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Case 4.6 – Dysmenorrhea & Menorrhagia (Adolescence)

Category: Endocrine & Reproductive Systems | Discipline: Obstetrics & Gynaecology | Setting: General Practice

Case

Min Li aged 16 years presents with her mother complaining of painful periods. Her mother is concerned because Min is missing school for two to three days every time she has a period and she is worried because Min's school grades have dropped from excellent to above average. She has given Min Panadeine but it doesn't help.

Questions

1. Summarise the pathophysiology of dysmenorrhea.

Pathophysiology of Dysmenorrhea:

Dysmenorrhea is caused by vasoactive eicosanoids producing abnormal uterine contractions and decreasing uterine blood flow, with subsequent ischemia similar to angina.

Classification

It is helpful to classify dysmenorrhea into primary and secondary:

Type Duration Cause
Primary Lasting 1-2 days of menstrual blood flow Mainly due to prostaglandin "excess"/"sensitivity" and consequent intense uterine cramping. Can also cause nausea, diarrhoea, and mild pyrexia
Secondary Lasting almost throughout flow Mainly due to pelvic pathology e.g. PID and endometriosis. Endometriosis can present in adolescent years

Lifestyle Factors that Can Aggravate Dysmenorrhea

  • Weight > 90th percentile
  • Alcohol consumption
  • Smoking
  • Early age of menarche
  • Lack of exercise
  • Caffeine containing drinks
  • Lack of sleep
  • Constipation

Note: New Zealand has developed a web page specific for endometriosis in adolescence to increase awareness: https://nzendo.org.nz/managing-endo/

2. List the key elements of history, examination, investigations and management in this case.

History

Essential Elements:

  • Always include age of menarche
  • Normal development
  • Flow of menses
  • Patient's expectations
  • Family history (mother in particular)
  • Risk taking history (drugs, smoking, alcohol, eating habits)
  • Obstetric, gynae and surgical history
  • Specifically ask if sexually active
  • Contraceptive methods used if any
  • Pain with intercourse
  • Timings of pain, relieving factors, site of pain
  • Quality of life/affects on activities of daily living (ADLs)

Important: Always talk to the adolescent and don't treat the mother as the patient – may need to take history of sensitive issues independent of mother.

Examination

  • Consider pelvic examination if sexually active for STI screening
  • General examination is warranted (normal development, hair, breasts, thyroid)
  • No imperative if the patient feels uncomfortable with anything other than a cursory examination

Investigations

Guided by history but usually limited to:

  • FBC - may have dietary issues causing anaemia
  • Possible pelvis/abdominal U/S

Note: Mother and patient often convinced an abnormality exists owing to severity of pain and days required off school. An ultrasound will persuade them that you have taken them seriously. Just being told "it is physiological" without having some form of imaging may be perceived as inadequate care.

If dysmenorrhoea mainly secondary (particularly if associated with other symptoms suggestive of endometriosis: heavy periods, premenstrual brown staining, dyspareunia and dyschesia) then a diagnostic laparoscopy is appropriate. If this is a first hospital admission adolescents can find this quite traumatic requiring considerable post op pain relief and reassurance.

Management

Lifestyle Modifications:

  • Increasing exercise
  • Being proactive with analgesia
  • Being "believed" and being told the pain does not mean there is "something terribly wrong" is helpful in lessening the impact of pain

Pharmacological Management:

  • Prostaglandin synthetase inhibitors - Mefenamic acid/NSAID taken regularly at the first sign of discomfort
  • OCP (Oral contraceptive pill) - first line if contraception required, also used if minimal response to NSAID. When exact day of period anticipated with OCP can commence the NSAID 24-48 hours before for improved therapeutic response
  • Consider progesterone tablets, Depo-Provera or Mirena IUCD

If these measures are not effective: Laparoscopy + surgical treatment if endometriosis is present

3. If during the history Min tells you she bleeds for 10 days and it is heavy with clots and flooding for the first three days, what further history and examination and investigations would then be warranted?

Combined Dysmenorrhea and Menorrhagia

Additional History

  • Timings and flow quantities (pad numbers, size etc.)
  • Expectations of what is normal is vital - if the mother and daughter have expectations of virtually no vaginal loss then this will necessitate a different strategy
  • Detailed pain history
  • Quality of life/affects on activities of daily living (ADLs)

Examination

  • Pelvic examination only if sexually active

Investigations

  • FBC - quantifies loss
  • Ferritin
  • Serum Fe
  • TSH - hypothyroidism causes menorrhagia
  • Coagulation screen
  • Abdominal U/S (not transvaginal unless sexually active)

Management

Treat anaemia if present and address the need for contraception.

Treatment Effect Dose/Details
Tranexamic acid (antifibrinolytic) Reduces flow by 50% 1G every 6 hours
Mefenamic acid Reduces flow by 25% Regular dosing
OCP Decreases flow by 50% (and pain) Regulates cycle, can reduce absolute number of cycles (skip periods), provides contraception
Cyclical luteal phase progestogens Regulates menstrual cycle From day 12-26 (2 weeks) of each cycle (Day 1 = first day of bleeding)
e.g. medroxyprogesterone acetate 10mg tds
Note: May be difficult for an adolescent to remember - may need mother's help
4. What management would you instigate if her Hb was 8.9g/dl?

Management of Anemia (Hb 8.9 g/dl):

1. Dietary Management

  • Teenagers have poor diets - 50% of teenagers will be anaemic (Hb <11.5)
  • Common deficiencies: Fe deficiency, folate deficiency and B12
  • Dietary counseling and optimization

2. Identify and Treat Causes

  • In this case: menorrhagia
  • Treat as per question 3 (tranexamic acid, mefenamic acid, OCP, cyclical progestogens)

3. Replace Iron

  • Usually give Fe and folate combined as in pregnancy because of dietary issues
  • OR consider iron infusion

4. Monitor Response

  • If not improving - look at compliance and for other pathology
  • Recheck FBC in 4-6 weeks
5. Describe the additional management options for dysmenorrhea if this patient is 46 years old.

Additional Management Options for 46-Year-Old Patient:

At 46 years of age, if the patient has completed her family and conservative measures have failed, surgical options can be considered:

  • Hysterectomy +/- bilateral salpingo-oophorectomy

Considerations:

  • This is a definitive treatment for dysmenorrhea
  • Should only be considered after exhausting all conservative and medical options
  • Patient must have completed childbearing
  • Discuss risks and benefits including:
    • Surgical risks
    • Early menopause if ovaries removed
    • Need for hormone replacement therapy if bilateral salpingo-oophorectomy performed
    • Recovery time
  • Age-appropriate as patient approaching menopause