Dysmenorrhoea and Dyspareunia

Question 1

A 27-year-old woman has 2-year history of dysmenorrhoea and dyspareunia. She uses condoms. How would you assess and manage?

Answer 1

Impression
Given history of painful periods and painful sex, I am concerned about several gynaecological pathology. Can be primary, where it occurs in the absence of any detectable pathology, or secondary in which case the most likely underlying pathology is endometriosis.

DDX
REDS: ovarian torsion, ectopic
Primary: myometrial ischaemia in 
Secondary: 
- endometriosis
- adhesions (intraabdominal)
- PID
- uterine polyps, fibroids

Question 2

Dysmennorrhoea - History

Answer 2

History

• sx: dyspareunia - deep vs superficial, N/V, headache, fevers, other pelvic pain, bowel/bladder symptoms, vaginal discharge. ask if could be pregnant, rule out serious
• endo: cyclically worsening, infertility, poor relief with NSAIDS
• menstrual hx: age of menarche, regularity, flow, duration, variations, medication, associated pain and timing,
• sexual history
• obstetric history
• PMHx including history of abdo surgery
• medications

Question 3

Dysmenorrhoea - Examination

Answer 3

Examination

• general observation + vital signs
• abdominal examination: massess, tenderness
• pelvic examination: cervical motion tenderness, adnexal tenderness, vaginal discharge

Question 4

Dysmenorrhoea - Investigations

Answer 4

Investigations

• Bedside: UA, urina ß-HCG, opportunistic CST, high-vaginal swab + pcr for STIs
• Bloods: FBC, ESR/CRP,
• imaging: TA and TV ultrasounds: massess, fibroids,
• other: consider diagnostic/therapeutic laparoscopy

Question 5

Dysmenorrhoea - Management

Answer 5

Management
supportive
- patient education, provide fact sheet

Definitive
Medical
- analgesia (NSAIDS)
- continuous hormonal therapy to stop ovulation (COCP, IUD, progesterone only pill IM injection

SUrgical

• laparoscopy and ablation of endemtriosis (fertility sparing)
• total hysterectomy