Dysmenorrhea & Endometriosis:(crapriops)

Clarify ّ ِ ‫اﻻﻧﺘﺒﺎذ اﻟﺒﻄﺎﻧﻲ اﻟﺮﺣﻤﻲ ھﻮ اﺿﻄﺮاب ﻣﺆﻟﻢ ﻓﻲ أﻏﻠﺐ اﻷﺣﯿﺎن ﯾﻨﺘﺞ ﻋﻦ ﻧﻤﻮ ﻧﺴﯿﺞ ﻣﺸﺎﺑﮫ ﻟﻠﻨﺴﯿﺞ اﻟﺬي ﯾﺒ‬
‫ﻄﻦ‬
‫ﺷﺪﯾﺪًا ﻓﻲ ﺑﻌﺾ‬- ‫ﻗﺪ ﯾﺴﺒﺐ اﻻﻧﺘﺒﺎذ اﻟﺒﻄﺎﻧﻲ اﻟﺮﺣﻤﻲ أﻟًﻤﺎ‬. ‫ ﺧﺎرج اﻟﺮﺣﻢ‬-‫ﺑﻄﺎﻧﺔ اﻟﺮﺣﻢ‬- ‫اﻟﺮﺣﻢ ﻣﻦ اﻟﺪاﺧﻞ‬
.‫ﻀﺎ ﻣﺸﺎﻛﻞ اﻟﺨﺼﻮﺑﺔ‬ ً ‫ ﻗﺪ ﺗﻈﮭﺮ أﯾ‬.‫ ﺧﺎﺻﺔ ﺧﻼل دورات اﻟﺤﯿﺾ‬-‫اﻷﺣﯿﺎن‬

Reassure .‫ ﻓﮭﻨﺎك ﺑﻌﺾ اﻟﻌﻼﺟﺎت اﻟﻔﻌﺎﻟﺔ‬،‫وﻟﺤﺴﻦ اﻟﺤﻆ‬

Advise For primary dysmenorrhea: as adjunctive therapy to the 1st line : AAFP
Topical heat, Exercise , and nutritional interventions (supplementation or
increased intake of omega-3 fatty acids and vitamin B) may provide some
benefit, but the evidence is limited to small RCTs

From AAFP 2021 article :

Prescription • For primary dysmenorrhea :

1st NSAID : eg.
-celecoxib 400 mg initially then 200mg every q12h
-ibuprofen 200mg – 600mg every 6h

2nd : hormonal : see the table bellow :

AAFP
 Endomeiosis :
• Medical therapy
1- Mild to moderate pelvic pain without complications (Empirical medical
therapy ) NSAIDs and continuous hormonal contraceptives
o Note : NSAID alone if pregnancy is desired
o Synthetic androgens (e.g., danazol)
2- Severe symptoms
- GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs

• Surgical therapy
• First-line: by (laparoscopic excision and ablation of endometrial implants)
o To confirm the diagnosis and exclude malignancy
o No response to medical therapy
o Treat expanding endometriomas complications (e.g.,
bowel/bladder obstruction, rupture of endometrioma, infertility)
• Second-line:
• open surgery with hysterectomy with or without bilateral salpingo-
oophorectomy
o Treatment-resistant symptoms
o No desire to bear additional children

Refer To gynecology :

if Red flags: Abnormal uterine bleeding, menorrhagia, dyspareunia, noncyclic

pain, changes in intensity and duration of pain, post-coital bleeding, inter-
menstrual bleeding, and infertility.

Complication:

1- Anemia , ↑ risk of ectopic pregnancy (Endometriosis in the uterotubal

junction inhibits implantation of the zygote) ,
2- fibrous adhesions → strictures and entrapment of organs
(Intestines: constipation or diarrhea; in rare cases, intestinal
obstruction, ileus, or intussusception may occur ),Ureter: urine retention
3- Symptoms of ovarian cancer (Endometriosis slightly increse risk)
Observation Within 3 day or 1 week .
(F/U)
Preventive/ Influenzas vaccine
promotion
Safety If failure of treatment.
netting
Approach to pt. with dysmenorrhea
Primary dysmenorrhea
• Definition: recurrent lower abdominal pain shortly before or during menstruation (in
the absence of pathologic findings that could account for those symptoms).
• Manifests during adolescence typically within three years of menarche)
AAFP(Onset is typically six to 12 months after menarche, with peak prevalence occurring
in the late teens or early twenties).
•

• Etiology
o The etiology of primary dysmenorrhea is not completely understood.
o Associated risk factors: -
- early menarche,
- nulliparity,
- smoking,
- obesity,
- positive family history

• Pathophysiology: increased endometrial prostaglandin (PGF2 alpha) production leads

to vasoconstriction/ischemia and stronger, sustained uterine contractions (to prevent
blood loss).

• Clinical features
o Usually occurs during the first 1–3 days of menstruation
o Spasmodic, crampy pain in the lower abdominal and/or pelvic midline (often
radiating to the back or thighs)
o Headaches, diarrhea, fatigue, nausea, and flushing are common accompanying
symptoms.
o Normal pelvic examination
• Diagnostics
o Primary dysmenorrhea is a diagnosis of exclusion.
o Rule out conditions that cause secondary dysmenorrhea (e.g., endometriosis).
• Treatment
o Symptomatic treatment: pain relief (e.g., NSAIDs), topical application of heat
o Hormonal contraceptives (e.g., combined oral contraceptive pill, IUD with
progestogen).
Secondary dysmenorrhea [5][7]

• Definition: recurrent lower abdominal pain shortly before or during menstruation that is
due to an underlying condition
• Epidemiology
May begin later than primary dysmenorrhea
o
o Commonly affects female individuals ≥ 25 years of age.
AAFP(Secondary dysmenorrhea results from specific pelvic pathology. It should be
suspected in older women with no history of dysmenorrhea until proven otherwise.)
• Endometriosis is the most common cause of secondary dysmenorrhea.7 The
incidence is highest among women 25 to 29 years of age and lowest among
women older than 44 year
o
• Etiology
o Uterine causes
§ Pelvic inflammatory disease (PID)
§ Intrauterine device (IUD)
§ Adenomyosis
§ Fibroids (intracavitary or intramural)
§ Cervical polyps
o Extrauterine causes
§ Endometriosis
§ Adhesions
§ Functional ovarian cysts
§ Inflammatory bowel disease
• Clinical features
o Depend on the underlying cause
o Secondary dysmenorrhea should be suspected in the following cases:
§ Abnormal pelvic examination (e.g., uterine size, cervical motion
tenderness, adnexal tenderness, masses, vaginal/cervical
discharge)
§ The pain tends to get worse over time.
§ No previous history of pain with menstruation
§ Infertility (e.g., adhesions, endometriosis, PID)
§ Irregular cycles
 § Heavy menstrual flow (e.g., adenomyosis, fibroids, polyps)
§ Dyspareunia or postcoital bleeding
§ Partial or no response to therapy with NSAIDs and/or hormonal
contraceptives
• (Abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and
duration of pain, and abnormal pelvic examination findings suggest underlying
pathology (secondary dysmenorrhea) and require further investigation. )AAFP

• may lead to school and work absenteeism, as well as limitations on social,

academic, and sports activities (if sever)

• Diagnostics
o Depend on the underlying cause
o Initial laboratory testing
§ CBC with differential (rules out infection)
§ Urinalysis (rules out UTIs)
o Other
§ β-hCG (rules out ectopic pregnancy),
§ Gonococcal/chlamydial swabs (rule out STDs and PID)
o Pelvic ultrasound
• Treatment: depends on the underlying cause

Pain typically lasts eight to 72 hours and usually occurs at the onset of menstrual flow.
Other associated symptoms may include low back pain, headache, diarrhea, fatigue,
nausea, or vomiting.1 A family history may be helpful in differentiating primary from
secondary dysmenorrhea; patients with a family history of endometriosis in first-degree
relatives are more likely to have secondary dysmenorrhea