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Definition

Dysmenorrhea is a common gynecologic disorder affecting as many as 50% of menstruating women.

Primary dysmenorrhea refers to menstrual pain without pelvic pathology, usually appears within 1 to 2 years of menarche, when ovulatory cycles are established. The disorder affects younger women but may persist into the 40s.

Secondary dysmenorrhea is defined as painful menses associated with underlying pathology, usually develops years after menarche and can occur with anovulatory cycles.

Symptoms

The pain of primary dysmenorrhea usually begins a few hours before or just after the onset of a menstrual period and may last 48 to 72 hours with suprapubic cramping, and may be accompanied by lumbosacral backache, radiating down the anterior thigh.

Nausea, vomiting, diarrhea, and rarely syncopal episodes.

Signs

The vital signs are normal. The suprapubic region may be tender to palpation. Bowel sounds are normal, and there is no upper abdominal tenderness and no abdominal rebound tenderness. Bimanual examination at the time of the dysmenorrheic episode often reveals uterine tenderness; however, severe pain does not occur with movement of the cervix or palpation of the adnexal structures. The pelvic organs are normal in primary dysmenorrhea

Diagnosis

To diagnose primary dysmenorrhea, it is necessary to rule out underlying pelvic pathology and confirm the cyclic nature of the pain. The differential diagnosis of secondary dysmenorrhea includes primary dysmenorrhea and noncyclic pelvic pain. Whereas the diagnosis of primary dysmenorrhea is based on history and presence of a normal pelvic examination,

The diagnosis of secondary dysmenorrhea may require review of a pain diary and an ultrasound examination or laparoscopy or hysteroscopy or both. During the pelvic examination, the size, shape, and mobility of the uterus; the size and tenderness of adnexal structures; and the nodularity or fibrosis of uterosacral ligaments or rectovaginal septum should be assessed. Cervical studies for gonorrhea and chlamydia and, if relevant, a complete blood count with an ESR, are helpful to rule out subacute salpingo-oophoritis. If no abnormalities are found, a tentative diagnosis of primary dysmenorrhea can be established.

Treatment

· Prostaglandin synthase inhibitors, or NSAIDs, are effective for the treatment of primary dysmenorrhea The medication may be contraindicated in patients with gastrointestinal ulcers or bronchospastic hypersensitivity to aspirin. Side effects are usually mild and include nausea, dyspepsia, diarrhea, and occasionally fatigue.

· Acupuncture or transcutaneous electrical nerve stimulation (TENS), may also be useful.

· Spinal manipulation.

In clinical trials, however, it has not been found to be effective. Methods used only rarely to treat primary dysmenorrhea include surgical laparoscopic uterine nerve ablation and presacral neurectomy.

Ectopic pregnancy is a potentially life-threatening condition in which the embryo implants outside the uterine cavity.

Incidence

The incidence of ectopic pregnancy has more than quadrupled in the USA. Currently, 20 cases occur per 1000 pregnancies.

Ectopic pregnancies account for 10% of pregnancy-related maternal deaths in th USA. Most are attributed to hemorrhage and are potentially preventable.

Risk Factors

· High risk : tubal corrctive surgery, tubal sterilization, previous ectopic pregnancy.

· Moderate risk : infertility, previous genital infection, multiple partners.

· Slight risk L previous pelvic or abdominal surgery, smoking, douaching, sexual intercourse before 18 years.

Signs and Symptoms

· Pain : remain the most common symptom. Most patients also report abnormal vaginal bleeding, usually spotting or slight intermittent bleeding.

· Patients with acute rupture present with sharp, tearing, pelvic pain associated with fainting.

· Tachycardia, hypotension and cervical motion tenderness.

Diagnosis

· A Thorough history and physical examination are essential. The extent should be dictated by the severity of symptoms at presentation.

· Serial quantitative levels of the β-hCG levels are important.

· Transvaginal ultrasonography can detect an intrauterine gestational sac.

Management

Medical Therapy

Metotrexate chemotherapy is effective treatment for select patient with small, unrupteured ectopic pregnancies. Metotreaxate (MTX) side effects (nausea, vomiting) are generally mild. Localized, mild abdominal pain is a common complaint following MTX due to serosal irritation. However, patients should be closely monitored since rupture is a known risk.

Surgical Therapy

· In a patient who is hemodynamically unstable due to rupture of the ectopic pregnancy, emergency surgery (usually laparatomy with or without removal of the rupture fallopian tube) remains the treatment of choice.

· In a hemodynamically stable patient with a ruptured tubal pregnancy, laparoscopy and either removaql (salpingectomy) or segmental resection of the tube may be necessary.

· In a hemodynamically stable patient with an unreuptured tubal pregnancy, conservative surgery with tubal salvage.

· Oophorectomy is only indicated to achieve hemostasis.

Evaluation strategies

· The history provieds a description of the nature, intensity, and distribution of the pain. However, imprecise localization is typical with intra-abdominal processes.

· The physical examination includes a comprehensive gynecologic examination. Specific attention should be paid to reproducing the pain symptoms.

· Culturesm serum chemistry and electrolyte evaluations, or ultrasonography and other imaging studies may be indicated.

· Specialized diagnostic studies based on the presumptive diagnosis may be require consultation with other specialist in anesthesiology, orthopedics, neurology or gastroenterology.