When does onset of primary dysmenorrhea normally occur?
First few postmenarchal years (Teenage years)
What are the three pathophysiologic theories of primary dysmenorrhea?
Myometrial stimulation and vasoconstriction
Neuronal hypothesis -> type C pain fibers
Vasopressin contribution
Myometrial inflammation is likely due to _____ influence
Luteal hormone
What hormone is elevated during luteal phase?
Progesterone is elevated
What happens when there is elevated progesterone, what happens in terms of the chemical pathway?
Phospholipase released and cell membrane phospholipids hydrolyze and arachidonic acid and icosatetraenoic acid generated which are precursors for COX and prostaglandins and leukotrienes are produced
Uterine Angina is a form of _______
Myometrium inflammation
Arachidonic acid turns into _______ and ______
Prostaglandin and leukotrienes
What are effects of prostaglandin and leukotrienes on the uterus?
Prolong uterine contractions
Decrease endometrial blood flow
Neuronal hypothesis, type ____ pain fibers, which are the ____ pathway fibers and this signals nociception
C
Slow
T/F: C fibers are stimulated by aerobic metabolites that are generated from an ischemic endometrium
False; C fibers are stimulated by anaerobic metabolites generated from an ischemic endometrium
T/F: anterior pituitary hormones increases response to elevated prostaglandin
False; posterior pituitary hormones- vasopressin, increases response to elevated prostaglandins which results in myometrial hypersensitivity and reduced uterine blood flow and pain
T/F: pelvic exams are necessary for evaluation of primary dysmenorrhea when h/o intercourse
False; for primary dysmenorrhea, pelvic exams are deferred if there is no history of intercourse
Parasympathetic effect on the uterus is _____, sympathetic effect on the uterus is _____
Uterine vasodilation
Uterine vasoconstriction
What is the recommended dosing frequency of NSAID for primary dysmenorrhea?
Taken 1-2 days before the anticipated onset of menses and continue on a fixed schedule for 2-3 days (Wtf, this is so unnecessary)
What are some therapeutic interventions for primary dysmenorrhea?
NSAID use – first line treatment
Supportive measure – such as heat pack
Hormonal contraceptive
OMT- sacral
What is secondary dysmenorrhea?
Associated with pelvic pathology and not always gynecologic
But menses exacerbates the symptoms
(vs primary dysmenorrhea does not involve)
What are symptoms of secondary dysmenorrhea?
Menorrhagia
Intermenstrual bleeding
Dyspareunia
Postcoital bleeding
Infertility
Pathophysiology shared visceral innervation of dysmenorrhea is ____
T10-L1
Onset of secondary dysmenorrhea usually occurs ages _____
30+
(vs primary is during teenage years)
Characteristic of secondary dysmenorrhea of a gynecological cause would have pain in ______
Crampy low anterior pelvic discomfort
T/F: gynecologic cause of secondary dysmenorrhea would be non-cyclic and intensifies with menses
True
Non-gynecological causes of secondary dysmenorrhea include:
IBS IBD
Peritoneal inflammation or irritation
Urinary cause – ie nephrolithiasis
MSK and psychologic
What is adenomyosis?
slightly enlarged globular tender uterus within uterine musculature
a gynecologic etiology of secondary dysmenorrhea
what is inguinal adenopathy?
local infection such as HSV, GC, syphilis
a gynecologic etiology of secondary dysmenorrhea
what is leiomyomat?
benign, enlarged irregular tumor, nonpainful uterus, may be palpable abdominally
a gynecologic etiology of secondary dysmenorrhea
what is endometriosis?
presence of endometrial glands and stroma outside endometrial cavity and uterine musculature
nodularity, thickening of uterosacral ligaments, cervix fixed displaced laterally
a gynecologic etiology of secondary dysmenorrhea
T/F: Pelvic inflammatory disease would have positive chandelier sign on exam
True; chandelier sign is indicative of cervical motion tenderness
what is chandelier sign?
Cervical motion tenderness on exam
Mullerian defects can be evaluated using _____ imagining; tubal and uterine cavity patency can be evaluated using _____ imagining
MRI
HSG
T/F: most common cause of secondary dysmenorrhea is endometriosis
True
How is endometriosis diagnosed?
TVUS (Transvaginal ultrasound)
Diagnostic laparoscopy
What is the first line treatment for dysmenorrhea caused by endometriosis?
OCP use
How is Adenomyosis diagnosed?
TVUS
MRI
TVUS is used to diagnose which conditions?
Endometriosis
Adenomyosis
Ovarian cyst
Ovarian torsion
Ectopic pregnany
T/F: leiomyomata is diagnosed with TVUS
False; it is usually diagnosed with ultrasound, hysteroscopy or MRI
Cysts, endometriomas, neoplasms, torsion, and mittelschmerz are _______ cause of ______ dysmenorrhea
Ovarian gynecologic
Secondary
T/F: ovarian torsion is a surgical emergency
True; necessary to preserve function of ovaries
What is Mittelschmerz?
Recurrent midcycle pain in female with regular ovulatory cycles caused by normal follicular enlargement just prior to ovulation. Unilateral mild pain
Tubal infections can cause secondary dysmenorrhea, and include these conditions:
Ectopic pregnancy
Pelvic adhesions
PID
Pelvic congestion
Ectopic pregnancy is present ____ weeks after last menstrual period
6-8
Common causes of pelvic inflammatory disease?
C trachomatis
N honorrhoeae
Which condition would you likely to admit the patient for IV antbiotics?
PID
Venography is used to diagnose_____
Pelvic congestion syndrome
What is pelvic congestion syndrome?
damage to valves in ovarian veins results in valvular incompetence leading to reflux and chronic dilation
Cystitis, pyelonephritis, interstitial cystitis, nephrolithiasis are _____ causes of ____ Dysmenorrhea
Urinary non-gyn
Secondary
Acute Appendicitis/peritonitis, bowel obstruction, diverticulitis, gastroenteritis, IBD, IBS are ____ causes of ____ Dysmenorrhea
