Dysmenorrhea secondary

Dysmenorrhea is commonly defined as crampy pelvic pain occurring with or just prior to menses. Primary dysmenorrhea implies pain in the setting of normal pelvic anatomy and physiology, whereas secondary dysmenorrhea is associated with underlying pelvic pathology.17... 

The most significant mechanism for primary dysmenorrhea is the release of prostaglandins in the menstrual fluid and possibly vasopressin-mediated vasoconstriction.5,17 Causes of secondary dysmenorrhea may include cervical stenosis, endometriosis, pelvic infections, pelvic congestion syndrome, uterine or cervical polyps, and uterine fibroids.20... 

Observational data illustrate a reduction in dysmenorrhea from 60% to 29% with the levonorgestrel-releasing IUD after 3 years.17 As observed with depo-medroxyprogesterone acetate, this reduction is likely secondary to the increasing incidence of amenorrhea in users of this contraceptive device. 

Stenchever MA, Droegemueller W, Herbst AL, Mishell DR. Primary and secondary dysmenorrhea and premenstrual syndrome Etiology, diagnosis, and management. In Stenchever MA, ed. Comprehensive Gynecolgy. 4th ed. St. Louis Mosby 2001 1065-1078. 

The major uses of progestogens are for hormone replacement therapy and for hormonal contraception where they suppress ovulation and make the cervical mucus impenetrable to spermatozoa. Other indications include secondary amenorrhea, dysmenorrhea, infertility and habitual abortion and endometrium suppression in endometriosis. Progestogens are also used for palliation in metastasized endometrial and breast carcinoma. Medrogestone has been used in the treatment of fibroid uterine tumors. 

Secondary symptoms Fullness in the chest, hoarseness, cough, distension in the stomach, obviously reduced or increased appetite, belching, nausea, vomiting, difficult urination, difficult bowel movement or diarrhea, dysmenorrhea, irregular menstruation. 

Because medical conditions, emotional/behavioral symptoms, and physiologic indices change during the premenstrual and per-imenopause phases, it is important to rule out other disorders that may contribute to mood fluctuations or pain syndromes (Table 78-2). For example, dysmenorrhea may be primary, which occurs during ovulatory cycles, or secondary, which relates to pelvic pathology (e.g., infection caused by the placement of intrauterine devices, endometriosis, pelvic inflammatory disease, ovarian cyst, endometrial cancer, adhesions, and benign uterine tumors). 

Leiomyomas, or fibroids, are the most common benign tumors of the uterus. The incidence of fibroids is difficult to estimate and frequencies reported in the literature range between 25% and 50%. In autopsy studies, leiomyomas of the uterus have been found in up to 77% of women [2, 21, 30]. Only about one third of affected women have fibroids that become clinically apparent before menopause. Fibroids may cause abnormal menstrual bleeding (menorrhagia with secondary anemia, dysmenorrhea) or pelvic pressure due to their mass effect (urinary frequency, constipation, pelvic pain, dyspareunia). Finally, leiomyomas of the uterus are also implicated in female infertility and are the most common indication for hysterectomy in western industrialized countries. In the USA 200,000 hysterectomies are performed for uterine fibroids each year [42,47,170]. 

Two of the most frequent ailments of females of reproductive age are dysmenorrhea and premenstrual syndrome. Dysmenorrhea can be subdivided into two distinct forms, primary and secondary. Alhough all three can be found in the same patient, premenstrual syndrome, primary dysmenorrhea, and secondary dysmenorrhea are often discussed separately. 

Secondary dysmenorrhea (acquired dysmenorrhea) painful menses associated with definable pathology. 

Pain is a highly subjective part of history taking. Alone, it is not sufficient to make a diagnosis. Symptoms must alter the patient s activities of daily living (ADL) and persist for more than several hours. The symptoms may last as long as several days in acute situations. In the case of secondary dysmenorrhea, weeks to months may pass with major ADL changes before the patient seeks attention. 

Practiced palpatory skills applied to physical diagnosis and a good history combined with appropriately selected diagnostic laboratory and radiologic examinations should separate secondary dysmenorrhea from both primary dysmenorrhea and PMS. 

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