Gynecology Topic 08. Dysmenorrhea. Premenstrual tension

I. Dysmenorrhea: Definition and Classification

Definition

• Dysmenorrhea: painful menstruation that interferes with normal activities.
• Typical pain: lower abdominal cramping during menses → may radiate to lower back/thighs.
• Associated symptoms: nausea, vomiting, fatigue, diarrhea, headache.

Primary Dysmenorrhea

• Definition: idiopathic menstrual pain without identifiable pelvic pathology.
• Onset: adolescence, usually after ovulatory cycles begin.
• Pathophysiology: progesterone-primed secretory endometrium → increased prostaglandins → uterine hypercontractility + vasoconstriction → ischemic cramping pain.
• Risk factors: stress/anxiety, obesity, smoking, early menarche, long/heavy menses.
• Physical examination: usually normal.

Secondary Dysmenorrhea

• Definition: painful menses due to underlying pelvic disease.
• Onset: later onset, often >25 years, or new/worsening pain after previously painless menses.
• Causes: endometriosis, adenomyosis, PID, uterine fibroids, cervical stenosis, pelvic adhesions.
• Clinical clue: pain may start before menses, progress through luteal phase, persist after bleeding, or occur between menses.
• Other symptoms: dyspareunia, chronic pelvic pain, abnormal bleeding, infertility, fever/discharge if infection.

II. Dysmenorrhea: Diagnosis and Treatment

Diagnosis

• Primary dysmenorrhea is mainly clinical: typical cyclic pain + normal examination + no red flags.
• History: onset, relation to bleeding, pain severity/radiation, associated symptoms, sexual history, contraception, fertility wish.
• Physical examination: abdominal/pelvic exam if sexually active, atypical symptoms, severe pain or suspected secondary cause.
• Rule out pathology when needed: beta-hCG, pelvic US, urine culture, cervical swab, hormone tests if cycle/endocrine symptoms.
• Laparoscopy: persistent suspected endometriosis or unexplained pain despite empirical treatment.

Treatment of Primary Dysmenorrhea

• NSAIDs: first-line; inhibit COX → decreased prostaglandin synthesis → less uterine contraction and ischemia.
• Use: start at pain onset or 1 day before expected menses; continue for 1-3 days.
• Hormonal contraception/OCPs: suppress ovulation/endometrial proliferation → ↓ prostaglandins and uterine hypercontractility.
• Non-medical: abdominal heat packs, regular exercise, rest, stress reduction, psychotherapy/CBT if stress-anxiety component.

Treatment of Secondary Dysmenorrhea

• Rule: treat the underlying disease.
• Endometriosis: NSAIDs + hormonal suppression; laparoscopy/excision if refractory or infertility/diagnostic uncertainty.
• Adenomyosis/fibroids: hormonal treatment, LNG-IUD, uterine-sparing procedure or surgery according to fertility wish.
• PID: antibiotics and partner/STI management.

III. Premenstrual Syndrome and PMDD

Definition

• Premenstrual syndrome (PMS): cyclic physical, emotional, and behavioral symptoms in the luteal phase that improve after menstruation begins.
• Premenstrual tension syndrome: older name for PMS.
• Premenstrual dysphoric disorder (PMDD): severe PMS variant with prominent mood symptoms and major impairment.
• Pattern: symptoms appear 5-10 days before menses → symptom-free interval after menstruation.

Etiology and Pathophysiology

• Exact cause unclear.
• Main concept: abnormal sensitivity to cyclic estrogen/progesterone changes after ovulation → neurotransmitter effects.
• Possible mechanisms: serotonin deficiency, GABA interaction, stress/environmental factors, possible Mg/Ca/vitamin B6 deficiency.

Clinical Features

• Physical: breast tenderness, headache, abdominal/back pain, bloating, edema.
• GI: nausea, vomiting, food craving, appetite change.
• Cognitive/neurologic: poor concentration, confusion, fatigue, sleep disturbance.
• Mood/behavioral: irritability, mood swings, depression, anxiety, insomnia.

IV. PMS / PMDD Diagnosis and Treatment

Diagnosis

• Diagnosis is clinical and prospective.
• Symptom diary: record symptoms and timing for at least 2 cycles.
• PMS: luteal symptoms with symptom-free interval after menstruation and interference with daily life.
• PMDD: ≥5 marked symptoms in most cycles for about 1 year with significant impairment.
• Exclude mimics: thyroid disease, anemia, medication effects, depression, anxiety disorder, bipolar disorder.

Lifestyle and Psychological Treatment

• Regular exercise, sleep, stress reduction.
• Diet: reduce caffeine, sugar, alcohol, and salt if they trigger symptoms.
• Supplements: calcium, magnesium, vitamin B6 may be tried; effect is variable.
• Cognitive-behavioral therapy: useful for mood symptoms and coping.

Pharmacological Treatment

• SSRIs: first-line for prominent mood symptoms; examples: fluoxetine, sertraline.
• Combined oral contraceptives: useful for cyclic symptom control.
• NSAIDs: aches, headache, breast pain and associated dysmenorrhea.
• Spironolactone: edema and bloating when fluid retention is prominent.
• GnRH agonist: refractory severe PMS/PMDD → ovarian suppression; add-back may be needed.