DYSMENORRHEA

PREMENSTRUAL SYNDROME
ENDOMETRIOSIS
PATHOPHYSIOLOGY

primary dysmenorrhea occurs

during ovulatory cycles and
(unlike secondary dysmenorrhea)
has no detectable
‘pelvic pathologic condition’
such as
adhesions on the reproductive organs
EPIDEMIOLOGY DYSMENORRHEA
Estimated that 30-50% of woman in childbearing age are
affected by painful menstrual periods or
dysmenorrhea
10-15% of those women are capacitated
for 1 to 3 days each month
Dysmenorrhea is the greatest single cause
of absenteeism from school and work among young
women
CLINICAL PRESENTATION
The most common symptom is
spasmodic pain of the lower abdomen
that can
radiate to the back and along the thighs
The pain accompanied by one or more of
- nausea and vomitting
- fatigue
- diarrhea
- lower backache
- headache
The duration is usually 48 to 72 hours with
the pain starting a few hours before or just after
the onset of menstrual flow
DIAGNOSIS

The etiology of these symptoms has been

determined to be related to the
pharmacologic action of
PROSTAGLANDIN PGE2 dan PGF2@
which are formed from the phospholipids
of dead cell membranes in the uterus
PGE2 causes disaggregation of platelets
and is a vasodilator
PGF2@ mediates or potentiates pain
sensations and stimulates smooth
muscle contraction
Estrogens can stimulates synthesis and/or release of
PGF2@
Progestin-dominant combination oral contraceptives
are often used to alleviate dysmenorrhea
TREATMENT GOALS DYSMENORRHEA

Avoid lower abdominal spasmodic pains and

other prostaglandin-induced effects
Efficacy monitoring of therapy is dependent
solely upon the subjective responses of the
patient
TREATMENT-DRUG THERAPY OF
PRIMARY DYSMENORRHEA
Clinical Drug Of Choice --- CDOC
NSAIDs
proprionic acids often used initially
Clinically, there is no way to predict whether
a certain NSAID will give maximal benefit to any
given patient based on current data in the
literature
The initial selection should be tried for at least
two to four cycles
Patient should be told that NSAIDs need not be taken
until the onset of symptoms because the half-life of
prostaglandins is only minutes.
With the short-term use of NSAIDs for dysmenorrhea,
side effects are infrequent and usually mild.
Gastrointestinal irritation is best avoided by taking
the NSAIDs with food or milk.
Other NSAIDs such as aspirin should be avoided with
the use of NSAIDs listed in ‘table’ because they
may greatly enhance side effects and toxic effects
such as peptic ulceration, liver damage and renal
damage
COX-2 inhibitor
has the potential benefit of fewer gastrointestinal
side effects, was approved for the treatment of
primary dysmenorrhea
Combination Oral Contraceptives
relieve dysmenorrhea in 90% of patients, probably
by a reduction in the amount of endometrium
formed and consequently the amount of
prostaglandins formed
Compliance with the COC regimen is esential for
maintenance of anovulatory cycles
@-adrenergic agonists
useful as last-alternative therapy because
- NSAIDs do not relieve pain in 20-30% of
pasients
- COCs do not relieve pain in 10% of patients
- Dysmenorrhea has been proposed that
includes excessive stimulation of the uterus
by the adrenergic nervous system
 PHARMACOECONOMICS

The use of a generic NSAID would be

most cost effective
Followed by
Brand name NSAIDs
Oral contraceptives
COX-2 inhibitor
PREMENSTRUAL SYNDROME

Unlike primary dysmenorrhea, there is no

consensus on the definition of PMS
The most widely accepted definition
the signs and/or symptoms must occur
cyclically, recur to some degree in the luteal
phase (after ovulation) of the menstrual cycle,
and are usually present to some degree each
cycle
During the follicular phase
(before ovulation) , the patient should be free of
symptoms.
There must be at least 7 symptom-free days in each
cycle.
Most patiens do not have symptoms for several days
after the onset of menses until near ovulation
The combination of distressing physical,
psychological or behavior changes are
sufficiently severe to result in
deterioration of interpersonal
relationships and/or interfere with
normal activities
TREATMENT GOALS PMS

Alleviated the symptoms of PMS

Efficacy monitoring of therapy depends
largerly on the subjective responses of
the patient and on the observations of
persons close to her and patient’s
health care providers
EPIDEMIOLOGY
Estimated that 30 -80% of menstruating women
experience symptoms of PMS, with 20-30%
reporting moderate to severe symptoms
Absenteeism due to PMS is costly because 60%
of women are in the workforce
DIAGNOSIS

The etiology of PMS remains as elusive as

the definition and myriad of symptoms
attributed to this disorder.
See the list !!!
many of the commonly reported chief
symptoms of PMS.
TREATMENT: PHARMACOTHERAPY

Some authors believe that 80% of patients

with PMS can be treated without drugs

See the effectivenes!!!

 NONPHARMACOLOGIC THERAPY

A recent study concluded that dietary

supplementation with 1200mg of elemental
calsium from calsium carbonate is a simple and
effective treatment in PMS, resulting in a major
reduction in overall luteal phase symptoms.
Furthermore, all four symptom factors (negative
affect, water retention, food cravings and pain)
were significantly reduced
ALTERNATIVE THERAPY
Mild PMS has been treated with:
1g elemental calsium daily
50-100mg pyridoxin once or twice daily
50-100mgmagnesium twice daily
Multivitamin with mineral supplements
Unfortunately there is little clinical evidence of
the efficacy of these alternative therapies
ENDOMETRIOSIS

5-15% premenopausal women have

endometriosis to some degree.
75% women with endometriosis are
between 24 and 50 years old.
TREATMENT GOALS

Ameliorate pain
Correct menstrual irregulaties and
infertility by the suppression of
ectopic endometrial implants
PATHOPHYSIOLOGY

Endometriosis is a disorder in which there

is a presence of islands of endometrium
in extrauterine locations, which exhibit
the histologic and hormonal
responsiveness of native endometrium.
Cyclic change in these island of
endometrium is assosiated with
menstrual-like bleeding and resultant
localized inflammation.
Endometriosis most commonly occurs within the
pelvis, on or within the ovaries, on the peritonium,
or beneath the serosa of pelvic viscera.
Extrapelvic endometriosis, which occurs less often,
involves locations outside the genital tract, such as
the bowel, rectum, appendix, umbilicus, scars,
pleura, lung, kidney, ureter, bladder and nerves,
 CLINICAL PRESENTATION
AND DIAGNOSIS
The most frequent symptoms of genital tract
endometriosis are secondary dysmenorrhea and
pelvic pain, menstrual irregulaties and infertility
Depending on the location of the extrapelvic
endometriosis, the symptom and signs vary.
Interestingly, the severe of the disease does not
directly correlate with the severity of the symptoms
TREATMENT

Danazol = antigonadotropin
Medroxyprogesterone acetate
Gonadotropin-Releasing Hormone
PHARMACOECONOMICS

Costs include the cost of

diagnostic prosedures such as
ultrasonography or laparoscopy
May be clinical and economic
benefits when GnRH agonists
are used to treat endometriosis
without a surgical diagnosis