Dysmenorrhea - CRASH! Medical Review Series

Dysmenorrhea - CRASH! Medical Review Series

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00:13
we're back again with our OBGYN lectures this talk is going to be on dysmenorrhea so dis meaning painful memory abhi menstrual flow so painful menstrual flow painful menses and this is the cause of chronic or cyclical chronic pelvic pain in women of reproductive age so this is the most common cause of pelvic pain of cyclical pelvic pain in women of reproductive age you'll run into this
00:46
quite often so a 17 year old girl comes in to your clinic complaining of crampy lower abdominal and pelvic pain with her periods over the last year the pain predictably comes the day before she gets her period when she starts bleeding and it lasts about three or four days and it's completely gone by the time it stops bleeding right now she's presently having some lower abdominal pelvic pain she rates it as a plus four out of ten she also tells you that her last period
01:19
was four weeks ago and she says that she's a virgin and has no history of STDs physical exam is remarkable for my lower abdominal pain to palpation no rebound or guarding pelvic exam is unremarkable so what do we do with this patient what is our best next step in the management of this patient and you will run into this question on the test even though she says she's a virgin this goes for any woman of reproductive age if she comes in with abdominal pain your next
01:51
step is going to be pregnancy test so we're going to get a urine qualitative HCG and that is negative and the reason why we would want to get a pregnancy test is not only because we want to know is this a pregnancy is this an ectopic pregnancy but even if it were of course we're going to treat her pain and we want to know if she's pregnant because if she is pregnant we want to avoid n cents now that said giving NSAIDs very very very early on in pregnancy is probably not going to be a big deal it's more of a problem to give NSAIDs
02:23
later in the pregnancy but NSAIDs are contraindicated during pregnancy anyway so we don't want to give n sets if she's pregnant that said we know she's not pregnant the most likely diagnosis here is primary dysmenorrhea and the reason we can presume that diagnosis is because she doesn't have any other associated symptoms with the pain this is solely menstrual pain now if the question or the scenario had resulted in her having
02:55
a mass or that she had associated symptoms like diarrhea or constipation or if she the physical exam was remarkable for a fix Rett reverted uterus uterus sacral nodularity then we would want to look into alternative diagnosis but in this case this is pretty straightforward primary dysmenorrhea and it's common for it to present for the first time in a younger woman it's not very common to present for the first time and a woman
03:27
over the age of 25 so 17 would be right around the age we would expect it to show up okay so uh about six years ago I was vacationing in Europe and went to ballet in Switzerland and I visited a monastery that was open to the public and it happened to be dedicated to saint maurice who was a third century Roman Legionnaire headed
03:55
the Roman Theban army and it was told to me that this Saint has been traditionally prayed to invoked by women who have painful periods so how we came from an association of this Legion year this this warrior how he came to be associated with menstrual cramp in I wasn't able to get an answer but that is the legend behind saint-maurice okay
04:28
dysmenorrhea one of the most common causes of chronic pelvic pain and a woman of reproductive age if not the most common cause of chronic pelvic pain now dysmenorrhea is an umbrella term and when we're talking about dysmenorrhea in this lecture we're talking about primary dysmenorrhea because there are lots of things that we've already talked about like endometriosis fibroids that can cause chronic cyclical pelvic pain definitely endometriosis you get pain
05:00
with your periods that is a common cause of dysmenorrhea but that's a secondary dysmenorrhea we're going to talk about primary dysmenorrhea going forward here so dysmenorrhea is a cause of cyclical pelvic pain it comes and goes in predictable intervals which may be known or unbeknownst to the patient and so it's very important when a woman says that she has pain that comes and goes you want to know how often does it come and go because if it comes and goes every month then we're looking at a a
05:33
discman area situation most women will know I have pain with my periods I have my periods and I've got this awful pelvic pain that comes with it so you won't need to do a whole lot of probing just as a matter of practicality dysmenorrhea as mentioned can be primary or secondary so primary dysmenorrhea is like we had in this vignette it's cyclical menstrual pain with no identifiable underlying cause this is a diagnosis of exclusion so we always need
06:04
to rule out secondary causes like endometriosis adenomyosis fibroids etc before we render a diagnosis of primary dysmenorrhea we also need to rule out pregnancy as well so secondary dysmenorrhea is cyclical menstrual pain with an underlying cause there are a lot of causes of chronic pelvic pain so good on the list here lots and lots and lots of things can cause chronic pelvic pain
06:36
that is why you want to know is this pain cyclical does it come and go in predictable intervals because if you can identify this as a chronic cyclical pelvic pain you've narrowed your differential down quite significantly down to endometriosis adenomyosis leiomyoma dysmenorrhea may be a mild torsion and so if you know that it's
07:10
cyclical then you can you really help yourself otherwise then you have quite a wide differential another thing you can if you get a if you have an obstruction of the of the the outlet the the cervical outlet if there's an obstruction there that can cause a cyclical pelvic pain as well so lots of different causes of pelvic pain chronic pelvic pain but if you can get this
07:40
narrowed down that this is a cyclical pelvic pain then you're well on your way to rendering a diagnosis physical exam will be very very useful to you so lots and lots of causes don't worry about memorizing all these the ones in the red are the ones that are more important for the test in my opinion okay so the risk factors for primary dysmenorrhea include an earlier age at menarche can explain
08:13
that I don't know why longer menstrual periods not sure why here but my inclination is that women who have primary dysmenorrhea and have longer menstrual periods they're going to have more days of pain and therefore they're going to be more likely to come in and ultimately be diagnosed that's what I think higher BMI smoking and then we do know that parity appears to be associated with a decreased incidence of
08:44
primary dysmenorrhea do not know why I really don't know why these risk factors are what they are but that's what you have so the pathophysiology we know that endometrial cells release prostaglandins and so when they begin to die off and they release all these prostaglandins the prostaglandins stimulate Maya metrio contraction and they also incite ischemia
09:15
they cause ischemia of the by causing constriction of the spiral arteries this leads to ischemia and death of the endometrial cell lining and this is all instigated by that progesterone withdrawal when the corpus luteum involute so you have these prostaglandins and the prostaglandins they stimulate the myometrium tractions they help get that lining out but these
09:46
prostaglandins also cause pain prostaglandins are painful and that goes for anywhere anywhere you have prostaglandins like an inflammation you're going to have an associated pain and what is thought is that women with primary dysmenorrhea appear to release higher levels of prostaglandins than women who don't have the diagnosis of primary dysmenorrhea so that that's what we think is behind why some women are more likely to have painful periods than
10:16
other women so comparing primary to secondary dysmenorrhea primary dysmenorrhea tends to have an earlier age of onset 16 to 25 years the onset of pain comes just prior to menses whereas with secondary dysmenorrhea a lot of times it will be a longer duration of pain primary dysmenorrhea usually only lasts 3 4 5 days the symptoms of primary dysmenorrhea
10:47
when you have a patient coming in and you do a review of systems and you ask what do you have right now women with primary dysmenorrhea will tell you they have pain and you're not going to get a whole lot else from them for secondary dysmenorrhea a lot of times there will be other symptoms present so for instance if they have a mass maybe they'll say they feel have a feeling of pelvic fullness maybe they'll say they have some associated diarrhea or maybe they'll say they have mood swings or
11:19
maybe they'll say they get short of breath or something like that there'll be other symptoms present and that's going to point you towards a secondary cause response so when we treat a woman with primary dysmenorrhea they should respond to NSAIDs or combined oral contraceptives a woman with secondary dysmenorrhea either won't respond or she won't respond sufficiently with NSAIDs and combined oral contraceptives that
11:52
said some women let's say for instance with endometriosis they will respond well to NSAIDs or combined oral contraceptives but it's important that you recognize the other factors that will point you towards endometriosis because if you just treat their symptoms but you don't diagnose the underlying cause you haven't really done that woman a whole lot of a favor and as you can imagine with primary dysmenorrhea
12:23
physical exam will be unremarkable whereas with secondary dysmenorrhea it depends on the cause but a lot of them there will be something on physical examination that will point you towards that the number one cause of secondary dysmenorrhea is endometriosis so we look for history of infertility we look for pain during intercourse utero sacral nodularity fix retro fix retro verted uterus things like that will make you suspect endometriosis and endometriosis
12:55
the symptoms of that can come on at anytime usually a little bit earlier in life but really any time it it can show up so you should suspect the secondary dysmenorrhea in women who have an onset of dysmenorrhea after age 25 women who have abnormal pelvic exam findings women a history of infertility or menstrual abnormalities a lot of times women with secondary dysmenorrhea will have a heavier flow
13:26
not all the time though women who have dis Perona so women with primary dysmenorrhea will typically not have dyspareunia only pain associated with menstruation and then women who don't respond to conventional therapy for primary dis material so what do we do for workup well you want to get a good history and physical so as far as your history you want to get a family history a lot of women with primary dysmenorrhea their siblings mother will also have primary
13:58
dysmenorrhea or a history thereof you want to know her obstetric history and the reason for that is because another cause of chronic pelvic pain is pelvic organ prolapse which you're more likely to get if you have had more children and sexual history so one of the big causes of chronic pelvic pain is pelvic inflammatory disease so if she has a history of gonorrhea um that's something we want to know obviously and we're
14:28
going to culture her if she does have a recent history of having sex with somebody if it's unprotected ok review of systems obviously you want to get that because you want to know if there's any associated symptoms besides the pelvic pain you want to get a physical examination especially a pelvic exam don't defer that you want to look at her anatomy you want to see if there's any obstruction especially in a
14:59
younger woman 16 17 years of age you want to see if there's any anatomic abnormalities you want to feel for Masse's labs you want to get a urine pregnancy test and any woman who presents complaining of pelvic pain that is a rule you always get a pregnancy test and a woman complaining of pelvic pain in select patients those with a recent sexual history unprotected sex multiple partners
15:30
you'll get chlamydia and chuckle swamps and then other labs you'll get as indicated by the clinical picture so if there's a CVA tenderness or if she has pain on urination obviously you're going to get a urinalysis with culture if there's a mass you want to visualize it you can get a transvaginal ultrasound like I said pregnancy must always be excluded in a woman presenting with pelvic pain all right now this is a menstrual diary and this is useful for women who have an
16:05
unclear association between when their pain is happening and when their menstrual cycle is where they're at in their menstrual cycle now this is a rather rudimentary menstrual diary that I have up here for you but there are other ones that can she can plot when she's having her menstrual flow when she's having her pain and then also any other symptoms she's having on that particular day and this becomes very useful in distinguishing dysmenorrhea from something else that looks rather
16:35
similar and can be a cause of pelvic pain but is something that we treat a little bit differently and that is premenstrual syndrome PMS and a lot of these women will have pain but they'll also have other symptoms and these symptoms tend to happen in the luteal phase the two weeks leading up to the period so what are the other symptoms that women with PMS have they will often have mood swings tenderness and their
17:05
breasts they can have irritability maybe even depression a lot of them will describe food cravings maybe they're a little bit more tired than usual sometimes they'll have diarrhea nausea constipation a whole variety of symptoms and so a woman may have pain with menstruation but if she's having these other symptoms in the two weeks leading up to her period then this fits more of a diagnosis of PMS and we treat this differently with dysmenorrhea we treat
17:37
the pain with PMS we tend to treat it with SSRIs so you want to know the difference between these two for any licensing examination it's very important you know the difference between these two because they're treated differently so our treatment for primary dysmenorrhea is going to be NSAIDs this is our first line of treatment and we go for these because they inhibit prostaglandins they inhibit the production of prostaglandins and prostaglandins are what's causing the
18:09
pain so it makes sense that we go for NSAIDs is our first line of therapy so ibuprofen is time-tested works really well give her 400 milligrams of ibuprofen to take every four to six hours and that works wonderfully about 80 to 90 percent of women will respond to NSAIDs another one is Naprosyn you can use that 500 milligrams when her period starts then go 250 milligrams every six to eight
18:39
hours so these other ones melon amic acid also known as Pancho and ketoprofen aren't used so much now if she can't take NSAIDs maybe because she's got a ulcer or acid reflux or something she doesn't want to take NSAIDs she can take other things combined oral contraceptives can be used or she can use progestin-only contraceptives she can use the web and addressed ro device
19:10
so there are lots of more steroidal contraceptives that she can take so these can be used in women who either don't want to take NSAIDs aren't supposed to take NSAIDs or they don't respond and sets or it can be used as a first line of therapy and women who also want contraception so if a woman wants contraception then you can kill two birds with one stone it can help with her menstrual pain and it can also
19:42
provide contraception however NSAIDs are the best answer when asked when answering a question you have a woman with dysmenorrhea what do we do for treatment - the answer is NSAIDs second line is combined oral contraceptives okay so let's do another vignette this one's a little bit different and I want you to see what's different here and what this might be and this is where a menstrual diary can also be useful so here we have another seventeen-year-old girl who is
20:14
presenting to your clinic complaining of crampy lower abdominal pelvic pain that comes and goes every month but with her the pain is predictably created predictable and lasts about 12 to 24 hours and usually it's either on the left or right side but not both after a normal physical exam and exclusion of pregnancy be a urine HCG you send her home with a menstrual diary to record her episodes of pain and follow-up in two months two months later she returns to your clinic and when you review her diary you find
20:45
that her pain is indeed predictable and comes about two weeks before her menses what is the diagnosis here you will get a question possibly get a question on the test about this and you want to be familiar with this concept this is midal Schmidt's middle Schmitz is German for middle pain and it comes in the mid cycle so two weeks before she
21:15
menstruates during ovulation and this is classically a one-sided lower abdominal pain that coincides with ovulation it comes on the site where she's ovulating from the precise mechanism for this pain is unknown it's possibly due to a release of fluid or blood from the antrum of the follicle which then irritates the lining of the abdomen but we're not exactly sure why this happens it can last anywhere from a few minutes up to 48 hours usually it's going to be
21:49
the women that it happens a little bit longer in that you're pets that are going to come in so more like a day or two the treatment here is quite simple it's over-the-counter analgesics a lot of women this is not a huge deal for them because it only lasts for a short period of time but they will describe this as a sharp or crampy abdominal pain and so if they do come in with this and you find that in a slow cyclical pain that comes in the middle of their cycles two weeks before their period the diagnosis is middle Schwartz and we
22:20
treat this with over-the-counter analgesics NSAIDs Tylenol etc

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