Dysmenorrhoea

From Ganfyd

Tranexamic acid is more effective than NSAIDs which are more effective than hormones.

Painful, usually implying excessive (although this is strictly termed menorrhagia), menstrual bleeding.

Most is not medicalised and much is not treated even with over the counter medicines.

Three classes of drugs have commonly been used for this:-

1. Hormone (Norethisterone)
2. NSAIDs
3. inhibitors of clot lysis eg Tranexamic acid

In 1995, a paper demonstrated that the treatments ranked for efficacy in the reverse of the order of their frequency of use by British GPs.^[1] Tranexamic acid is more effective than NSAIDs ^[2] which are more effective than hormones.

Treatments may be combined, and the combined oral contraceptive pill is effective and reasonable for non-smoking women under the age of (say) 40.

Menorrhagia

For research purposes, excessive menstrual bleeding is defined as a measured loss in excess of 80 ml per cycle.

In practice diagnosed on flooding, passage of large clots and social inconvenience. More than 7 days bleeding may also be included.

Incidence: around 20% of women.

In the absence of a specific cause, it is called dysfunctional uterine bleeding.

Causes

• may be due to organic cause
• may be due to alteration of endocrine / local endometrial control of menstruation
• may be anovulatory cycles - failure of ovulation leads to a prolonged proliferative phase of the endometrium and heavier bleeding when oestrogen withdrawal eventually occurs.

Organic causes

• Fibroids, esp. if intramural / submucous
• Diffuse adenomyosis
• Endometrial polyps
• Chronic pelvic infection / pelvic inflammatory disease (rarely)
• Blood dyscrasia
• Hypothyroidism

Examination

Using professional judgement consider examining

• Anaemia
• Thyroid disease
• Breasts
• Abdomen
  • pelvic mass (pregnancy, tumour, fibroids, ovarian cyst), surgery scars, hair distribution, tenderness, striae, ascites.
• Vaginal exam
  • discharge, scarring, reduced mobility, nodules, masses, tenderness

Investigation

• Full blood count
• Thyroid function
• Clotting
• Pregnancy Test
• (Transvaginal) ultrasound
  • endometrium >5mm width postmenopausally needs biopsy / curettage
• Hysteroscopy
• Endometrial biopsy/curettage

Treatment

Medical management

Indications

• Dysfunctional uterine bleeding
• Bleeding due to blood disorders
  • Von Willebrands disease
  • Thrombocytopenia
• Systemic diseases
• Temporary period before surgery to correct anaemia
• Refuses surgical interventions
• Associated factors
  • contraception
  • reduction in size of fibroids

Drugs

As mentioned above, the options, in no particular order include:

• NSAIDs
  • Inhibit prostaglandin synthesis e.g. mefenamic acid, flufenamic acid
• Progesterones (progestagens)
• Oestrogen and progesterone(Combined oral contraceptive pill, OCP)
• Antifibrinolytics, e.g. tranexamic acid
• Antigonadotrophins, e.g. danazol
• Ethamsylate
• GnRH analogues e.g. Goserelin (Zoladex)
• Desmopressin(in Von Willebrands disease)
• Intra-uterine progestagen (e.g. Mirena system)

Other measures

• correction of anaemia

Surgical treatment

Factors to consider

• Presence of cancer
• Requirements for future fertility
• Age
• Sexual function
• Patient wishes

Techniques

The following options are availabel for hysteroscopic treatment:

• Under local anaesthetic
  • Polypectomy
• Under general anaesthetic
  • submucous fibroid or fibroid polyps can be removed

Hysteroscopic myolysis is research technique undergoing evaluation.

If the woman has no further wish to remain fertile then surgical techniques can be offered with the aim of creating an artificial Asherman's syndrome (intrauterine adhesions). These include:

• Trans-Cervical Resection of Endometrium
• Radio-frequency ablation

Depending on the underlying pathology or severity of symptoms then more radical surgical options can be offered:

• Myomectomy
• Hysterectomy

Risks

• Uterine perforation
• Haemorrhage
• Fluid overload (a glycine-based medium is used to allow diathermy and can cause problems with sodium levels)
• Anaphylaxis
• Infertility

External links

• PRODIGY guideline
• Clinical Evidence
• Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea Cochrane Systematic Review
• eMedicine chapter
• PRODIGY patient information leaflet.

See also Menstrual cycle

References