Dysmenorrhoea, dyspareunia & PMS

1. Dysmenorrhoea, dyspareunia & PMS Dr hashmihajrasi Consultant in OBS & GYN MBBCh, DGO, MRCOG, D’MAS

2. Learning objectives By the end of the lecture the student is expected to • understand the definition, possible causes of dysmenorrhoea, dyspareunia and impact on women’s life • Know how to investigate and come up with a diagnosis • Treatment options and effectiveness

3. Have a basic knowledge on PMS in term of the common symptoms, possible theories behind its occurrence • Know how to reach a diagnosis using symptom chart and exclusion • Know the commonly suggested treatment options and their efficacy

4. Dysmenorrhoea • Defined as painful menstruation. • Although some pain during period is normal, pain that is sever enough to limit normal activity or requires medication is abnormal and requires evaluation. • Affects about 50% of menstruating women and regarded as sever in 10% of sufferers • Dysmenorrhoea is the leading cause for absence from school or work

5. classification • Primary dysmenorrhoea: occurs in otherwise healthy women with no organic cause • Secondary dysmenorrhoea: due to an underlying disease or structural uterine abnormality

6. Primary dysmenorrhoea • Onset a few years after menarche • Cycles are regular • Pain for less than 2 days • Cramping pain radiating to the thighs • Nausea and other GI symptoms • relieved after childbirth • Prostaglandins & leukotrins play a major role

7. Secodarydysmenorrhoea Causes : • endometriosis • adenomyosis • chronic pelvic inflammatory disease • Pelvic congestion syndrome • pelvic adhesions • IUD • fibroids

8. Dysmenorrhoea evaluation • History • Physical examination: • Is pelvic examination needed? Recommended in all cases except if not sexually active with typical primary dysmenorrhoea

9. Dysmenorrhoea Investigations needed ? • Pelvic Ultrasound if • clinical pelvic examination abnormal • symptoms suggestive of secondary dysmenorrhoea but PV not conclusive or not possible • Laparoscopy • Sometimes needed

10. Primary dysmenorrhoea …..Treatment • Simple analgesics: paracetamol, NSAID • Hormonal therapy: as a second line when simple analgesia fails. COCP are 90% effective

11. Secondary dysmenorrhoea...treatment • Treat the underlying cause • NSAID’s • Hormonal contraceptives • Pre-sacral neurectomy in selected cases

12. Dyspareunia • Defined as pain during or after intercourse • It is not a disease ,but rather a symptom of an underlying physical or psychological disorder • Could be superficial at entrance of the vagina or deep in the pelvis on deep penetration

13. Causes Superficial dyspareunia: • Vaginismus • Vaginal infection • Episiotomy scars & narrowed vagina • Insufficient vaginal lubrication • Atrophic vagina due to menopause

14. Vaginismus Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse” Etiological background • lack of sex education/information • negative attitudes about sexuality • sexual abuse or trauma

15. Deep dyspareunia: • PID • Endometriosis • Ovarian cysts • Ectopic pregnancy • Pelvic congestion

16. Dyspareunia.....management • Aimed at identifying & properly treating the underlying cause • Adequate foreplay or k-y gel for vaginal dryness • Topical oestrogen for atrophic vagina • surgery may sometimes be required for vaginal prolapse or inadequate vagina

17. Vaginismus.....treatment • Insertion of a graduated set of dilators in the vagina • psychotherapy

18. Premenstrual syndrome

19. Distressing physical, psychological and behavioural symptoms, not caused by organic disease, which regularly recur during the same phase of the menstrual (ovarian) cycle and which significantly regress or disappear during the remainder of the cycle Magos & Studd (1984) Premenstrual Syndrome Modern Definition

20. Affects 30-40% of women of child bearing age but in 10% the symptoms are so sever and disabling (premenstrual Dysphoric dysorders (PMDD) • Over 150 symptoms have been documented but the three most prominent are , irritability, tension & dysphoria (unhappiness)

21. aetiology Is poorly understood but a major role played by • Cyclical ovarian activity • Estradiol • Progesterone • Neurotransmitters serotonin & GABA

22. PMS vs PMDD PMDD may be viewed as a more severe form of PMS Rapkin A. Psychoneuroendocrinology. 2003.

23. Premenstrual Symptoms Disorders PMDD (Pre-menstrual Dysphoric Disorder) (Sever symptoms) PMS (Pre-menstrual Syndrome) Moderate symptoms Pre-menstrual Minor symptoms More common/ Less severe Less common/ More severe

24. Prevalence of Premenstrual Symptoms in Women (USA) Ginsberg KA, et al. 2000.

25. Signs and Symptoms of PMS/PMDD Symptoms occur Ovulation Follicular Phase Luteal Phase 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Days of Menstrual Cycle more… Malone DC. Am J Manag Care. 2005 Dickerson LM et al. Am Fam Physician. 2003.

26. Signs and Symptoms of PMS/PMDD (continued) More than 150 symptoms associated with PMS Psychological Physiological Behavioral Malone DC. Am J Manag Care. 2005 Dickerson LM et al. Am Fam Physician. 2003.

27. Diagnosis of PMS/PMDD Occur in luteal phase Resolves near the start of menstruation Creates problems or impairment Not better explained by another diagnosis Johnson SR. Obstet Gynecol. 2004; Rapkin AJ. Am J Manag Care. 2005; ACOG. ACOG Practice Bulletin No. 15. 2000; Dickerson LM et al. Am Fam Physician. 2003.

28. Menstrual Symptoms Chart for Diagnosis of PMS/PMDD List the symptoms you have in the left column. Circle the dates of your menstrual period. Fill in the boxes on the days your symptoms occur. Indicate severity by filling in the boxes as shown: Mild, Moderate, Severe Download from: www.arhp.org/menstrualsymptomschart

29. Multiple Visit Diagnostic Approach for PMS/PMDD more… Kaur G, et al. Cleve Clin Med. 2004. Johnson SR. Obstet Gynecol. 2004.

30. Multiple Visit Diagnostic Approach for PMS/PMDD (continued) Kaur G, et al. Cleve Clin Med. 2004. Johnson SR. Obstet Gynecol. 2004.

31. PMS/PMDD Treatment Considerations “…no single intervention is effective for all women.” Dimmock PW et al Lancet 2000 Dimmock PW et al. Lancet. 2000. Steiner M. Am Fam Physician. 2003.

32. Treatment stratiges • General advice about diet, exercise & stress reduction should be considered before starting specific treatment • Women with marked underlying psychopatology should see a psychiatrist • Symptom diary should be used to assess the effect of treatment

33. Eat frequent and smaller portions of foods high in complex carbohydrates Treatment of PMS: Dietary Changes Johnson SR. Obstet Gynecol. 2004.

34. Treatment of PMS: Nutritional Supplementation Medications *limited benefit Bhatia SC et al. Am Fam Physician.2002; Bowman MA. 2000. Freeman EW, Sondheimer SJ. J Clin Psychiatry. 2003; Endicott J et al. Patient Care. 1996; Johnson WG et al. Psychosom Med. 1995; Rapkin AJ. Am J Manag Care. 2005.

35. Treatment of PMS: Behavioral Changes • Aerobic exercise/Yoga • Relaxation and stress management • Anger management • Self-help support groups • Therapy (individual, couples, cognitive-behavioral, ) • Smoking cessation • Regular sleep

36. pharmacological • Selective serotonin re-uptake inhibitors (SSRI) ....e.g Fluoxetine significantly reduces tension, irritability & dysphoria (4-6 times better ) • Progestogens • COCP • Diuretics • Antidepressants • danazole • GnRH A

37. surgical • Hysterectomy & BSO

38. conclusion • Dysmenorrhoea is not uncommon complaint. Detailed history & gynae examination together with pelvic USS and sometimes laparoscopy enables diagnosis appropriate treatment • Dyspareunia can be very distressing and a cause for broken sexual life. It may be confused with vaginismus though this is largely due to fear of pain .previous H/O sexual abuse or trauma must be sought but an organic must be excluded

39. PMS can be confused with so many other conditions and diagnosis sometimes by exclusion. PMS diary helps to establish diagnosis and assess severity of symptoms • Treatment requires multidisciplinary team approach involving gynaecologist, psychotherapist, social worker, self-support groups and husband support • Pharmacological agents help to alleviate symptoms but eventually oophorectomy may be required