GYN 14

• Dysmenorrhea


  Painful menstruation of sufficient magnitude so as to incapacitate day to day activities
• Types of dysmenorrhea


  • Primary
  • Secondary

  
• Primary dysmenorrhea


  No identifiable pelvic pathology
• Primary dysmenorrhea


  • Mostly confined to adolescents
  • Almost always confined to ovulatory cycles
  • The pain is usually cured following pregnancy and vaginal delivery
• The incidence of primary dysmenorrhea of sufficient magnitude with incapacitation is about 15–20%

  
• With the advent of oral contraceptives and nonsteroidal anti-inflammatory drugs (NSAIDs), there is marked relief of the symptom
• Causes of pain in primary dysmenorrhea

  • Dysrhythmic uterine contractions and uterine hypoxia
  • Psychosomatic factors of tension and anxiety during adolescence; lower the pain threshold
  • Abnormal anatomical and functional aspect of myometrium
  • Imbalance in the autonomic nervous control of uterine muscle
  • Role of prostaglandins
  • Role of vasopressin
  • Endothelins causes myometrial smooth muscle contractions
  • Platelet activating factor (PAF) is also associated with the etiology of dysmenorrhea
• Junctional zone (JZ)


  • Marked hyperperistalsis in women with endometriosis and adenomyosis
  • Irregular thickening and hyperplasia of smooth muscle and less vascularity in women with dysmenorrhea
• Junctional zone hyperplasia

  Dysperistalsis and hyperactivity of the uterine JZ are the important mechanisms of primary dysmenorrhea

  
• Differentiating features between primary and secondary dysmenorrhea

  • Primary: No identifiable pelvic pathology, Mostly in adolescents, Confined to ovulatory cycle, Starts with the onset or just before the mens
  • Secondary: Secondary to pelvic pathology, Elderly/parous women, Pain starts 7–10 days before the onset of menstruation, No systemic discomfort, Intermenstrual period not completely free of pain

  
• Clinical features of primary dysmenorrhea

  • The pain begins a few hours before or just with the onset of menstruation
  • The severity of pain usually lasts for few hours, may extend to 24 hours but seldom persists beyond 48 hours
  • The pain is spasmodic and confined to lower abdomen; may radiate to the back and medial aspect of thighs
  • Systemic discomforts like nausea, vomiting, fatigue, diarrhea, headache and tachycardia may be associated
  • Vasomotor changes causing pallor, cold sweats and occasional fainting

  
• Abdominal or pelvic (rectal) examination does not reveal any abnormal findings
• Ultrasound is very useful for detection and exclusion of any pelvic abnormalities
• Treatment for primary dysmenorrhea

  • General measures: Improvement of general health, Simple psychotherapy, Usual activities including sports to be continued, Keep bowels empty
  • Drugs: Prostaglandin synthetase inhibitors, Oral contraceptives, Dydrogesterone, LNG-IUS
  • Surgery: Transcutaneous electrical nerve stimulation (TENS), Laparoscopic uterine nerve ablation (LUNA), Laparoscopic presacral neurectomy, Dilatation of cervical canal

  
• Laparoscopic uterine nerve ablation (LUNA) for primary dysmenorrhea has not been found beneficial
• Secondary dysmenorrhea


  Menstruation-associated pain occurring in the presence of pelvic pathology

  
• Common causes of secondary dysmenorrhea

  • Endometriosis
  • Adenomyosis
  • IUCD in utero
  • Obstruction due to Müllerian anomalies
  • Cervical stenosis
  • Pelvic adhesions
  • Uterine fibroid
  • Pelvic congestion
  • Endometrial polyp
  • Chronic pelvic infection

  
• The pain in secondary dysmenorrhea may be related to increasing tension in the pelvic tissues due to premenstrual pelvic congestion or increased vascularity in the pelvic organ
• Hormonal treatments for dysmenorrhea

  • Combined oral contraceptive pills: 1 tablet daily
  • Oral progestins (dydrogesterone): D5-D25
  • LNG-IUS

  
• Surgical treatments for dysmenorrhea

  • Laparoscopic uterine nerve ablation (LUNA)
  • Laparoscopic presacral neurectomy (LPSN)
  • Dilatation of cervical canal
• Laparoscopic presacral neurectomy (LPSN)


  Done to cut down the sensory pathways (via T11–T12) from the uterus. It is not helpful for adnexal pain (T9–T10) as it is carried out by thoracic autonomic nerves along the ovarian vessels. As such its role in true dysmenorrhea is questionable.

  
• Dilatation of cervical canal

  Done under anesthesia for slow dilatation of the cervix to relieve pain by damaging the sensory nerve endings. It is not commonly done.
• Causes of secondary dysmenorrhea pain

  • Increasing tension in the pelvic tissues due to premenstrual pelvic congestion
  • Increased vascularity in the pelvic organs
• Patient profile for secondary dysmenorrhea

  Usually in their thirties, more often parous and unrelated to any social status

  
• Clinical features of secondary dysmenorrhea

  Dull pain situated in the back and in front without any radiation, appears 3–5 days prior to the period and relieves with the onset of bleeding, no systemic discomfort, may have discomfort even in between periods, may present with other gynecological symptoms like dyspareunia, dysuria, abnormal uterine bleeding and infertility

  
• Investigations for secondary dysmenorrhea

  • Transvaginal sonography
  • Saline infusion sonography
  • Laparoscopy
  • Hysteroscopy

  
• Right ovarian vein syndrome


  Right ovarian vein crosses the ureter at right angle. During premenstrual period, due to pelvic congestion or increased blood flow, there may be marked engorgement in the vein → pressure on ureter → stasis → infection → pyelonephritis → pain.
• Other causes of unilateral dysmenorrhea

  • Ovarian dysmenorrhea
  • Bicornuate uterus
  • Unilateral location of pelvic endometriosis
  • Small fibroid polyp near one cornu
  • Right ovarian vein syndrome
  • Colonic or cecal spasm

  
• Mittelschmerz's syndrome (ovulation pain)

  Ovular pain that appears in the midmenstrual period, usually situated in the hypogastrium or in either of the iliac fossa, located on one side depending upon the side of ovary is ovulating, does not change from side to side, rarely lasts more than 12 hours, may be associated with slight vaginal bleeding or excessive mucoid vaginal discharge

  
• Probable factors for mittelschmerz

  • Increased tension of the Graafian follicle just prior to rupture
  • Peritoneal irritation by the follicular fluid following ovulation
  • Contraction of the tubes and uterus
• Treatment for mittelschmerz


  Effective with assurance and analgesics, cure is absolute by making the cycle anovular with contraceptive pills
• Pelvic congestion syndrome


  Disturbance in the autonomic nervous system, which may lead to gross vascular congestion with pelvic varicosities, patient has a congestive type of dysmenorrhea without any demonstrable pelvic pathology
• Pathogenesis of pelvic congestion syndrome

  Chronic pelvic pain, sensation of heaviness and pelvic pressure are due to the congested and tortuous ovarian and pelvic veins, mainly due to incompetent valves in the veins to cause retrograde flow and stasis, estrogen is also implicated in the pathology of venous dilatation in addition to the mechanical factors
• Diagnosis of pelvic congestion syndrome


  Made by physical examination, tenderness at the junction of the middle and lateral third of a line drawn between the symphysis and the anterior superior iliac spine or direct ovarian tenderness, radiologic study (pelvic venography), Doppler scan, duplex ultrasound scans, CT, MRI or angiography, dilated tortuous ovarian vein with diameter ≥6 mm, laparoscopic diagnosis is difficult as with intraperitoneal pressure and Trendelenburg position, these vessels may be compressed but will reappear as the pressure is reduced
• Clinical features of pelvic congestion syndrome

  Vague disorders with backache and pelvic pain with long standing position, at times with dyspareunia, may have menorrhagia or metrorrhagia, uterus may feel bulky and boggy
• Treatment options for pelvic congestion syndrome

  • Hormonal suppression
  • Ovarian vein embolization
  • Hysterectomy with bilateral salpingo-oophorectomy (BSO)
• Premenstrual syndrome (PMS)


  A psychoneuroendocrine disorder of unknown etiology, often noticed just prior to menstruation, with cyclic appearance of a large number of symptoms during the last 7–10 days of the menstrual cycle, several biological factors like estrogen, progesterone, neurotransmitters—gamma aminobutyric acid (GABA), serotonin and the renin-angiotensin–aldosterone system (RAAS) are thought to be involved
• Diagnosis of premenstrual syndrome (PMS)


  According to American Psychiatric Association (2013) Diagnostic and Statistical Manual (DSM) recommends symptoms to be confirmed by prospective patient mood charting for at least two menstrual cycles, common psychiatric conditions like depression and anxiety disorders are excluded, additionally other medical conditions that have a multisystem presentation are also ruled out

  
• Neuroendocrine factors involved in PMS

  • Serotonin (decreased synthesis during luteal phase)
  • Endorphins (withdrawal during luteal phase)
  • GABA (suppresses anxiety level in the brain)
• Psychological and psychosocial factors may be involved to produce behavioral changes in PMS