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Dysmenorrhea

Dysmenorrhea. Preeti Matkins, MD CMC Dept of Pediatrics Teen Health Connection July 2006. Suzie chief complaint of “painful periods”. 14 ½ year old female periods about every month soaks through pads about every 3 hours. Menstrual Disorders. Amenorrhea Dysfunctional Uterine Bleeding

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Dysmenorrhea

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  1. Dysmenorrhea Preeti Matkins, MD CMC Dept of Pediatrics Teen Health Connection July 2006

  2. Suziechief complaint of “painful periods” • 14 ½ year old female • periods about every month • soaks through pads about every 3 hours

  3. Menstrual Disorders • Amenorrhea • Dysfunctional Uterine Bleeding • Longer menses or shortened cycle • Menorrhagia • Heavy menstrual flow • Metorrhagia • Longer menstrual flow • Menometorrhagia • Longer and heavier flow • Dysmenorrhea • Painful menses

  4. Dysmenorrheapainful menses • Primary • Begin in adolescence • Not due to pelvic disease • Secondary • Uncommon in adolescence • Due to pelvic pathology

  5. Dysmenorrhea • Most common gynecologic condition of adolescence • Prevalence 20-90% • Most teens do not seek medical care • Use OTC • Not sure who will treat • Fear pelvic exam

  6. Menstrual Cycle • Follicular phase (Proliferative Phase) • Estrogen dominates • Ovulatory Phase • Luteal Phase (Secretory Phase) • Progesterone dominates

  7. Menstrual CycleFollicular phase(Proliferative Phase) Estrogen dominates • GNRHLH/FSH • Dominant follicle makes estrogen • Endometrial proliferation • Negative feedback of estrogen on FSH

  8. Menstrual CycleOvulatory Phase • Estrogen LH surge  ovulation

  9. Menstrual CycleLuteal Phase(Secretory Phase) Progesterone dominates • Dominant follicle makes progesterone • Progesterone • inhibits endometrial proliferation • Cleavage plane readied for implantation • HCG pregnancy • No HCGcorpus luteum diminishes • Decreased estrogen • Decreased progesterone •  sloughing • HPO axis

  10. Anovulatory Cycle/Dysfunctional Uterine Bleeding Estrogen (increases uterine vasculature) unopposed byProgesterone (thickens endometrium) • High levels of estrogen  • NO Negative feedback on hypo/pit • So High FSH  multiple follicles (none dominant) • Low Progesterone  • No LH surge= No ovulation

  11. Anovulatory Cycle/Dysfunctional Uterine Bleeding Causes • Immature HPO-pituitary-ovarian axis • Stress • Weight loss • Chronic Disease • IBD • DM • Hypothyroidism • Prolactinoma • Late onset CAH • Addison's Disease • …many more

  12. Anovulotory cyclesHow long is normal? • 55-80% anovulatory 2 yrs post menarche • 10-20% anovulatory up to 5 yrs post menarche “Menstrual Disorders” Braverman, Peds in Review, Vol 18, No 1 Jan 1997.

  13. DysmenorrheaPathophysiology • Ovulation • PG increase in cell membrane phospholipids • Release AA and Omega 7 fatty Acids • PG and LK start inflammatory cascade * uterus is more sensitive to PG in second half of cycle • Prostaglandin • Cyclooxygenase metabolite • Myometrial hypertrophy • Uterine Vasoconstriction • Leukotrienes • Increases sensitivity of uterine pain fibers • Vasoconstriction of uterus • Inflammatory mediator

  14. Dysmenorrhea • End of Luteal Phase • Decreased progesterone • Phospholipids A2 • Converts Phospholipids to Arachadonic Acid • Via Cyclic peroxidase/PG synthetase  • PGE2 and PGF 2a

  15. Primary Dysmenorrhea • HPO axis takes time to mature • 1/3 of females are not having ovulatory cycles until 5 yrs post menarche • Must be ovulating to have dysmenorrhea • May not have symptoms of dysmenorrhea until few years after menarche

  16. 2o dysmenorrhea • Fibroid • Endometriosis • Adenomyosis

  17. Risk factors • Early menarche • Heavy flow • Nulliparity • Age <20 yo • Family history • Depression/anxiety • +/- tobacco

  18. Dysmenorrhea • Not risk factors • Ht • Wt • BMI • History of abortion, uterine instrumentation, or surgery • Protective? • Tobacco may decrease estrogen levels and result in anovulatory cycles (inconsistent)

  19. Non Uterine effects of Dysmenorrhea • Low back Pain • Referred pain from spinal nerves • Bloating • PG effect on smooth muscle • Migraine Headaches • Related to decreased estrogen in premenstrual stage of cycle • Loose Bowel Movements • PG mediated • “PMS” • Hormonal fluctuations in estrogen/progesterone • Neurotransmitter changes

  20. PMDDpremenstrual dysmorphic disorder • DSM-IV Depressive Disorder NOS 311.0 • Symptoms last week of luteal phase • Significantly impair life/work • Absence of symptoms at least 1 wk post menses • Incidence 3-5% menstruating women • Serafem (flouxetine) Eli Lilly • 10-20 mg/d days 14-28

  21. Suziechief complaint of “painful periods” • Menarche age 11 ½ • Loose bm and HA when her “period is coming” • No family history of • Endometriosis • Menorrhagia • Bleeding disorders • Infertility • Breast or ovarian cancer

  22. Differential Diagnosis • PID • Pelvic adhesions • Ovarian cysts • IBD • IBS • Interstitial cystitis

  23. Symptoms of 1o dysmenorrhea • Crampy abdominal pain • Begin 1-2 days prior to menses; worst first days of flow; resolve by end of menses • Bloating • Headaches • Referred pain • Nausea/emesis • Breast tenderness

  24. Symptoms of 2o dysmenorrhea • Begin several days to 2w before flow • Persist throughout flow

  25. Exam • Mild mid abdominal pain • No rebound • No CMT or AT • Mass • Consider uterine outlet obstruction • severe pain early after menarche • Other tumors

  26. Pelvic exam • Not always necessary • Sexual history • STD, PID, AT, CMT • Vaginal discharge • Non menstrual uterine pain • Do need external genital exam • Imperforate hymen

  27. Suziechief complaint of “painful periods” • A/B honor roll • Misses 1-2 days of school /mo • Sits out cross country practice • Confidential Interview • Has boyfriend of 2 months • No sexual contact

  28. Other conditions to consider(Common is Common) • Irritable Bowel Syndrome • IBD • GER • Gastritis • Didelphic uterus • Vaginal septum • Cervical agenesis • Cervical stenosis • Uterine septum

  29. Evaluation • Get a history first! • Symptom Calendar • Hemoglobin • Menorrhagia • Bleeding disorder-von Willebrands Disease • IBD • Consider Hemoccult • Consider bimanual exam or ultrasound if initial tx does not alleviate symptoms

  30. Suziechief complaint of “painful periods” • Hemoglobin 11.5 • Medications • Tylenol • Midol • periods about every month • soaks through pads about every 3 hours

  31. Treatment • NSAIDS • Other OTC • Used by 30-70% of adolescents • OCP • Extended cycling • Other hormonal therapies • Non medical treatments • CAM

  32. TreatmentNSAIDS(cyclooxygenase inhibitors) • Inhibit prostaglandin synthesis • Decrease volume of menses • May also decrease diarrhea, nausea • Most effective • If started before pain and menstrual flow • Do not need to continue through flow

  33. TreatmentNSAIDS(cyclooxygenase inhibitors) • All NSAIDS and aspirin more effective than acetomenophen • Ibuprofen • Naproxen • FYI: COX-2 similar to NSAIDS; no better • Appropriate Dose • 400-800 mg every 8 hours 1-2 before flow to 1-2 d into flow • *Consider GI (and other) side effects • Cochrane Review: NSAIDS are effective treatment

  34. OTC Analgesics Marketed for DysmenorrheaMulticomponent FormulationsMidol (Bayer Healthcare LLC) • “Menstrual Complete” • 500 mg acetaminophen, 60 mg caffeine, 15 mg pyrilamine (antihistamine) • “Premenstrual Syndrome” • 500 mg acetaminophen, 25 mg pamabrom(diuretic), 15 mg pyrilamine • “Teen Formula” • 500 mg acetaminophen, 25 mg pamabrom Hilliard, P.,”Dysmenorrhea”, Peds in Review, Vol 27, No 2 Feb 2006

  35. OTC Analgesics Marketed for DysmenorrheaMulticomponent FormulationsMidol (Bayer Healthcare LLC) • “Cramps and body aches” • ibuprofen 200 mg • “Maximum strength extended relief” • naproxen sodium 200 mg (approved by FDA) Hilliard, P.,”Dysmenorrhea”, Peds in Review, Vol 27, No 2 Feb 2006

  36. OTC Analgesics Marketed for DysmenorrheaMulticomponent FormulationsPamprin (Chattem, Inc) • “Multi-symptom” • 500 mg acetaminophen, 25 mg pamabrom, 25 mg pyrilamine • similar to Midol Premenstrual except 15 mg pyrilamine • pamabrom is a diuretic • “All Day” • 220 mg naproxen sodium • “Cramp” • 250 mg acetaminophen, 250 mg magnesium salicylate, 25 mg pamabrom Hilliard, P.,”Dysmenorrhea”, Peds in Review, Vol 27, No 2 Feb 2006

  37. “Oral Contraceptives for Dysmenorrhea in Adolescent Girls”Davis, AR, et al. Obstetrics and Gynecology; 2005;106:97-104 • n= 76; <19 yo • Screen for depression, stress • Randomized to low dose (20mcg estrogen) OCP or placebo • Could take other OTC meds • Moos Menstrual Distress Scale • Phone f/u monthly x 2; then exit interview month 3 • Baseline :severe pain 58%; 55% nausea, 39% missed activites

  38. Moos Menstrual Distress Scale • Designed 1968 • 6 point Likert Scale • Cycle • menstrual, premenstrual, intermenstrual • Symptoms • Pain • Concentration • Behavior changes • Autonomic reactions • Water retention • Control

  39. “Oral Contraceptives for Dysmenorrhea in Adolescent Girls”Davis, AR, et al. Obstetrics and Gynecology; 2005;106:97-104

  40. TreatmentOral Contraceptive Pills • Inhibit ovulation • Decreased progesteroneless PG • Less menstrual flow • Cochrane rates as effective • No evidence low dose vs 30 or 35mcg estrogen pills • Pelvic exam not always required

  41. TreatmentOral Contraceptive Pills • Use Monophasic estrogen containing pills • Lower estrogens • spotting • less efficacious as contraception if • >155 pounds • Miss pills • 30 mcg • 35mcg • Some studies used 50+ mcg estrogen/pill • Nausea!

  42. Treatment • Depo-Provera • Extended cycling OCP • Mirena

  43. Treatment • Extended Cycling Oral Contraceptives • Reduced flow • Less frequent flow • Seasonale • Can use any monophasic OCP • Other benefits

  44. TreatmentOther Hormonal • Contraceptive Patch: Ortho Evra • Less effective than oral OCP for dysmenorrhea • Intravaginal OCP

  45. TreatmentLeukotriene Recepetor AntagonistsWill Singulair decrease PG and relieve symptoms?* • n= 22 adolescents completed • mean age 16 • 4 + 1 year post menarche • RDB crossover • 13 got 10 mg Singulair days 21 to end of cycle x 2 cycles; then 2 month placebo • other group had reverse order • 3 drop-outs: noncompliance, other disease dx “The Use of the Leukotriene Antagonist Montelukast (Singulair)in the Management of Dysmenorrhea in Adolescents” Harel, et al. J of Pediatric and Adolescent Gynecology, 2004; 17:183-186. * Funded by Merck

  46. TreatmentLeukotriene Receptor AntagonistsWill Singulair decrease PG and relieve symptoms?* • Cox Menstrual Scale • No difference in pain scores with use of Singulair for dysmenorrhea “The Use of the Leukotriene Antagonist Montelukast (Singulair)in the Management of Dysmenorrhea in Adolescents” Harel, et al. J of Pediatric and Adolescent Gynecology, 2004; 17:183-186. * Funded by Merck

  47. Treatment Depo-Provera • Most patients amenorrheic by 9 months • May have irregular bleeding 3-6 months • Bone effects • May recover

  48. TreatmentSuppression of Menses • Danazol (Danocrine) • Leuprolide acetate (Lupron) • Expensive • Significant Side effect • Generally not for Primary dysmenorrhea

  49. TreatmentOther Modalities • Supplements RCT showed pain reduction compared to placebo • Thiamine 100mg daily • Fish Oil • Vitamin E • Herbal remedies Insufficient data

  50. Duration: 5 years Vaginal Bleeding 60% amenorrhea 12% rare 28% scant, regular Not appropriate if risk of STD TreatmentLevonorgestrel Intrauterine System: Mirena (This is a schematic and is not anatomically proportional.) schematic from www.contraceptiononline.org

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