General Gynecology and Oncology: Dysmenorrhea Overview

Dysmenorrhea is defined as pain during menstruation that significantly impacts a woman's daily activities and often requires medication. It can be categorized into primary, secondary, and membranous types based on underlying causes. The pathogenesis involves elevated prostaglandin levels and potential psychologic factors. Clinical findings typically arise during ovulatory cycles and may lead to significant absenteeism in adolescents. Differential diagnosis includes considerations of secondary dysmenorrhea, such as endometriosis. Treatment options range from NSAIDs to surgical interventions.

• Dysmenorrhea
• Gynecology
• Abnormal Bleeding
• Womens Health

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1. Unit III. General Gynecology & Oncology Mihretu Molla 2/17/2025 Mihretu Molla 1

2. Presentation out line Dysmenorrheal AUB (Abnormal uterine Bleeding ) & DUB 2/17/2025 Mihretu Molla 2

3. Dysmenorrhea 2/17/2025 Mihretu Molla 3

4. Dysmenorrhea (definition) Dysmenorrhea is pain during menstruation that prevents women from normal activity and requires medication. 2/17/2025 Mihretu Molla 4

5. Types of dysmenorrhea primary (no organic cause) secondary (pathologic cause) membranous (cast of endometrial cavity shed as a single entity) 2/17/2025 Mihretu Molla 5

6. Pathogenesis prostaglandin activity (Prostaglandins are present in much higher concentrations in women with dysmenorrhea than in those with mild or no pain). increased leukotriene levels as a contributing factor. Psychologic factors may be involved, including attitudes passed from mother to daughter. Emotional anxiety due to academic or social demands may be a cofactor. 2/17/2025 Mihretu Molla 6

7. Clinical Findings Because dysmenorrhea almost always is associated with ovulatory cycles, it does not usually occur at menarche but rather later in adolescence. As many as 14 26% of adolescents miss school or work as a result of pain. Typically, pain occurs on the first day of the menses, usually about the time the flow begins, but it may not be present until the second day. Nausea and vomiting, diarrhea, and headache may occur. The physical examination does not reveal any significant pelvic disease. When the patient is symptomatic, she has generalized pelvic tenderness, perhaps more so in the area of the uterus than in the adnexa. 2/17/2025 Mihretu Molla 7

8. Differential Diagnosis secondary dysmenorrhea due to endometriosis 2/17/2025 Mihretu Molla 8

9. Treatment NSAIDs or acetaminophen may relieve mild discomfort Antiprostaglandins :naproxen (550 mg/day.), Cyclooxygenase-2 (COX- 2) inhibitors such as valdecoxib (20 40 mg/day Oral Contraceptives Surgical Treatment : Laparoscopic uterosacral ligament division and presacral neurectomy 2/17/2025 Mihretu Molla 9

10. Abnormal uterine bleeding Def: any bleeding from the uterus that differs from the usual menstrual cycle in frequency, amount, duration of flow. 2/17/2025 Mihretu Molla 10

11. Patterns of AUB Menorrhagia hypermenorrhea heavy or prolonged menstrual flow Causes submucous myoma Complications of pregnancy adenomyosis Endometrial hyperplasia malignant trs, DUB 2/17/2025 Mihretu Molla 11

12. Patterns. Hypomenorrhea cryptomenorhea Light menstrual flow Causes Hymenal or cervical stenosis Uterine synechia, ocp 2/17/2025 Mihretu Molla 12

13. Patterns. Metrorrhagia intermenstrual bleeding bleeding occur at any time between menstrual periods Causes endomerial polyps endometrial and cervical Ca exogenous est 2/17/2025 Mihretu Molla 13

14. Patterns. Menometrorrhagia period that occurs at irregular intervals irregular, prolonged and excessive in amount. Causes anovulation est secreting trs 2/17/2025 Mihretu Molla 14

15. Patterns. Polymenorrhea period that occurs too frequently a menstrual cycle interval of < 21 days Causes Anovulation shortened luteal phase 2/17/2025 Mihretu Molla 15

16. Patterns. Oligomenorrhea menstrual periods that occurs more than 35 days apart causes An ovulation est secreting trs 2/17/2025 Mihretu Molla 16

17. Patterns.. Contact bleeding- post coital bleeding Must be considered a sign of cervical Ca until proved other wise. Other causes cervical polyp cervical or vaginal infection 2/17/2025 Mihretu Molla 17

18. Causes of AUB prepubertal premenarchal Vulval lesions vulval fissure, maceration, condy lomas F. body Vulvovaginitis Precocious puberty Trauma - abuse, penetration Vaginal and ovarian trs Exogenous hormones 2/17/2025 Mihretu Molla 18

19. Causes of AUB Adolescence anovulation (90%)- hypothalamic immaturity pregnancy related bleeding exogenous hormones Hematologic abnormalities 2/17/2025 Mihretu Molla 19

20. Adolescence AUB infections- cervicitis, PID endocrine or systemic problems thyroid and hepatic dysfunction PCOS Mullerian abnormalities Long vaginal septa UX didelphis 2/17/2025 Mihretu Molla 20

21. Causes . Reproductive age group pregnancy related bleeding DUB Exogenous hormones, endocrine causes Anatomic causes Myoma, adenomyosis , endometrial polyps cervical lesions polyps, infections, lesions ,condyloma ,HSV ulcer Hematologic causes Coagulation abn thrombocytopenia, v. will brand s - Leukemia Neoplasia Ca (cervical , endometrial ,vaginal) Infectious causes - cervicitis,endometritis 2/17/2025 Mihretu Molla 21

22. Causes Dysfunctional uterine bleeding Def-abnormal Ux bleeding for which no specific organic cause can be found , after a thorough evaluation and work up of Pt. Most often occurs in the absence of the cyclic hormonal changes that regulate the menstrual cycle. 2/17/2025 Mihretu Molla 22

23. DuB.. Is often a dx of exclusion organic causes must be excluded AUB at extremes of reproductive life usually is due to anovulation (DUB) Pathophysiology of DUB Most common etiology is est. withdrawal or est break through bleeding In absence of ovulation est stimulates the endometrium without production of progesterone 2/17/2025 Mihretu Molla 23

24. Pathophysiology.. unopposed est leads to excessive glandular proliferation with lack of stromal support unstable, fragile, hetrogenous endometrium prone to superficial breakdown and bleeding. endometrium slough off in isolated location, the remaining raw surface is restimulated by est and heals as another part of endometrium is slough off 2/17/2025 Mihretu Molla 24

25. Etiology of DUB A .Causes of anovulation or oligoovulation Anovulatory cycles are sms of disruption of the normal regulatory mechanisms that control menstrual cycle. abnormalities at any site of hypothalmo- pituitary ovarian axis 2/17/2025 Mihretu Molla 25

26. 1.Dysfunction of hypothalamic pituitary ovarian axis Any factor that interferes with the normal pulsatile secretion of GnRH leads to an ovulation Causes .Hyperprolactinemia P. adenoma, psychotropic drugs,hypothyroidism stress and anxiety rapid weight loss anorexia nervosa 2/17/2025 Mihretu Molla 26

27. 2.Immaturity of hypothalamic pituitary ovarian axis -in post pubertal adolescence shortly after menarche 3. Abnormalities of normal feed back signals Estradiol levels play a critical role in controlling the sequence of events during normal ovulatory cycles medical conditions hepatic ds , thyroid abnormalities affect metabolism and clearance of estradiol 2/17/2025 Mihretu Molla 27

28. 4. other causes Pcos b. causes with ovulation DUB 2ry to hormonal causes may occur during ovulatory cycles ovulatory pts with AUB are more likely to have an underlying organic pathology & are not true DUB pts 2/17/2025 Mihretu Molla 28

29. Evaluation of AUB A. History age, parity, marital status, sexual Hx current pattern of bleeding menstrual Hx age at menarche, cycle frequency and duration, contraceptive use & other medications anticoagulants, psychotropic drugs 2/17/2025 Mihretu Molla 29

30. Evaluation medical Hx sms of endocrine & other organic diseases bleeding tendency & family Hx of bleeding disorder s/s of stress & s/s of PID 2/17/2025 Mihretu Molla 30

31. Physical examination General P/E thyroid enlargement, galactorrhea, ecchymosis, purpura pallor, v/s Gynecologic exam 2ry sexual x-stics, vaginal trauma, sign of infection, atrophic vaginitis and F.body 2/17/2025 Mihretu Molla 31

32. Lab evaluation based on Hx physical findings CBC- Hgb & HCT, WBC, platlet count Pregnancy test should be done in all pre menopausal AUB Test for -STI Coagulation profile PT, PTT TSH, LFT 2/17/2025 Mihretu Molla 32

33. Androgen profile Testesterone, DEA, 17 alpha hydoxy progestrone Diagnostic procedures ultrasonography & sonohysterography Intra Ux polyps, submucous myoma, ovarian masses Ux contour, endometrial thickness 2/17/2025 Mihretu Molla 33

34. endometrial biopsy to R/o endometrial ca Indication those at risk for endometrial hyperplasia or ca those older than 40 yrs of age those younger than 40 yrs of age who have chronic unopposed est breakthrough bleeding 2/17/2025 Mihretu Molla 34

35. Hysteroscopy with endometrial sampling Indication cervical stenosis precluding adequate end ometrial biopsy pt intolerance of endometrial biopsy anatomic factors precluding adequate end biopsy 2/17/2025 Mihretu Molla 35

36. Hysteroscopy presence of AUB in a pt undergoing another surgical procedure with GA Direct visualization of endometrial cavity, allow targeted biopsy or excision of the lesion Gold standard for Dx of AUB 2/17/2025 Mihretu Molla 36

37. Management of AUB Depends on the etiology of the bleeding In identifiable causes the Rx is targeted to wards the cause Objective of Rx Control bleeding Prevent recurrence Preserve fertility Correct associated disorders 2/17/2025 Mihretu Molla 37

38. The Mx of DUB depends on age of pt severity of bleeding desire for future pregnancy presence of associated pathology 2/17/2025 Mihretu Molla 38

39. Rx A. Hormonal Rx 1. progestins - Rx of choice for anovulatory DUB - stops endometrial growth, support & stabilize the endometrium an organized sloughing off the endometrium occurs after its withdrawal. - oral medroxy progesterone acetate 10 mg/day for the 1st 12 days each month or day 16 through 25 of each cycle 2/17/2025 Mihretu Molla 39

40. Rx 2 .oral contraceptive therapy Convert a fragile, overgrown endometrium into a pseudo decidualized structurally stable lining Controls bleeding with in 24 hrs 2/17/2025 Mihretu Molla 40

41. OCP Low dose combined OCP 2 to 3x a day for 5 to 7 days, then once a day for 3 months. 3. High dose estrogen - promotes rapid endometrial regrowth to cover denuded epithelial surfaces - conjugated equine estrogen 10 mg Po/day qid or 25mg lv Q 2 to 4hrs for 24hrs then oral est 10mg/day for 21 to 25days and medroxy progesterone acetate10mg/day for the last 7-10days. - bleeding usually stops with in 24hrs 2/17/2025 Mihretu Molla 41

42. B .Medical therapy 1. non steroidal anti inflammatory agents - inhibit synthesis of PGs - alter the balance b/n thromboxane & - effective in ovulatory DUB - eg. Ibuprofen, Naproxen 2. GnRH agonists - down regulate pituitary synthesis of FSH & LH and induce medical menopause - last resort when all modalities fail prostacycline 2/17/2025 Mihretu Molla 42

43. 3. Rx of coagulation disorder - desmopressine factor VIII - antifibrinolytic agents E. aminocaproic acid tranexamic acid 2/17/2025 Mihretu Molla 43

44. Surgical therapy 1. D&C with or without hysteroscopy Done in pts with bleeding refractory to medical therapy Can be diagnostic & therapeutic modality In age above 40 yrs it must be done Age 20 to 40yrs postponed Age <20yrs should be deffered 2/17/2025 Mihretu Molla 44

45. Surgical 2 .Hysterectomy If failed to respond to medical Rx, repeated curettage, endometrial ablation More definitive -consider age of the pt, her desire for future fertility 2/17/2025 Mihretu Molla 45

46. 3 Endometrial ablation Destruction of the endometrium For woman who are not candidate for hysterectomy Using laser, electrocautery, thermal destructive technique 2/17/2025 Mihretu Molla 46

47. Post menopausal bleeding Defn. bleeding that occurs after 12 months of amenorrhea in a middle aged woman more likely to be caused by pathological disease must always be investigated at least of PMB woman have neoplasia 2/17/2025 Mihretu Molla 47

48. PMB Etiology - Exogenous hormones -30% HRT frequency of bleeding depends on the regimen used atrophic endometritis/ vaginitis -30% Commonest cause of pmb due to hypoestrogenism results in a thin surface that is prone to bleed especially after trauma 2/17/2025 Mihretu Molla 48

49. - Endometrial ca-15% - endometrial or cervical polyps-10% - endometrial hyperplasia -5% - miscellaneous- cervical ca, uterine sarcoma -10%, ovarian ca, vaginal ca 2/17/2025 Mihretu Molla 49

50. Dx pelvic examination endometrial sampling office biopsy Hysteroscopy D&C Pelvic u/s Mx cause directed 2/17/2025 Mihretu Molla 50

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