Painful Menstruation, PMS,

Endometriosis And Polycystic

Ovary Syndrome
RISHAM MAHMOOD(ROLL#12)
FARTASHIA TARIQ (ROLL#14)
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Objectives

 Define Dysmenorrhoea
 Identify causes of Primary and Secondary amenorrhoea
 Outline management plan of primary Dysmenorrhoea
 Briefly discuss the clinical features and management plan of a
women presenting with premenstrual Syndrome
 Discuss Clinical features, investigations and management plan of
endometriosis
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Dysmenorrhoea

 Dysmenorrhoea is defined as Painful Menstruation

 Experienced by 45-95% women of reproductive age
 It can be Primary or Secondary
 Primary Dysmenorrhoea describes painful Periods since onset of
Menarche and is unlikely to be associated with any pathology ( Some
evidence suggests that it improves after Childbirth and with increasing
age)
 Secondary Dysmenorrhoea is painful periods that have developed
overtime and usually have a secondary cause.
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Aetiology of secondary Dysmenorrhoea

 Endometriosis and adenomyosis

 Pelvic inflammatory disease
 Cervical stenosis and haematometra (rarely).
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History and examination

 Patients will have different ideas as to what constitutes a painful period

 To ascertain the actual severity of the pain, the following questions are useful:
❖ Do you need to take painkillers for this pain? Which tablets help?
❖ Have you needed to take any time off work/school due to the pain?
➢ Some primary dysmenorrhoea is associated with flushing and nausea, which may
be prostaglandin related
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 It is important to distinguish between menstrual pain that precedes the

period (a vital clue in endometriosis) and pain that only occurs with
bleeding. Other important clues about the aetiology include pain that
occurs with passage of clots, in which case medication to reduce flow
may be effective.
 Secondary dysmenorrhoea may be associated with dyspareunia or
AUB, which may point towards a pathological diagnosis.
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Investigations
 High vaginal and endocervical swabs.
 TVUSS scan may be useful to detect endometriomas or appearances suggestive of adenomyosis
(enlarged uterus with heterogeneous texture) or to image an enlarged uterus.
 Diagnostic laparoscopy: performed to investigate secondary dysmenorrhoea
 When the history is suggestive of endometriosis
 When swabs and ultrasound scan are normal, yet symptoms persist
 When the patient wants a definite diagnosis or wants reassurance that their pelvis is normal
 If features in the history suggest cervical stenosis, ultrasound-guided hysteroscopy can be used to
investigate further
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Management

 Non-steroidal anti-inflammatory drugs (NSAIDs): examples are naproxen,

ibuprofen and mefenamic acid.
 Hormonal contraceptives. Progestogens, either oral (desogestrol) or parenteral
(medroxyprogesterone, etonogestrel) may be useful to cause anovulation and
amenorrhoea.
 LNG-IUS
 Lifestyle changes
 GnRH analogues
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Amenorrhoea

 Amenorrhoea is defined as the absence of menstruation for more than 6

months in the absence of pregnancy in a woman of fertile age
o Primary amenorrhoea is when girls fail to menstruate by 16 years of age
o Secondary amenorrhoea is absence of menstruation for more than 6
months in a normal female of reproductive age that is not due to
pregnancy, lactation or the menopause.
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Polycystic ovary syndrome

 PCOS is a syndrome of ovarian dysfunction along with the cardinal features of
hyperandrogenism and polycystic ovary morphology
 25% of all women but is not always associated with the full syndrome
 Clinical manifestations include menstrual irregularities, signs of androgen excess
(e.g. hirsutism and acne) and obesity. Elevated serum LH levels, biochemical
evidence of hyperandrogenism and raised insulin resistance are also common
features.
 PCOS is associated with an increased risk of type 2 diabetes and cardiovascular
events
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Clinical features

 Oligomenorrhoea/amenorrhoea in up to 75% of patients, predominantly

related to chronic anovulation.
 Hirsutism.
 Subfertility in up to 75% of women.
 Obesity in at least 40% of patients.
 Acanthosis nigricans (areas of increased velvety skin pigmentation occur
in the axillae and other flexures).
 May be asymptomatic.
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Gross appearance of a polycystic ovary (A) and transvaginal ultrasound scan

image (B).
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Acanthosis nigricans
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Diagnosis

 Patients must have two out of the three features below:

 • Amenorrhoea/oligomenorrhoea.
 • Clinical or biochemical hyperandrogenism.
 • Polycystic ovaries on ultrasound. The ultrasound criteria for the
diagnosis of a polycystic ovary are eight or more sub capsular
follicular cysts <10 mm in diameter and increased ovarian
stroma. While these findings support a diagnosis of PCOS, they
are not by themselves sufficient to identify the syndrome.
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Management

 Combined oral contraceptive pill (COCP) to regulate menstruation. This also

increases sex hormone binding globulin, which will help reduce androgenic
symptoms.
 Cyclical oral progesterone: used to regulate a withdrawal bleed.
 Clomiphene: this can be used to induce ovulation where subfertility is a factor.
 Lifestyle advice: dietary modification and exercise
 Weight reduction.
 Ovarian Drilling.
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 Treatment of hirsutism/androgenic symptoms:

 Eflornithine cream applied topically
 Cyproterone acetate (an antiandrogen)
 Metformin: this is beneficial in a subset of patients with PCOS, those with
hyperinsulinemia and cardiovascular risk factors.
 GnRH analogues with low-dose HRT: this regime should be reserved for
women intolerant of other therapies
 Surgical treatments
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Premenstrual Syndrome

It is the occurrence of cyclical somatic, psychological and emotional

symptoms that occur in the luteal (premenstrual) phase of menstrual
cycle and resolves by the time menstruation ceases.
 Premenstrual symptoms occur in almost all women of
reproductive age.
 Sometimes symptoms are severe causing disruption to every day
life.
 Clinical Features

Patient is likely to complain some or all of the following:

1. Bloating
2. Cyclical weight gain
3. Mastalgia
4. Abdominal cramps
5. Fatigue
6. Headache
7. Depression
8. Irritability
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Management
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Endometriosis

 Endometriosis is a common condition and is defined as endometrial tissue lying outside the
uterine cavity.
 It is usually found within pelvis, being commonly located on peritoneum lining the pelvic
side walls, Pouch of Douglas, uterosacral ligaments and bladder.
 Ectopic endometrial like tissue can induce fibrosis and be found infiltrating into deeper
tissues such as rectovaginal septum and bladder.
 If endometrial tissue is implanted into ovary, an endometrioma is formed.
 This cyst may be large containing old, altered blood with thick brown appearance called
chocolate cyst.
 Less common sites: umbilicus, abdominal scars and the pleural cavity.
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• Endometrial tissue under response of cyclical hormones undergoes cyclical bleeding and
local inflammatory reactions.
• Regularly repeated episodes of bleeding and healing lead to fibrosis and adhesion
formation between pelvic organs causing pain and infertility.
• In extreme cases frozen pelvis results ,where extensive adhesions tether the pelvic organs
and obliterate normal anatomy.
• Endometriosis occurs in approx. 5-10% of women of reproductive age. It is found in at
least 1/3rd of the women undergoing diagnostic laproscopy for pelvic pain or infertility.
• If resolves after menopause because it is estrogen dependent.
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Aetiology

 There are several theories

1. Sampson’s implantation theory
2. Meyer’s coelomic metaplasia
3. Genetic and immunological factors
4. Vascular and lymphatic spread
Site Symptoms
Female reproductive 1. Dysmenorrhea
tract 2. lower abdominal and pelvic
pain
3. Dyspareunia
4. Rupture/torsion endometrioma
5. Lower back pain
6. Infertility
Urinary tract 1. Cyclical hematuria/dysuria
2. Loin/flank pain (ureteric
obstruction)
Gastrointestinal tract 1. Dyschezia(pain on
defaecation)
2. Cyclical rectal bleeding
3. Obstruction
Site Symptoms

Surgical scars/umbilicus 1. Cyclical pain, swelling and

bleeding

Lungs 1. Cyclical haemoptysis

2. Haemopneumothorax
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Physical Examination

An abdominal and pelvic examination should be performed.

Certain signs associated with endometriosis include
 Adnexal mass
 Thickening or nodularity of the uterosacral ligaments
 Tenderness in pouch of Douglas
 Fixed retroverted uterus
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Investigations

 Transvaginal ultrasound: can detect gross endometriosis involving

the ovaries (endometriomas or chocolate cysts) and occasionally the
rectum.
 MRI: it can detect lesions >5mm in size , particularly in deep
tissues e.g. rectovaginal septum.
 Diagnostic Laparoscopy: gold standard method, visualise the
lesions, can also take biopsy for histological confirmation
 Biomarkers: such as CA125
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 RED LESIONS BLACK MATCHSTICK LESIONS WHITE FIBROUS LESION

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Endometriosis and infertility

• It is estimated that between 30% and 40% of patients with

endometriosis complain of difficulty in conceiving.
• In more severe stages of endometriosis there is commonly anatomical
distortion with peri adnexal adhesions and destruction of ovarian tissue
when endometriomas develops.
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Infertility And Endometriosis Possible Mechanisms

Ovarian function 1. Luteolysis caused by prostaglandin f2

2. Oocyte maturation defects
3. Endocrinopathies
4. Altered prolactin release
Tubal function 1. Impaired fimbrial oocyte pick up
2. Altered tubal mobility
Coital function 1. Deep dyspareunia
Sperm function 1. Antibodies causing inactivation
2. Macrophage phagocytosis of spermatozoa
Early pregnancy failure 1.Prostaglandin induced
2.Immune reaction
3. Luteal phase deficiency
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Management

 Medical therapy
1. NSAIDS
2. Combined oral contraceptives
3. LNG-IUS
4. Gonadotropin releasing hormone agonists
5. Lifestyle changes
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Surgical treatment
1. Fertility sparing surgery
2. Hysterectomy and oophorectomy
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Fertility sparing surgery

 Most surgery for endometriosis can be achieved laparoscopically.

 Symptomatic endometriotic chocolate cyst should be drained and inner cyst lining
should be excised to reduce the risk of reoccurrence, however this will damage the
functional ovarian tissue.
 Deposits of superficial peritoneal endometriosis can be easily ablated or excised
during laparoscopy using diathermy or laser.
 Recurrent risks are high as 30% and therefore concurrent long term medical
therapy is often necessary and started straight after surgery .
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Hysterectomy and oophorectomy

• Hysterectomy with removal of ovaries and all the visible endometriosis lesions
should be considered only in women who have completed their family and failed
to respond to more conservative treatments.
• Estrogen only hormone replacement therapy or combined HRT can be started
immediately after surgery or after 6 months to prevent activation of any residual
disease.
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