Kembara Xtra - Medicine - Dysmenorrhea

Kembara Xtra - Medicine - Dysmenorrhea 
Pelvic pain, which can occur during or around the time of menstruation, is a prominent cause of absenteeism among young women (under 30 years old).
Primary dysmenorrhea is defined as pelvic pain in the absence of pathologic physical signs and is a diagnosis of exclusion. 
Secondary dysmenorrhea: typically more severe, comes from a specific pelvic pathology; frequently resistant to the conventional therapies for dysmenorrhea; severity dependent on activity impairment: - Mild: uncomfortable, although it only occasionally interferes with everyday function or necessitates the use of analgesics - Moderate: everyday activities are disrupted, infrequent instances of absence, and analgesics are required. - Severe: everyday activities are impacted, the likelihood of absenteeism is raised, and analgesics provide only minimal relief.
Affected system: the reproductive system
● Menstrual cramps are another name for these.

Epidemiology 
Primary: onset 6 to 12 months after the start of menarche, teens to early 20s Secondary: 20s to 30s Predominant age: onset 6 to 12 months after the start of menarche, adolescents to early 20s Predominant sex: women only 
Up to ninety percent of menstrual women have reported having primary dysmenorrhea at some point in their lives.

Due to dysmenorrhea, up to 42% of women miss one or more days of school or work each month.
Up to twenty percent of people reported being impaired in their day-to-day activities and/or sleep.

Causes and effects: etiology and pathophysiology 
Primary: Nonrhythmic hypercontractility and increased uterine muscle tone with vasoconstriction and concomitant uterine ischemia are caused by elevated prostaglandin (PGF2) production through indirect hormonal regulation (reduction in progesterone at the start of menses leads to increase in prostaglandins). This increases the risk of uterine ischemia. Ischemia causes a hypersensitization of the pain nerve fibers of type C, and the intensity of cramping is directly proportional to the amount of PGF2 that is released.
- Endometriosis (most prevalent cause)
Adenomyosis Congenital abnormalities of uterine/vaginal anatomy Cervical stenosis Pelvic inflammatory disease Ovarian cysts Pelvic tumors, including leiomyomata (fibroids) and uterine polyps Adenomyosis Congenital abnormalities of uterine/vaginal anatomy Cervical stenosis Ovarian cysts Pelvic tumors Genetics
Not well studied


factors of danger 

Primary – Cigarette smoking – Alcohol use – Early menarche (age 12 years) – Age 30 years – Family history of dysmenorrhea – Irregular or heavy menstrual flow – Nonuse of oral contraceptives – Sexual abuse or history of sexual assault – Psychological symptoms (depression, anxiety, increased stress, etc.) Secondary – Nonuse of oral contraceptives – Irregular or heavy – Nulliparity
Secondary: pelvic infection; use of an intrauterine device (IUD) in the few months following insertion; structural pelvic malformations; a family history of endometriosis in a first-degree relative; structural pelvic malformations;

Primary prevention strategies include regular exercise; early births and higher parity; and the use of hormonal contraceptives. Secondary prevention strategies include taking steps to lower the likelihood of contracting sexually transmitted infections (STIs).

Considerations Relating to Children

An increased risk of genital tract anatomic anomaly is associated with the onset of the first menstrual period. These abnormalities include transverse vaginal septum, imperforate or minimally perforated hymen, and uterine malformations.


Associated Conditions Anxiety and depression a lower quality of life Irregular or heavy menstrual periods a longer menstrual cycle length and duration of bleeding a longer duration of bleeding

Diagnosis 
Typically, a clinical diagnosis is made based on the history of distinctive symptoms such as cramping or discomfort in the suprapubic or low back that occurs at or near the beginning of menstrual flow and lasts for eight to seventy-two hours.


Providing an Account of History 

Patients with primary endometriosis may experience accompanying symptoms such as nausea, vomiting, diarrhea, headache, lethargy, sleeplessness, pain radiating into the low back or inner thighs, and infrequently syncope and fever. The start of primary endometriosis in teenagers occurs once ovulatory cycles are established; on average, 6 to 12 months following menarche. All of these are believed to be secondary effects of the release of prostaglandin.

Pelvic pain that occurs in between periods of menstruation is not likely to be caused by dysmenorrhea because it does not recur at the same time or immediately before the beginning of the menstrual flow.
- Occurring in conjunction with the majority of menstrual periods (cyclic).
The temporary alleviation of acute symptoms linked with the following: - The utilization of analgesics, most notably NSAIDs
- Application of heat to a localized area of the body – Orgasm
Response to non-steroidal anti-inflammatory drugs (NSAIDs) helps establish diagnosis.
The effect that symptoms have on one's daily activities can be used as a guide to assist estimate the severity.
Secondary: can be related with chronic pelvic pain, midcycle pain, dyspareunia, abnormal uterine bleeding, typical onset after age 25 years, nonmidline pain, development of intensity, lack of response to NSAIDs/hormonal treatment, and infertility. Primary: can be associated with midcycle pain, dyspareunia, abnormal uterine bleeding, dyspareunia, and abnormal uterine hemorrhage.

The Patient's Clinical Examination 

Primary: A normal physical examination is usually found. Only if the history does not fit the pattern of primary dysmenorrhea should an examination to rule out secondary dysmenorrhea be performed. If the patient is sexually active, a pelvic exam is recommended to rule out the possibility of infection.
Secondary: Check for cervical discharge, enlarged uterus, uterine pain, irregularity, and fixation.

Differential Diagnosis: The primary indicator is the patient's medical history.

Endometriosis as a secondary cause (the most common cause)
Uterine or ovarian neoplasm – UTI – Complication with IUD use – Congenital uterine or cervical abnormality – Adenomyosis – Leiomyomata (fibroids) – Pelvic adhesions
– Irritable bowel syndrome – Chronic pelvic discomfort (idiopathic) – Crohn's disease (inflammatory bowel disease)

Results From the Laboratory 
Initial Tests (lab, imaging)
The majority of cases of primary dysmenorrhea can be identified based only on the patient's medical history. All tests should only be undertaken if needed based on the patient's history or if the patient exhibits symptoms that are resistant to first-line therapy.
Test to determine pregnancy

Examining the urine for signs of infection
Cervical testing for gonorrhea and chlamydia, particularly in women under the age of 25 and in locations with a high prevalence of the diseases
Primary: A pelvic ultrasound should be considered to eliminate the possibility of secondary abnormalities.
Ultrasound and/or laparoscopy may be used, depending on the severity of the condition, to define the patient's anatomy. If ultrasonography is not diagnostic and there is a suspicion of fibroids, ovarian torsion, deep endometriosis, or adenomyosis, then MRI may be useful as a second-line noninvasive imaging technique.
Additional Assessments, as well as Other Important Factors
Advice on the most effective ways to avoid sexually transmitted infections and unintended pregnancies.
Diagnostic Methods and Other Procedures
Laparoscopy is an invasive procedure that should only be performed when absolutely necessary, such as when transvaginal ultrasonography fails to unequivocally identify pelvic adhesions or when endometriosis is suspected.

Test Interpretation - Primary: none - Secondary: Specific anatomic abnormalities may be observed (for more information, see "Differential Diagnosis").

Things to Think About When Expecting
When a patient has a positive pregnancy test but also experiences pelvic pain along with vaginal bleeding, you should think about the possibility of an ectopic pregnancy.

Treatment It is important to reassure the patient that successful treatment is possible if they follow the guidelines. It is possible that relief will require the use of many treatment modalities at the same time.

Non-Invasive General methods to treat PainRegular exercise and the application of topical heat are two non-invasive general methods that can be taken to treat pain. When compared to the use of an NSAID on its own, the combination of local heat with an NSAID is more effective.

It has been discovered that high-frequency transcutaneous electrical nerve stimulation, sometimes known as TENS, can be beneficial.

Because it does not offer any benefits beyond those offered by a placebo, low-frequency TENS is not suggested.
Treatment of a suspected or verified underlying cause of discomfort is considered to be secondary dysmenorrhea.

Medication 

First Line
NSAIDs work by preventing the formation of prostaglandins in the body's periphery. No nonsteroidal anti-inflammatory drug (NSAID) has been demonstrated to be superior to the others. The prescribed medication should be taken according to the dose schedule beginning one to two days before the commencement of menstruation and continued for two to three days (1), (2). If one preparation of an NSAID does not alleviate the patient's symptoms, then another preparation of an NSAID should be attempted.
Before making any conclusions about the efficacy of any preparation, the whole course of treatment—at least three menstrual cycles—ought to be completed as directed.
Ibuprofen: 400 milligrams orally every eight hours; naproxen sodium: 500 milligrams orally every twelve hours; celecoxib: 400 milligrams orally on day one, followed by 200 milligrams orally every twelve hours; mefenamic acid: 500 milligrams orally on day one, followed by 250 milligrams orally every six hours; maximum dosage: three days
Hormonal contraceptives are advised for women who want to prevent pregnancy but also suffer from primary dysmenorrhea.
Directly inhibits ovulation and restrains the growth of the endometrium, which leads to a decrease in the synthesis of prostaglandin, as well as in intrauterine pressure and uterine contractions.
It was discovered that continuous dosing, as opposed to cyclical dosing, is more effective for the management of pain. It is possible for amenorrhea, in any form, to alleviate the symptoms of dysmenorrhea. Contraceptives containing estrogen are the treatment of choice for secondary dysmenorrhea caused by endometriosis; however, progestin-only approaches have also been demonstrated to be helpful. Estrogen-containing contraceptives are the recommended first-line treatment.
It has been discovered that low- and high-dose combination oral contraceptives (COCs), as well as transdermal and intravaginal combined contraceptives, are all superior to the placebo.
- Levonorgestrel IUDs are just as effective as COCs.
– Progestin-only contraceptions, such as subcutaneous and subdermal preparations, appear to lessen primary dysmenorrhea; however, they do so to a smaller amount than combined alternatives and IUDs.

Possible adverse effects from using NSAIDs and COCs together – illnesses of the platelets in the blood – Ulcerative colitis or gastritis of the stomach – A personal or family history of thromboembolic illnesses
- Vascular disease
- Migraines accompanied by an aura
- Smoking in its purest form
Cautionary notes on first-line options: – Irritation of the gastrointestinal tract – Lactation – Coagulation problems
- Alterations in the function of the kidneys
- Problems with the heart
– Abnormalities in the liver – Being pregnant – High blood pressure
● Significant possible interactions – Anticoagulants of the Coumadin type – Aspirin and other nonsteroidal anti-inflammatory drugs


The second line of defense is that acetaminophen and acetaminophen combined with caffeine are superior to the placebo and have a lower risk of adverse effects than NSAIDs.

Pain relief from primary dysmenorrhea may be achieved by the use of behavioral therapies such as relaxation techniques, which may include yoga.
Nifedipine may be beneficial in some women, and it is approved for use in women who are attempting to become pregnant (pregnancy Category C).

Surgical Methods and Operations 
Laparoscopic uterosacral nerve ablation and pre sacral neurectomy have both been found to alleviate pain after six and twelve months, respectively. However, these procedures are currently only performed on patients who have pain that is resistant to all other first- and second-line therapy. Although hysterectomy is an excellent treatment for dysmenorrhea, the procedure should only be considered in extremely unusual circumstances and after all of the children that the patient desires have been born.


Alternative Medication 
There is some evidence that Chinese herbal therapy can reduce pain, but this theory needs to be confirmed by more research.
It has been demonstrated that acupuncture treatments can lessen the pain associated with dysmenorrhea; however, additional trials that are randomized and well-designed are required. In order for these therapies to be effective, they need to be administered frequently and at the appropriate times.
In terms of relieving pain, the use of acupoint stimulation, particularly noninvasive stimulation (acupressure), has produced equivocal results.
Primary dysmenorrhea may be alleviated by performing an aromatherapy abdomen massage once day for ten minutes, beginning seven days before the commencement of menstruation.
There is a need for additional research to determine the benefits and risks associated with regular use of oral fennel, oral ginger, oral fenugreek, oral valerian, extracorporeal magnetic innervation, vitamin K1 injection into the spleen-6 acupuncture point, use of high-frequency vibratory stimulation tampon, transdermal nitroglycerin, and vaginal sildenafil. 

Admission 
The treatment for both primary and secondary dysmenorrhea is often carried out in an outpatient environment.
Outpatient treatment comes first.
Tertiary: most frequently outpatient treatment

Maintain the Status Quo
 
Assure the patient that primary dysmenorrhea can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), COCs, intrauterine devices (IUDs), exercise, or local heat, and that the condition will typically improve with age and the number of children a woman has.

Secondary: likely to require therapy based on the underlying cause Prognosis: primary: lowered with age and parity secondary: likely to require therapy

Complications 
At the forefront: anxiousness and/or sadness
Tertiary: infertility as a result of an underlying ailment