspect of the thighs.
• The pain often disappears or improves after the
  birth of the first child.
• Dysmenorrhoea is often associated with vomiting
  and diarrhoea
• Pelvic examination reveals no abnormality of the
  pelvic organs.

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Pathophysiology of primary dysmenorrhoea

• Primary dysmenorrhoea is a feature of ovulatory
  cycles and usually appears within 6 to 12 months
  of the menarche.
• The etiology of primary dysmenorrhea has been
  attributed to uterine contractions or ischemia,
  psychological factors, and cervical factors.
• Psychological factors may alter the perception
  of pain but are not unique to the problem of
  dysmenorrhea.
• There is no convincing evidence of cervical
  stenosis in patients with dysmenorrhea, so there
  is no basis for incriminating cervical stenosis
  or psychological factors as major contributors to
  the
• problem of primary dysmenorrhea.

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Pathophysiology of primary dysmenorrhoea

• Women with dysmenorrhea have increased uterine
  activity, which may manifest as increased resting
  tone, increased contractility, increased
  frequency of contractions, or incoordinate
  action.
• Prostaglandins are released as a consequence of
  endometrial cell lysis with instability of
  Iysosomes and release of enzymes. which break
  down cell membranes
• The evidence that prostaglandins are involved in
  primary dysmenorrhoea is convincing. Menstrual
  fluid from women with dysmenorrhea has higher
  than normal levels of prostaglandins (especially
  PGF2a and PGE2), and these levels can be reduced
  to below normal with nonsteroidal
  anti-inflammatory drugs (NSAIDs). which are
  effective treatments.

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Clinical Symptoms

• Primary dysmenorrhoea usually begins 6 to 12
  months after menarche, almost invariably
  coinciding with the onset of ovulatory cycles.
  Patients complain of spasmodic or cramping lower
  abdominal pain that may radiate suprapubically or
  to the inner aspect of the thighs. They may have
  backache of varying severity. They may also have
  other accompanying symptoms, such as headache,
  nausea,vomiting, diarrhea, or fatigue. Symptoms
  typically last 48 hours or less, but sometimes
  may last up to 72 hours.

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Secondary dysmenorrhoea

• Secondary dysmenorrhoea is caused by organic
  pelvic pathology and it usually has its onset
  many years after the menarche.
• Any woman who develops secondary dysmenorrhoea
  should be considered to have organic pathology in
  the pelvis until proved otherwise.
• Pelvic examination is particularly important in
  this situation and, if the findings are negative,
  laparoscopy is indicated.
• Common associated pathologies include
  endometriosis, adenomyosis, pelvic infections and
  intra-uterine lesions such as
• submucous,fibroid.

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Pathophysiology of secondary dysmenorrhoea

• The mechanism of pain in secondary dysmenorrhoea
  is due to pelvic congestion which is more marked
  in the premenstrual period.
• Pain increases in its severity as menstruation
  approaches and is relieved by the onset of
  menstrual flow, due to the diminution of pelvic
  congestion.

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Clinical Symptoms

• Secondary dysmenorrhoea usually starts few days
  (about 3 to 5 days) before menstruation.
• Pain is continuous dull aching lower abdominal
  pain accompanied by backache occurring in parous
  women after many years of relatively painless
  menstruation.
• Secondary dysmenorrhoea may be associated with
  other symptoms as dyspareunia, infertility and
  abnormal bleeding.

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Management

• Primary dysmenorrhoea
• General and psychological treatment
• Discussion and reassurance are an essential
  part of management. Primary dysmenorrhoea tends
  to present some months after the menarche and is
  associated with ovulatory cycles, early cycles
  frequently being anovulatory. The intensity of
  pain may be aggravated by apprehension and fear,
  and reassurance that the pain does not indicate
  any serious disorder may lessen the symptoms. It
  is also common for the pain to either disappear
  or substantially lessen after the birth of the
  first child.

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• Drug therapy
• Dysmenorrhoea can be effectively treated by
  drugs that inhibit prostaglandin synthesis and
  hence uterine contractility.
• These drugs include aspirin, mefenamic acid,
  naproxen or ibuprofen. As dysmenorrhoea is often
  associated with vomiting, headache and dizziness,
  it may be advisable to start therapy either on
  the day before the period is expected, or as soon
  as the menstrual flow commences
• Mefenamic acid is given in a dose of 250 mg
  6-hourly. This drug also reduces menstrual flow
  in some women with menorrhagia.

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• If these drugs are inadequate, suppression of
  ovulation with the contraceptive pill is highly
  effective in reducing the severity of
  dysmenorrhoea. Where it is ineffective, then
  careful consideration should be given to the
  possibility of underlying pathology.
• If all conservative medical therapy fails, then
  relief may sometimes be achieved by mechanical
  dilatation of the cervix or by the surgical
  removal of the pain fibers to the uterus in an
  operation known as presacral neurectomy, but
  these methods of treatment should be approached
  with considerable caution.

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Physical therapy

• Encourage regular and aerobic exercises in fresh
  air to raise their general health .
• Relaxation techniques, as well as meditation and
  hypnosis may be helpful for raising their pain
  threshold.
• Avoid constipation.
• Massage .
• Hot packs on the lower abdomen for 10-15 minutes.
• Accupressure on the lumosacral area and 3 cm
  superior to the medial malleolus.

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• TENS
• Low level laser therapy

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• Secondary dysmenorrhoea
• In cases of secondary dysmenorrhoea, the
  treatment is dependent on the nature of the
  underlying pathology. If the pathology is not
  amenable to medical therapy, the symptoms may
  only relieved by hysterectomy. However, the role
  of physical therapy in such cases will consist of
  pre and post operative physical treatment.