Manage of Women with Gynaecological Conditions
Subtopic:
Dysmenorrhoea
Dysmenorrhoea is the clinical term for painful menstrual cramps. These cramps typically arise shortly before or at the onset of menstruation, which is the monthly shedding of the uterine lining.
In simpler terms: Dysmenorrhoea signifies menstrual periods that are accompanied by pain.
It’s a very common issue, with nearly half of all women experiencing some level of pain related to their periods. For approximately 1 in 10 women, the pain can be so severe that it interferes with their usual daily activities.
While dysmenorrhoea can affect women at various stages of life, it’s less frequent in the initial six months after menstruation begins and also becomes less common as women approach menopause. The condition is most prevalent among women in their late teens and early twenties, making it a significant health concern during these years.
Types of Dysmenorrhoea
Primary Dysmenorrhoea
Primary dysmenorrhoea is characterized by painful menstruation that typically begins shortly after puberty is established. Often, in cases of primary dysmenorrhoea, a specific underlying medical condition cannot be identified as the cause of the pain.
Underlying Mechanism
While the precise mechanism of primary dysmenorrhoea is not completely clear, it is largely attributed to the release of hormone-like substances known as prostaglandins within the uterus at the time of menstruation. These prostaglandins trigger the uterine muscles to contract forcefully, resulting in what are experienced as menstrual cramps.
Secondary Dysmenorrhoea
Secondary dysmenorrhoea refers to menstrual pain that arises due to an identifiable organic or structural cause. In essence, secondary dysmenorrhoea signifies pelvic pain that is a symptom of an underlying medical condition or disease process.
Typical Origins of Secondary Dysmenorrhoea
Uterine Fibroids: These are non-cancerous growths that develop in the uterus and can cause pain.
Endometriosis: A condition where tissue similar to the uterine lining grows outside of the uterus, leading to pain.
Adenomyosis: This condition involves endometrial tissue growing into the muscular walls of the uterus itself, causing pain.
Chronic Pelvic Inflammatory Disease (PID): Long-lasting infection and inflammation of the reproductive organs in the pelvis can result in persistent pain.
Endometrial Polyps: These are abnormal tissue growths that project from the inner lining of the uterus and can contribute to pain.
Leiomyomata: This is another term for benign (non-cancerous) tumours that originate from the muscle tissue of the uterus.
Intrauterine Device (IUD) Complications: Problems or issues related to the use of an intrauterine device for contraception can sometimes cause secondary dysmenorrhoea.
Signs and Symptoms of Dysmenorrhoea
Typically, women experiencing dysmenorrhoea start to notice symptoms around 12 hours prior to the onset of their menstrual period. Common symptoms include:
Lower Abdominal Cramps: Pain in the lower abdomen is a primary symptom, often starting several days or up to a week before menstruation begins. The pain intensity can vary greatly, from mild discomfort to severe, cramp-like pain that may radiate to the back, upper thighs, and legs. Pain levels may fluctuate or worsen once menstruation begins.
Pain Across Lower Abdomen: In secondary dysmenorrhoea, the pain often extends across both lower quadrants of the abdomen, indicating a broader pelvic involvement.
Back Pain: Lower back pain is a frequent complaint and can accompany the abdominal cramping.
Heavy Menstrual Bleeding (Menorrhagia): Some women experience abnormally heavy menstrual flow in conjunction with dysmenorrhoea.
Painful Sexual Intercourse (Dyspareunia): Discomfort or pain during or after sexual activity may be present.
Fertility Challenges (Infertility): Difficulties in becoming pregnant or conceiving can sometimes be associated with underlying causes of dysmenorrhoea.
Nausea: Feelings of sickness or nausea are common during painful periods.
Headaches: Head pain, ranging from mild to severe, is a frequently reported symptom.
Vomiting: In more severe instances of dysmenorrhoea, vomiting can occur due to the intensity of the pain.
Fatigue: A general sense of tiredness, exhaustion, or lack of energy is often experienced.
Dizziness: Some women might feel lightheaded or dizzy.
Changes in Bowel Habits: Dysmenorrhoea can sometimes be linked to altered bowel function, resulting in either constipation or diarrhoea.
Fainting Episodes: In very severe cases, dysmenorrhoea may lead to fainting spells due to the intensity of pain and physiological responses.
Mild Fever: Although less common, a slight increase in body temperature can occur in some individuals.
Factors Increasing Risk
Narrowed Cervical Opening (Cervical Stenosis): If the cervical opening is unusually narrow, the uterus has to work harder to expel its lining during menstruation. This increased effort can lead to stronger uterine contractions and consequently, more pain.
Reduced Endometrial Blood Flow (Ischaemia): Insufficient blood supply to the uterine lining can contribute to primary dysmenorrhoea. Lack of oxygen to the tissue can trigger pain signals.
Hormonal Imbalances: Fluctuations, particularly in prostaglandins, play a significant role. Elevated prostaglandin levels can cause stronger and more frequent uterine contractions and increase inflammation, leading to pain.
Retroverted Uterus: If the uterus is tilted backwards instead of forwards, it can sometimes create increased pressure within the pelvic cavity during menstruation, potentially exacerbating discomfort.
Psychological and Social Stressors: Emotional distress, fear, or anxiety can heighten the perception of pain during menstruation. Psychological factors can influence pain pathways and pain tolerance.
Diagnosis
Diagnosis of dysmenorrhoea typically involves:
Detailed Medical History: The process often starts with carefully gathering information about the patient’s menstrual history and the characteristics of their pain. This includes questions about the pain’s nature (type, location), duration, timing in relation to menstruation, and associated symptoms. This detailed history is often very informative in confirming the diagnosis.
Physical Examination: A physical examination is conducted to rule out any underlying pelvic abnormalities such as growths (tumours) or conditions like endometriosis. While physical exams may not always reveal the cause of primary dysmenorrhoea, they are crucial for excluding secondary causes. In many cases of primary dysmenorrhoea, the physical examination will be normal, further supporting the diagnosis of primary dysmenorrhoea as opposed to a secondary cause.
Management of Dysmenorrhoea
Goals of Management
To lessen the pain and discomfort linked to menstruation.
To identify and address any root causes or contributing elements.
To minimize the impact of dysmenorrhoea on everyday life and overall well-being.
Gathering Patient History
Detailed Gynaecological History: Obtain comprehensive details including: age, number of pregnancies, date of last menstrual period, age at first period, cycle length and regularity, and duration of menstrual flow.
Pain Assessment: Thoroughly document the pain characteristics: severity, duration, nature (e.g., cramping, sharp), location, where the pain spreads, and its relationship to the start of menstruation, menstrual flow, sexual activity, bowel movements, urination, and any associated symptoms.
Previous Pelvic Issues: Record any known or suspected past pelvic health problems.
Obstetric History: Review past pregnancy history, noting any first-trimester miscarriages.
Systemic Health Review: Explore past medical history for other health conditions that can present with pelvic pain.
Pelvic Infection History: Investigate history of pelvic infections, specifically noting any recent or past sexually transmitted infections (STIs), including STI history of current or previous partners.
Contraceptive History: Detail contraceptive use history, paying particular attention to past or current Intrauterine Device (IUD) use and oral contraceptive use. Document any symptom changes associated with specific contraceptive methods.
Surgical History: Review surgical procedures, including cervical surgeries, Caesarean sections, gynaecological procedures, and any other abdominal surgeries.
General Clinical Observation
Assess vital signs (Temperature, Pulse Rate, Blood Pressure).
Perform a thorough examination of the reproductive system. This includes a complete gynaecological exam with cervical screenings (abdominal, vaginal, and rectal examination).
Consider further investigations like laparoscopy and blood tests to measure progesterone and oestrogen levels, if needed.
Primary Dysmenorrhoea Treatment
Timing of Treatment: Initiate treatment approximately 2 days prior to the expected start of menstruation and continue until about 2 days after menstruation ceases.
Avoid Habit-Forming Medications: Due to the long-term nature of management, avoid medications with high potential for dependence.
Combined Oral Contraceptives (COCs): Contraceptive pills like COCs can be prescribed to suppress ovulation and alleviate pain. Typically used for 4-6 months, this treatment can provide lasting relief for many women even after discontinuation. COCs work by preventing ovulation and reducing prostaglandin production.
Dilation and Curettage (D&C): While D&C might help remove necrotic endometrial tissue, it’s generally not recommended due to the increased risk of infection.
Cervical Stenosis Management: If cervical stenosis (narrowing) is a factor, surgical widening of the cervical canal can be considered.
Counselling: Effective counselling is crucial as pain perception can have psychological components. Counselling helps to prevent drug dependence and misuse by addressing psychological aspects of pain.
Natural Relief: Point out that natural processes like childbirth or ageing can sometimes lead to a reduction in pain intensity as uterine muscles tend to relax over time.
Prescription Prostaglandin Inhibitors (NSAIDs): For severe dysmenorrhoea, prescription-strength Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that inhibit prostaglandin production may be necessary.
Over-the-Counter Prostaglandin Inhibitors: Suggest over-the-counter options like Aspirin (600 mg four times a day) or Ibuprofen (400 mg four times a day) for pain relief.
Psychotherapy and Reassurance: Provide explanation about dysmenorrhoea and offer reassurance.
Healthy Lifestyle: Encourage a well-balanced diet, adequate rest, and regular aerobic exercise.
Bowel Management: Advise emptying the bowel during menstruation to potentially reduce discomfort.
Medications for Primary Dysmenorrhoea
Drugs used to manage primary dysmenorrhoea symptoms work either by reducing prostaglandin production or by preventing ovulation.
| Class of Drug | Example Medications | Key Points |
| Nonsteroidal Anti-inflammatory Drugs (NSAIDs) | Mefenamic acid (500mg 8 hourly), Ibuprofen (400mg 8 hourly), Diclofenac (50mg 8 hourly), Indomethacin (50mg 8 hourly) | NSAIDs should be started one day before the anticipated onset of menstrual symptoms and continued for 2-3 days. Crucially, avoid prescribing these NSAIDs to patients with active peptic ulcer disease. |
| Combined Oral Contraceptives (COCs) | Examples: Pilplan plus, Microgynon | COCs function by suppressing ovulation, which in turn leads to a reduction in progesterone levels. Progesterone is essential for prostaglandin production. COCs are typically recommended for cases where NSAIDs have not provided sufficient relief. A course of COCs should be maintained for at least 3 months (3 menstrual cycles) to assess effectiveness. |
| Depot Progestogens | Examples: Depo provera, Injecta plan | Depot progestogens work by preventing ovulation, thereby reducing dysmenorrhoea symptoms. Similar to COCs, suppressing ovulation reduces the hormonal cascade that leads to prostaglandin release and subsequent uterine contractions. |
Secondary Dysmenorrhoea Treatment
Management focuses on addressing the underlying cause of the dysmenorrhoea.
Depending on the specific cause of secondary dysmenorrhoea, treatment strategies can range from surgical interventions (e.g., Dilatation and curettage, presacral neurectomy, hysterectomy, etc.) to medical management. The chosen treatment is always guided by the diagnosed underlying condition.
Lifestyle and Complementary Therapies
Promote healthy habits: Encourage sufficient rest, adequate sleep, regular exercise, good hygiene practices, and a nutritious diet.
Explore alternative and complementary therapies: Suggest considering options like hypnotherapy and acupuncture, which some women find helpful in managing pain.
Nursing Care Management
Nursing Diagnosis: Intense Pain related to heightened uterine muscle contractions, as reported by the patient.
Nursing Actions:
Administer Heat Therapy: Apply warmth to the lower abdomen to encourage blood vessel dilation and decrease spasmodic muscle contractions. This therapeutic application of heat can help soothe cramping and improve blood flow.
Perform Abdominal Massage: Gently massage the painful area of the abdomen to alleviate discomfort through touch-based therapy. Therapeutic touch can provide comfort and potentially reduce pain perception.
Promote Light Exercise: Encourage gentle physical activity to enhance blood circulation to the uterus and improve muscle tone. Light exercises can aid in reducing pelvic congestion and promoting overall well-being.
Employ Relaxation Techniques: Utilize relaxation methods to lessen tension and encourage a state of relaxation. Techniques like progressive muscle relaxation or guided imagery can help manage pain and stress.
Administer Analgesics as Ordered: Provide prescribed pain-relieving medications to block pain signals from reaching the brain. Analgesics are crucial in managing moderate to severe dysmenorrhoea pain by targeting pain receptors.
Nursing Diagnosis: Ineffective Coping Mechanisms related to emotional distress, as evidenced by patient’s expressions of difficulty managing symptoms.
Nursing Actions:
Evaluate Patient Understanding: Assess the patient’s current knowledge about their condition, recognizing that anxiety levels can be influenced by their understanding. Clearer understanding can often reduce anxiety.
Facilitate Discussion and Coping Strategy Identification: Provide opportunities for the patient to discuss their feelings and collaboratively identify effective coping strategies. Open communication helps in developing personalized coping mechanisms.
Ensure Rest and Sleep: Promote adequate periods of sleep and rest to facilitate overall relaxation and reduce stress. Sufficient rest is vital for both physical and emotional recovery.
Nursing Diagnosis: Potential for Inadequate Nutrition: Less Than Body Requirements related to nausea and vomiting episodes.
Nursing Actions:
Promote Rest and Relaxation: Ensure the patient has sufficient rest periods to aid in overall relaxation, which can indirectly help with nausea.
Suggest Small, Frequent, Bland Meals: Encourage the consumption of small, easily digestible meals at frequent intervals. Bland foods are less likely to trigger nausea and vomiting.
Administer Antiemetic Medications as Prescribed: Give anti-nausea medications, such as promethazine, as ordered by the physician to block the brain’s vomiting centre and reduce nausea and vomiting.
Key Nursing Considerations
Pain Assessment: Thoroughly evaluate the pain’s characteristics and severity, noting the location, intensity level, and duration of pain episodes.
Vital Signs and Complication Monitoring: Regularly monitor vital signs and observe for any indications of complications arising from dysmenorrhoea or its management.
Menstrual Pattern Evaluation: Assess and document menstrual cycle patterns, including the length of cycles and the heaviness of menstrual bleeding.
Quality of Life Impact Assessment: Evaluate how dysmenorrhoea is affecting the patient’s overall quality of life, emotional well-being, and their ability to perform daily activities.
Essential Nursing Interventions
Implement Pain Management Strategies: Provide pain relief as prescribed, ensuring timely administration of medications.
Apply Heat Therapy and Patient Education: Utilize heat application as a therapeutic intervention and educate the patient on the correct methods for safe and effective heat therapy at home.
Educate on Relaxation and Breathing Techniques: Teach relaxation techniques, deep breathing exercises, and guided imagery to empower the patient to manage pain through non-pharmacological methods.
Promote Rest and Comfortable Positioning: Encourage the patient to rest in a comfortable position during periods of pain to minimize discomfort.
Provide Patient Education on Condition and Management: Educate the patient comprehensively about dysmenorrhoea, its management strategies, and available treatment options to enhance understanding and self-management.
Collaborate with Healthcare Team: Work closely with the broader healthcare team to ensure coordinated and effective patient care.
Offer Emotional Support and Validation: Provide emotional support, acknowledging and validating the patient’s pain and distress. Empathy and understanding are crucial components of nursing care.