Case 32 - 33 yo with painful periods

Question 1

Dysmenorrhea

Answer 1

painful menses without pelvic pathology, associated with increasing prostaglandins, most often occurs in women’s teens or twenties, occurs ours to a day prior to onset of menses and can last 72 hours, incidence decreases with parity

Question 2

Risk factors for dysmenorrhea

Answer 2

• depression or anxiety
• smoking
• earlier age at menarche
• overall lower state of health

Question 3

Menorrhagia vs. metorrhagia

Answer 3

Menorrhagia = blood loss more than 80 mL, often longer periods, can be quantified with frequency of use of pads and tampons
Metorrhagia - irregular and frequent bleeding

Question 4

PMS vs PMDD

Answer 4

PMS - breast soreness, weight gain, bloating, diarrhea, irritability, crying
PMDD - more severe than PMS, sx must significantly affect the patient’s life

Question 5

Differential for 33 year old female with painful periods

Answer 5

1. Uterine leimyoma (fibroids) - most common sx is menorrhagia, can have anemia, dysmenorrhea, or pressure sx
2. Chronic PID - usually lower abdominal pain associated with menses, sometimes menorrhagia
3. Adenomyosis - heterogenously boggy uterus, some urinary or GI sx due to mass effect
4. Cervical stenosis -congenital or acquired, uterus is distended with blood
5. Endometriosis - endometrial glands ectopic to the uterus - dysmenorrhea and dyspareunia seen, pain in cul de sac, fixed uterus on exam
6. Ovarian cysts - recurrent, midcycle lower quadrant, non-midline pain
   Less likely: IBD, IBS, mood disorder, uterine polyps

Question 6

Studies for dysmenorrhea

Answer 6

• Pelvic ultrasound - study of choice for pelvic pathology, can evaluate endometrial stripe, anatomy within the uterus
• CBC - check for anemia
• pregnancy test
• TSH
• MRIs can be used for adenymyosis and leiomyomas

Question 7

Management of secondary dysmenorrhea secondary to leimyomas

Answer 7

• ibuprofen (decreases effect of prostaglandins)
• mirena IUD, helps reduce menstraul blood flow and decrease uterine volume
• combine hormonal OCP - can be used for anovulatory dysmenorrhea, does not decrease menstrual flow
• depo-provera - not as recommended
• hysterectomy - definitive option
• myomectomy - surgical removal of leimyoma with goal for preservation of fertility
• Uterine artery embolization - reserved for women who cannot tolerate hormonal treatments and don’t want hysterectomy
• Paraguard IUD - NOT a treatment for leimyoma, increases risk of dysmenorrhea and menorrhagias

Question 8

management of dysmenorrhea without uterine pathology

Answer 8

• accupuncture

- TENS unit (transcutaneous electric nerve stim, thiamine supplements and vitamin E supplements

Question 9

Management of premenstrual sydrome

Answer 9

• SSRI - can be given continuously or just during luteal phase of menses
• oral contraceptives can help with dysmenorrhea
• danazol - inhibits ovulation
• other GnRH agonists (leuprolide) - inhibits ovulation and therefore treats dysmenorrhea