Womens Health 530/16

Question 1

1. Dysmenorrhoea History

Answer 1

Dysmenorrhoea is a very common problem in adolescence and up to 60% of young women have symptoms. It is the most common cause of activity restriction and absence from school or work in adolescent girls.

Pain

It is important to determine if the pain is actually related to the menstrual cycle or has another underlying cause. Questions to ask the patient might include:

• Where is the site of the pain?
• How would you describe the pain (eg is it continuous or colicky)?
• How long has it been present?
• Is the pain associated with gastrointestinal function; do you have nausea, vomiting or diarrhoea/loose bowels?
• Does opening your bowels ease or make the pain worse?
• Do you have pain on urination?

Menstrual history

Questions in your consultation could include:

• How old were you when you first had your period?
• How often do you have periods and how long does each one last?
• Is the period heavy? If so, on which days of the period?
• What size tampon and/or pad do you use? Do you ever use both?
• How often do you change them?
• Do you ever flood through tampon/pad or at night in bed?
• Have your periods caused you to miss school/work/social activities before this period?
• What associated symptoms, including pain and discomfort, do you have?
• What pain relief have you taken and does it help?

Medical and family history

It is important to find out if the patient has a medical and/or family history of any serious illnesses, infections or operations. This includes a family history (mother, aunts and grandmothers) of painful, heavy periods, and endometriosis, adenomyosis, fibroids, infertility and/or hysterectomy. Questions could include:

• Do you have any family members (maternal and paternal side) with: – diagnosed endometriosis?

– pelvic pain or pain during menstruation?
– problems getting pregnant or involuntary childlessness?

Sexual history

Maddie’s mother may not be aware of her daughter’s sexual history, so the doctor would need to decide whether to ask the mother to leave the room to question her about this. An appropriate time might be before the history, which includes:

• when the first intercourse occurred
• male or female partner(s)
• route of intercourse
• use of contraception
• discussion of STIs
• vaccination history including the human papillomavirus
• pain or bleeding during sex.

Examination

• Perform an abdominal examination to rule out palpable pathology, checking for operation scars, tenderness, guarding and peritonism.
• Auscultate for bowel sounds.

Note

In an adolescent who has never been sexually active and has a typical history of mild-to-moderate dysmenorrhea, a pelvic examination is not appropriate.

A pelvic examination is indicated only in all patients not responding to conventional therapy of dysmenorrhea or when an organic pathology is suspected.

Depending on sexual history, an STI check and Pap test may be required.

Question 2

1. Dysmenorrhoea Dx

Answer 2

Diagnosis

It is possible that Maddie continues to have primary dysmenorrhea, but differential diagnoses should also include causes of secondary dysmenorrhoea, in particular, endometriosis and adenomyosis.

Management

The Society of Obstetricians and Gynaecologists of Canada (SOGC) Primary dysmenorrhea consensus guideline suggests the following management.

Women suffering from primary dysmenorrhea should be offered non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line treatment for the relief of pain and to improve daily activity, unless they have a contraindication to the use of NSAIDs. If this is the case, simple analgesics or the OCP would be recommended.

Oral contraceptives may be recommended for the treatment of primary dysmenorrhea. The added contraceptive advantage may make oral contraceptives a first-line therapy for some women.

Consideration may be given to continuous use of the active oral contraceptive pills to suppress withdrawal bleeding and the associated dysmenorrhea.

Maddie has previously used NSAID therapy and is now requesting contraception, so in this instance it would be appropriate to offer the oral contraceptive.

Given her family history, Maddie should have an abdominal ultrasound.

Question 3

1. Chronic dysmenorrhoea

Answer 3

Menstrual history

Because it has been 18 months since her last visit, it is important to find out what has happened in that time with her menstrual cycle and dysmenorrhea symptoms.

Questions include those asked previously:
• Is your period heavy?
• How long does it last?
• What size tampon and/or pad do you use? Do you ever use both? • How often do you change them?

• Do you ever flood through tampon/pad or at night in bed?
• Have your periods caused you to miss school/work/social activities before this period?
• What associated symptoms, including pain and discomfort, do you have?
• What pain relief have you taken and does it help?

In addition, you should ask Maddie if she has had any of the following:

• pain on defecation and/or urination. If so, where is the pain and is it associated with menstruation?

• pain during sex (if sexually active)
• history of benign ovarian cysts
• other symptoms/complaints and diseases.

Examination

A general physical examination should be performed, including a careful abdominal examination, palpating for abdominal masses, abdominal scars, bloating or tenderness

If sexually active, examination should include a speculum and bimanual examination, a Pap smear and swab for STI testing by polymerase chain reaction (PCR). The bimanual examination should include an assessment for pelvic tenderness, uterine size and adnexal masses and any nodularity in the uterosacral ligaments and the vagina. A pregnancy test is ordered.

Question 4

1. Chronic dysmenorrhoea DDx

Answer 4

Differential diagnosis could include:

• adenomyosis – a myometrial disorder where endometrial cells and stroma grow within the myometrium
• chronic constipation – this can lead to lower abdominal pain
• colitis – an inflammatory bowel disease that is an autoimmune condition with bowel symptoms of diarrhoea, rectal bleeding, severe cramping abdominal pain, weight loss, tiredness and exhaustion; it can occur in adolescents
• endometriosis – a chronic inflammatory, oestrogen-dependent, recurring disease of ectopic endometrial cells, which may lead to major impairment of quality of life, subfertility, chronic pelvic pain and potential difficulties with therapy, and may require surgical menopause
• irritable bowel syndrome – this often occurs together with endometriosis7 and causes abdominal cramping, alternating diarrhoea and constipation, nausea, bloating and pain relieving by passing wind
• pelvic inflammatory disease (PID) or STIs – these can cause symptoms that mimic those of dysmenorrhea.

Given the symptomatology, patient’s history and family history, the following investigations are recommended:

• full blood evaluation (FBE), ferritin levels, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels
• ultrasonography of the vagina (if possible it is preferable to refer to a specialist women’s ultrasound unit) to exclude any pelvic masses, ovarian cysts and evidence of endometriosis and/or adenomyosis.

Question 5

1. Endometriosis Hx & Exam

Answer 5

Without further investigation for confirmation, the likely diagnosis is endometriosis.

The following findings from history, examination and investigations support this diagnosis:

• cyclic pain
• progression of the severity of her pain
• pain is both premenstrual and menstrual, and has increased with time
• other associated symptoms, including onset of deep dyspareunia and abdominal symptoms
• severe pain during the vaginal ultrasonography
• strong family history – mother with fertility issues, and maternal grandmother may have had endometriosis, had only one child and an early hysterectomy and BSO.

A definitive diagnosis of endometriosis cannot be made on the basis of the clinical examination. However,

• pain on vaginal examination,
• the presence of tender nodules in the posterior fornix and
• adnexal masses, and
• immobility of the uterus suggest this as a diagnosis.

The gold standard for diagnosis of endometriosis is the combination of laparoscopy and the histological verification of endometrial glands and/ or stroma.

Question 6

1. Endometriosis Mx

Answer 6

Needs to be referred to a gynaecologist, preferably one with expertise in operative laporoscopy and, in particular, the management of endometriosis.

If confirmed, endometriosis management will depend on the patient’s age, severity of symptoms, medical history and stage of reproductive life.

The following management recommendations below are taken from the European Society of Human Reproduction and Embryology’s (ESHRE’s) guideline Management of women with endometriosis.

Analgesia

There is inconclusive evidence to determine whether NSAIDs are effective in the reduction of pain caused by endometriosis. They are effective in the treatment of dysmenorrhea so are often recommended.

Suppression of ovarian function

• Suppression of ovarian function using hormonal contraceptives and continuous progestogens can reduce the pain associated with endometriosis.
• Second-line treatments include gonadotropin releasing hormone (GnRH) agonists, levonorgestrel-releasing intrauterine device (IUD), etonorgestrel implant and oral dienogest.
• Danazol and gestrinone are rarely prescribed because of major side effects.
• There is no evidence to support the use of one ovarian suppression treatment over another.
• Emerging evidence suggests that aromatase inhibitors and neuromodulators may be useful in the treatment of endometriosis, but there is currently insufficient data to support their use.

Surgical treatment

• When endometriosis is identified at laparoscopy, it should be removed by excision or ablation. This has been shown to reduce endometriosis pain.
• Advanced laparoscopic skills are required, especially when endometriosis affects the bowel and other organs in a small percentage of women. For this reason a woman with suspected or diagnosed deep, infiltrative endometriosis should be referred to an expert or multidisciplinary centre.

Management of infertility

• An estimated 25–50% of women with infertility have endometriosis and around 30–50% of women with endometriosis have infertility. Medical treatment in women with endometriosis and subfertility has not been shown to improve fertility and may delay conception. Instead, treatment focuses on the removal or reduction of the endometriosis to restore normal pelvic anatomy and increase the likelihood of pregnancy.
• Referral to an appropriate gynaecologist is paramount to initiate the required treatment and maximise fertility outcomes.

Prognosis

• Endometriosis is a chronic condition and has a recurrence rate of 10–50% one year after surgery. This increases with time.13
• In women who undergo surgical treatment of endometriosis, clinicians are recommended to prescribe postoperative use of a levonorgestrel- releasing IUD or a combined hormonal contraceptive for at least 18–24 months, as one of the options for the suppression of the recurrence of endometriosis or endometriosis-related pain.