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week 4- Dysmenorrhea Flashcards

1
Q

dysmenorrhea

A

pelvic pain (cramping) that occurs with menses

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2
Q

primary vs secondary dysmenorrhea

A

primary dysmenorrhea - menstrual pain with no identifiable pelvic pathology

secondary dysmenorrhea - menstrual pain associated with an identifiable pelvic pathologic condition (e.g. endometriosis, ovarian cysts)

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3
Q

membranous dysmenorrhea

A

intense cramping pelvic pain associated with the spontaneous sloughing of the endometrium in one piece that retains the shape of the uterine cavity (i.e. a single cast); rare

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4
Q

dysmenorrhea in what % of women

A

16-91%

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5
Q

Primary vs secondary dysmenorrhea peak onset

A

primary is in adolescent and early 20s (decrease with age and parity/births)

secondary is 40-50s

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6
Q

risk factors for dysmenorrhea

A

heavy menses, age, family hx, nulliparity (never given birth)

modifiable: smoking, weight loss attempts, high waist to hip ratio

mental health, social network disruption, sexual abuse

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7
Q

protective factors for dysmenorrhea

A

exercise, OCP, early childbirth, fish intake

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8
Q

highest OR for risk factors for dysmenorrhe

A

heavy menstrual flow (4.7)
PMS (2.4)
< 30 yoa (1.9)

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9
Q

primary dysmenorrhea

A

menstural pain without pathology, usually begins 6-12 months after menarche

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10
Q

diagnosis of primary dysmenorrhea

A

clinical
-pelvic exam normal
-urine test to rule out pregnancy (hCG) and infection (STIs)

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11
Q

manage primary dysmenorrhea

A

nonpharmalogical or NSAIDs

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12
Q

sx of primary dysmenorrhea

A

recurrent, crampy, suprapubic pain occurring just prior to or during menses (typically lasts 2-3 days), with or without radiation to the back or legs; may be associated with nausea, fatigue, bloating, general malaise

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13
Q

causes of primary dysmenorrhea

A

biological (not psychological or anatomical)

-abnormal and increased prostanoid secretion causing abnormal uterine contractions which reduce uterine blood flow and lead to uterine hypoxia

-drop in prosesterone –> slough endometrial lining –> prostaglandin F released –> contractions

-leukotriene

-vasopressin

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14
Q

what is increased in primary dysmenorrhea and causes uterine contractions

A

prostanoid (also possibly eicosanoid)

then prostaglandin F released when progesterone drops

leukotreiene

vasopressin

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15
Q

physical exams finding suggest which type of dysmenorrhea

A

secondary cause of dysmenorrhea (e.g. pelvic mass, uterine outflow obstruction)

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16
Q

pelvic examination vs abdominal exam and inspect external genitalia

A

-pelvic: sexual active adolescence (high risk of PID)

-ab+ external: no sex

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17
Q

high risk of PID in

A

adolescents who are sexually active

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18
Q

do pelvic exam if

A

suspect endometriosis or secondary causes of dysmenorrhea

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19
Q

endometriosis vs adenomyosis vs PID findings on imaging

A
  • endometriosis: fixed uterus or reduced uterine mobility, adnexal masses, and uterosacral nodularity
  • adenomyosis: uterine enlargement or asymmetry
  • PID: mucopurulent cervical discharge
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20
Q

diagnosing primary vs secondary dysmenorrhea

A

primary: cramping pain lasts 3 days max and responds to NSAIDs
secondary: variable history and clinical presentation

physical and pelvic exam
primary: normal
secondary: abnormal (+)

imaging for secondary causes i.e. laparoscopy

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21
Q

primary dysmenorrhea vs endometriosis in adolescent

A

usually primary but if 3-6 months of therapy and still bad check is secondary dysmenorrhea (most common in adolescent in endometriosis)

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22
Q

secondary dysmenorrhea causes

A
  • endometriosis
  • adenomyosis
  • uterine leiomyomas (fibroids) or uterine polyps
  • pelvic inflammatory disease (PID) or pelvic adhesions
  • obstructive vaginal or uterine congenital anomalies
  • cervical stenosis
  • ovarian cysts

other differentials to consider (including non-gynecologic):
- ectopic pregnancy
- malpositioned intrauterine device (IUD)
- urinary tract infection (UTI)
- interstitial cystitis
- irritable bowel syndrome
- musculoskeletal causes (e.g. abdominal wall, pelvic and hip muscles/joints)

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23
Q

endometriosis

A

chronic, estrogen-dependent condition characterized by ectopic implantation of functional uterine tissue (endometrial glands and stroma) outside the uterine cavity

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24
Q

endometriosis risks

A

25-29 yrs, caucasian, menorrhagia, nulliparity, …

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25
symptoms of endometriosis
asymptomatic or chronic and cyclic pelvic pain, dysmenorrhea, dyspareunia, dysuria, dyschezia, sub-fertility or infertility; possibly hyperalgesia
26
diagnosis of endometriosis
history, pelvic exam, CA125, TVUS, MRI, laparoscopy, histology tender vaginal exam, palpable nodules in posterior fornix, adrenal mass, uterine immobility
27
prognosis of endometriosis
infertility, miscarriage, endometrial cancer
28
3 subtypes of endometriosis
endometrioma, deep infiltrating endometriosis, superficial peritoneal endometriosis
29
findings with high LR+ for endometriosis
palpable abnormality in rectovaginal septum palpable abnormality in pouch of Douglas history of pain that increases during menses + infertility
30
imaging and labs with high LR+ for endometriosis
TVUS- SonoPODogrpahy MRI
31
endometriosis classification
superficial vs deep stage1-4 ovary and peritoneum... slide 19- 21?????
32
adenomyosis
ectopic endometrial tissue within the uterine myometrium
33
risks for adenomyosis
increased estrogen exposure (parity, early menarche, short cycles, high BMI, OCP use..), prior uterine surgery
34
sx of adenomyosis
dysmenorrhea, menorrhagia, chronic pelvic pain, dyspareunia; asymptomatic
35
diagnosis test for adenomyosis
TVUS** pelvic exam: boggy enlarged uterus blood: CBC, ferritin (anemia)
36
cure for adenomyosis
hysterectomy
37
prognosis of adenomyosis
commonly coexists (leiomyoma 50%, endometriosis 11%, endometrial polyps 7%)
38
transvaginal ultrasound (TVUS) signs of adenomyosis
hyperechoic islands linear striations myometrial cysts s-shaped endometrium asymmetrical myometrial thickening
39
uterine leiomyomas (fibroids)
a group of benign smooth muscle tumours
40
how many female has uterine leiomyomas (fibroids)
70-80% females by age 50
41
risks for uterine leiomyomas (fibroids)
early menarche, use of OCP before age 16yrs, increased BMI, African-descent
42
sx of uterine leiomyomas (fibroids)
asymptomatic or pelvic pain, pressure, abnormal vaginal bleeding (AUB)
43
diagnosis of uterine leiomyomas (fibroids)
TVUS and physical: enlarged irregular uterus CBC, ferritin (anemia)
44
uterine (endometrial) polyp
overgrowths of endometrial glands and stroma within the uterine cavity
45
risks for uterine (endometrial) polyp
abnormal uterine bleeding, unopposed estrogen, chronic tamoxifen use, 40-49 yoa
46
diansogis of uterine (endometrial) polyp
TVUS, tissue sample, pelvic exam (speculum) see pedunculate endometrial polyp from external os hCG, CBC, coagulation panel (INR, aPTT, fribrinogen) for anemia and coagulopathy
47
uterine (endometrial) polyp prognosis
mostly benign risk of malignancy increase with age and polyp size and postmenopausal, PCOS
48
pelvic inflammatory disease (PID)
inflammation of the upper genital tract (uterus, fallopian tubes, and/or ovaries) due to infection (most often polymicrobial)
49
peak incidence of PID
15-25 yrs old, 85% from sexually transmitted bacteria
50
sx of PID
asymptomatic or pelvic/lower abdominal pain, vaginal discharge, dyspareunia, and/or abnormal uterine bleeding, increased urinary frequency or dysuria
51
diagnose PID
pelvic exam: adnexal or uterine tenderness, cervical discharge ESR, CRP elevated vaginal swab nucleic acid amplification test (NAAT) for gonorrhoea or chalmydia
52
PID physical exam findings with higher LR+
NAAT positive for n. gonorrhoea of chlamydia (45-98) purulent endocervical secretion (3.3) rebound tenderness (2.5)
53
determining treatment of PID
sexually active? screen for STI ab pain? cervical motion tenderness, uterine tenderness, or adnexal tenderness present additional test to consider other causes of pain or empirical treatment of PID (LOOK AT SLIDE 33 flow chart)
54
(functional) ovarian cyst
fluid-filled structures that may be simple or complex
55
risk factors for functional ovarian cyst
fertility treatment, Tamoxifen, pregnancy, hypothyroidism, maternal gonadotropins, smoking, tubal ligation
56
symptoms of functional ovarian cyst
often asymptomatic; unilateral pain/pressure in lower abdomen, pain may be intermittent or constant, characterized as sharp or dull; with rupture - acute, severe pain possibly with N/V
57
diagnose ovarian cyst
TVUS hCG (pregnancy) and UA (UTI) CA125 pelvic exam -palpate enlarged and tender ovary
58
prognosis of functional ovarian cyst
70-80% spontaneously resolve but can rupture, hemorrhage, ovarian torsion
59
ectopic pregnancy
the implantation of an embryo outside of the uterine cavity, most commonly in the fallopian tube (> 90% of ectopic pregnancies)
60
how many ectopic pregnancies are in fallopian tube
>90%
61
risk for ectopic pregnancy
older age, smoking, hx of ectopic pregnancy, tubal surgery, pelvic infections, IUD, assisted reproductive techonologies, DES (estrogen)
62
sx of ectopic pregnancy
pelvic or abdominal discomfort/pain, nausea/vomiting, syncope, lightheadedness, vaginal bleeding
63
diagnose ectopic pregnancy
hCG, TVUS vitals (hypotension, tachycardia) ab exam: tender, guard pelvic: palpable adnexal mass
64
ectopic pregnancy manangemnt
ER (emergent)
65
prognosis of ectopic pregnancy
100% mortality for developing embryo maternal mortality in 1st trimester, pregnancy death
66
interstitial cystitis / bladder pain syndrome (IC / BPS)
a complex, chronic condition characterized by inflammation of the bladder's lining possibly esp older men and women
67
sx of interstitial cystitis / bladder pain syndrome (IC / BPS)
suprapubic pelvic discomfort/pressure/pain > 6 weeks (worse with bladder filling, relieved with urination), severe urinary frequency, urinary urgency, nocturia; possibly dysuria, dyspareunia
68
what type of diagnosis is interstitial cystitis / bladder pain syndrome (IC / BPS)
by exclusion
69
diagnostic tests for interstitial cystitis / bladder pain syndrome (IC / BPS)
CBC, FBS, HbA1c, electrolytes, creatinine/eGFR, ALT, albumin urine culture negative neurological; CN, reflexes, power pelvic exam, cystoscopy **diagnosis of exclusion**
70
prognosis of interstitial cystitis / bladder pain syndrome (IC / BPS)
can last for 9 yrs, psychological and social health, sleep, sex, anxiety/depression
71
irritable bowel syndrome (IBS) ROME IV criteria
recurrent abdominal pain at least 1 day per week in the last 3 months, and is associated with at least two of the following: defecation, change in stool frequency, and/or change in stool appearance (form)
72
risks for IBS
psychologic distress, Hx of gastroenteritis (e.g. norovirus, rotavirus), ingestion of food high in fermentable carbohydrates, visceral hyperalgesia
73
sx of IBS
altered motility (constipation or diarrhea), cramping (often lower quadrants, relieved with BM), abdominal distention, sensation of incomplete evacuation, mucous with stool, urgency; fatigue, chronic headaches, disturbed sleep, anxiety and/or depressed mood
74
diagnose IBS
history and physical exam, ROME IV criteria CBC, BMP (FBG, electrolytes, BUN, creatinine), CRP, IgA, fecal calprotectin, TSH, LFTs
75
SLIDE 39-41 for diagnosing dysmenorrhea
normal history and physical = primary dysmenorrhea abnormal history and physical = secondary dysmenorrhea (do ultrasound, laparoscopy, MRI) --------------------------- if trial OCP or NSAID and gets better in 6 months then its primary dysmenorrhea if have ESR, CBC, urinalysis, gonororrhea or chlamydia then treat as secondary dysmenorrhea for PID CONTTT
76
primary and secondary dysmenorrhea will
respond to the same treatment so initial treatment doesnt need a precise diagnosis dont need pelvic exam before initiating treatment
77
when is pelvic exam indicated
in patients not responding to conventional therapy and when organic pathology is suspected.
78
first line for dysmenorrhea
NSAIDs
79
hormonal therapies for primary dysmenorrhea
offered to women and girls who are not currently planning pregnancy unless contraindications exist.
80
are combined hormonal contraceptives recommended for primary dysmenorrhea (consensus guideline)
yes
81
alternative therapies for primary dysmenorrhea in consnensus guideline
regular exercise heating pads high frequency transcutaneous electrical nerve stimulation acupoint stimulation ginger
82
prognosis for primary dysmenorrhea
chronic, recurring usually better in 3rd decade or after childbirth responds well to NSAIDs
83
prognosis for seocnady dysmenorrhea
depends on condition causing it complications can include: infertility, pelvic organ prolapse, menorrhagia, anemia
84
psychological considerations of dysmenorrhea
depression, anxiety, stress increased increased pain sensitivity
85
impact of primary and secondary dysmenorrhea
primary- not life threatening but impacts daily activities, absenteeism secondary causes absenteeism and many healthcare costs
86
primary vs secondary dysmenorrhea key notes
primary:::: - no identifiable pelvic pathology - most severe in young, nulliparous women - onset within 2 yrs after menarche - tends to improve with age - more common in people who smoke - pain relieved by NSAIDs or ovulation suppression (OCP) secondary::: - associated with pelvic pathology - age of onset is variable - suspect in women >25 yrs with no prior history of dysmenorrhea - only partial symptomatic improvement with NSAIDs
87
gynaecological and non-gycenocological differentials for dysmenorrhea
gyne: primary, endometriosis, adenomyosis, PID, membranous dysmenorrhea non-gyne: IBS, UTI, intersitital cystitis, MSK
88
SLIDE 53 flow chart to evaluate dysmenorrhea
xx
89
how long to do empiric therapy in suspected dysmenorrhea
3-6 months

CMS250 (31 decks)

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