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Premenstrual syndrome Dysmenorrhea


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Title: Premenstrual syndrome Dysmenorrhea

Premenstrual syndromeDysmenorrhea
  • Dr.Roaa H. Gadeer
  • MD

  • The presence of physical and/or behavioral
    symptoms that occur repetitively in the second
    half of the menstrual cycle and often the first
    few days of menses.

  • 70 - 80
  • Only 20 are clinically significant.
  • PMDD affect only 5-6
  • Relatively high rates
  • Mediterranean countries, the Middle East,
    Iceland, Kenya, and New Zealand

  • Premenstrual syndrome
  • 1. The presence by self report of at least one of
    the following somatic and affective symptoms
    during the five days prior to menses in each of
    the three menstrual cycles
  • Affective Depression, Angry, outbursts,
    Irritability Confusion, Social withdrawal,
  • Somatic Breast tenderness, Abdominal bloating
    ,Headache, Swollen extremities.
  • 2. Relief of the above symptoms within four days
    of the onset of menses, without recurrence until
    at least cycle day 13.

  • 3.The symptoms are present in the absence of any
    pharmacologic therapy, hormone , drug or alcohol
  • 4. Identifiable dysfunction in social or economic
    performance by one of the following criteria
  • Marital or relationship discord.
  • Difficulties in parenting.
  • Poor work or school performance.
  • Tiredness/Increased social isolation.
  • Legal difficulties.
  • Suicidal ideation.
  • Seeking medical attention for a somatic symptom.

  • interaction of cyclic changes in ovarian steroids
    with central neurotransmitters.
  • Serotonin.
  • Beta-endorphin.
  • Gamma-aminobutyric acid (GABA).
  • Autonomic nervous system.
  • Peripheral mechanisms.

  • Symptom
  • Fatigue 92
  • Irritability 91
  • Bloating 90
  • Anxiety/tension 89
  • Breast tenderness 85
  • Mood liability 81
  • Depression 80
  • Food cravings 78
  • Acne 71
  • Increased appetite 70
  • Over sensitivity 69
  • Swelling 67
  • Expressed anger 67
  • Crying easily 65
  • Feeling of isolation 65
  • Headache 60
  • Forgetfulness 56
  • Gastrointestinal symptoms 48

  • Diagnostic criteria are
  • The American Psychiatric Association DSM-IV
    criteria for PMDD
  • The University of California, San Diego (UCSD)
    criteria for PMS

  • DSM-IV criteria (PMDD)
  • Documentation of physical and behavioral symptoms
    being present for most of the preceding year.
  • Five or more of the following symptoms must have
    been present during the week prior to menses.
  • Resolving within a few days after menses starts.
  • At least one of the five symptoms must be one of
    the first four on this list
  • Feeling sad, hopeless, or self- deprecating
  • Feeling tense, anxious
  • Marked liability of mood / tearfulness
  • Persistent irritability, anger, and increased
    interpersonal conflicts
  • Decreased interest in usual activities /
    withdrawal from social relationships
  • Difficulty concentrating
  • Feeling fatigued, lethargic, or lacking in energy
  • Marked changes in appetite, which may be
    associated with binge eating or craving certain
  • Hypersomnia or insomnia
  • Being overwhelmed or out of control
  • Breast tenderness or swelling, headaches, joint
    or muscle pain, a sensation of bloating, weight

  • UCSD criteria (PMS)
  • In whom coexisting medical conditions or
    psychiatric disturbance were excluded by history,
    physical examination and psychometric testing.
  • The presence of at least one of the following six
    Behavioral symptoms
  • - Fatigue, irritability, depression, expressed
    anger, poor concentration, and social withdrawal.
  • at least one of the following four Somatic
  • - Breast tenderness, abdominal bloating,
    headache, or swollen extremities

(No Transcript)
Therapies for the premenstrual syndrome
  • Treatments with demonstrated efficacy
  • Serotonin reuptake inhibitors (NOT Anti
  • Alprazolam
  • Agents that suppress ovulation
  • GnRH agonists
  • Danazol
  • Treatments with possible efficacy
  • Oral contraceptives
  • Diuretics
  • Exercise
  • Ineffective treatments
  • Progesterone
  • Vitamin supplements/Dietary restrictions

  • Dysmenorrhea painful menstruation.
  • Primary Dysmenorrhea (PD) The presence of
    recurrent, crampy, lower abdominal pain that
    occurs during menses in the absence of
    demonstrable pelvic disease.
  • Secondary Dysmenorrhea The occurrence of painful
    menstruation in the presence of a pelvic
    pathology, such as endometriosis, adenomyosis,
    uterine leiomyomata, or chronic pelvic
    inflammatory disease

  •  PD typically begins during adolescence
  • Not until ovulatory menstrual cycles are
  • At two years postmenarche (18 to 45) teens have
    ovulatory cycles.
  • 80 are ovulatory by four to five years
  • The prevalence of dysmenorrhea among adolescent
    females ranges from 60 to 93 percent, but
    decreases with advancing age

  • Presentation at age less than 30 years.
  • Body mass index less than 20.
  • Menarche before age 12.
  • Longer cycles/duration of bleeding.
  • Irregular or heavy menstrual flow.
  • Premenstrual symptoms.
  • Pelvic inflammatory disease.
  • Sterilization.
  • History of sexual assault.
  • Heavy smoking.

Reduced risk of dysmenorrhea in
  • Use of oral contraceptives.
  • Fish intake.
  • Physical exercise.
  • Being married or in a stable relationship.
  • Higher parity.

  • Major causes of secondary dysmenorrhea
  • Gynecologic disorders
  • Endometriosis
  • Adenomyosis
  • Ovarian cysts
  • Pelvic adhesions
  • Pelvic inflammatory disease
  • Uterine polyps
  • Congenital obstructive müllerian malformations
  • Cervical stenosis
  • Nongynecologic disorders
  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Uteropelvic junction obstruction
  • Psychogenic disorders

  • PD is caused by frequent and prolonged uterine
    contractions that decrease blood flow to the
    myometrium resulting in ischemia (uterine
  • Stimulation of the endometrium by estrogen
    (follicular and proliferative phase) followed by
    progesterone (luteal and secretory phase)
    increases endometrial stores of arachidonic acid.
  • AA is a precursor to prostaglandin (PGF2),(PGE2)
    and leukotrienes.
  • Cyclooxygenase inhibitors decrease menstrual
    fluid prostaglandin levels and decrease pain.

  • Occurs during ovulatory cycles.
  • The pain begins just before or with the onset of
    menstrual bleeding.
  • Gradually diminishes over 12 to 72 hours.
  • The cramps are confined to the lower abdomen
  • Pain is strongest in the midline (back and thigh
  • Nausea, diarrhea, fatigue, headache, and a
    general sense of malaise accompany the pain.
  • By comparison, women with secondary dysmenorrhea
    often have symptoms and physical findings that
    alert the physician to the presence of pelvic
    pathology (Endometriosis).

  • Nonpharmacological interventions
  •   Heat
  •   Dietary, vitamin, and herbal treatments
  •   Exercise

  • Pharmacologic interventions
  • A placebo
  • Nonsteroidal antiinflammatory agents (NSAIDs)
  • Hormonal contraceptives.
  • Levonorgestrel intrauterine contraception IUD

  • Normal vaginal discharge consists of 1 to 4 mL
    fluid (per 24 hours).
  • White or transparent, thick, and mostly odorless.
  • Is formed by mucoid endocervical secretions in
    combination with sloughing epithelial cells,
    normal bacteria, and vaginal transudate.
  • The discharge may become more noticeable (
    during pregnancy, use of estrogen-progestin
    contraceptives, midmenstrual cycle close to the
    time of ovulation.
  • The pH of the normal vaginal secretions is 4.0
    to 4.5.
  • Dozens of different bacterial isolates.
  • Lactobacillus
  • Diphtheroids
  • S. epidermidis

Causes of vaginitis
  • Infectious vaginitis
  • Common causes
  • Bacterial vaginosis (40 to 50 percent of cases)
  • Vulvovaginal candidiasis (20 to 25 percent of
  • Trichomoniasis (15 to 20 percent of cases)
  • Less common causes
  • Foreign body with secondary infection
  • Desquamative inflammatory vaginitis
  • Streptococcal vaginitis (group A)
  • Ulcerative vaginitis associated with
    Staphylococcus aureus and toxic shock syndrome
  • Idiopathic vulvovaginal ulceration associated
    with HIV.
  • Noninfectious vaginitis
  • Chemical or other irritant
  • Allergic, hypersensitivity, and contact
    dermatitis (lichen simplex)
  • Traumatic vaginitis
  • Atrophic vaginitis
  • Postpuerperal atrophic vaginitis
  • Desquamative inflammatory vaginitis
  • Erosive lichen planus
  • Collagen vascular disease, Behcet's syndrome,
  • Idiopathic vaginitis

  • History  Symptoms of vaginitis include abnormal
    vaginal discharge, pruritus, irritation, burning,
    soreness, odor, and, less commonly, dyspareunia
  • Physical examination Appearance, cervical
    motion tenderness. The vulva usually appears
    normal in bacterial vaginosis. Erythema, edema,
    or fissure formation suggest candidiasis,
    trichomoniasis, or dermatitis.

Diagnostic studies
  • Vaginal pH
  • Vaginal pH is the single most important finding.
  • A strip of pH paper is applied to the vaginal
  • A pH above 4.5 in a premenopausal woman suggests
    infections such as bacterial vaginosis or
    trichomoniasis (pH 5 to 6), and helps to exclude
    candida vulvovaginitis (pH 4 to 4.5).
  • Vaginal pH may be altered (usually to a higher
    pH) by contamination with lubricating gels,
    semen, douches, and intravaginal medications.
  • Microscopy
  • Candidal buds or hyphae
  • Motile Trichomonas
  • Epithelial cells studded with adherent
    coccobacilli (clue cells)
  • Polymorphonuclear cells (PMNs).
  • The saline should be at room temperature and
    microscopy should be performed within 10 to 20

  • Vaginal discharge processing
  • is generally sampled with a cotton-tipped swab.
    The sample of vaginal discharge is mixed with one
    to two drops of 0.9 percent normal saline
    solution on a glass slide. Cover slips are placed
    on the slides, which are examined under a
    microscope at low and high power.
  • The addition of 10 percent potassium hydroxide
    (KOH) to the wet mount of vaginal discharge
    destroys cellular elements (Candida vaginitis).
  • Smelling ("whiffing") the slide immediately after
    applying KOH is useful for detecting the fishy
    (amine) odor of Bacterial Vaginosis.
  • Excess WBCs without evidence of yeast,
    trichomonads, or clue cells suggests cervicitis.
  • If microscopy is not available, diagnostic
    testing cards are an alternative rapid test for
    confirming the clinical suspicion.

  •  Vaginal culture
  • For Candida or Trichomonas , if microscopy is
    negative because microscopy is not sufficiently
    sensitive to exclude these diagnoses in
    symptomatic patients.
  • Cervical culture
  • For cervicitis, typically due to Neisseria
    gonorrhoeae or Chlamydia trachomatis, if you see
    a purulent vaginal discharge, fever, or lower
    abdominal pain (PID).
  • Sexual behaviors that result in STD-related
    vulvovaginitis (eg, trichomoniasis, herpes
    simplex virus) increase the odds of acquiring
    other STDs. The presence of high risk behavior or
    any sexually transmitted disease requires
    screening for HIV, hepatitis B, and other STDs.

Candida Albicans
Clue Cell (BV) Bacteroides species anaerobic
Peptostreptococcus species Fusobacterium sp. and
Atopobium vaginae
  • Candida
  • A-non complicated
  • Butoconazole (Femstat)
  • (Femstat) 2 percent cream 5 g/day for 3 days or
    1 day for sustained release formulation
  • (Gynazole) 2 percent cream 5 g/day for a single
  • Clotrimazole (Gyne- lotrimin, Mycelex) 1 percent
    cream 5 g/day for 7 to 14 days
  • 100 mg vaginal tablet 1/day for 7 days
  • Miconazole (Monistat) 2 percent cream 5 g/day for
    7 days
  • 100 mg vaginal suppository 1/day for 7 days
  • 200 mg vaginal suppository 1/day for 3 days
  • 1200 mg vaginal suppository 1 suppository
  • Tioconazole (Vagistat) 6.5 percent cream 5 g in a
    single dose
  • Terconazole (Terazol) 0.4 percent cream 5 g/day
    for 7 days
  • 80 mg vaginal suppository 1/day for 3 days
  • Nystatin (Mycostatin) 100,000 U vaginal tablet
    1/day for 14 days
  • Fluconazole (Diflucan)
  • B- complicated
  • Boric Acid

Trichomonas / BV
  • Metronidazole
  • PO 500 mg bid x 7 days OR 2 gms single dose.
  • PV
  • Clindamycin 300 mg po bid x 5 days for BV.
  • Treat the partner in Trichomoniasis

Atrophic vaginitis
  • Lubricating /moisturizing gel.
  • Low dose Estrogen
  • Systemic
  • Local

  • Thanks