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Upon completion of the chapter, the reader will be able to:
Describe the underlying etiology and pathophysiology of dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding and how they relate to selecting effective treatment modalities.
Describe the clinical presentation of dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding.
Recommend appropriate nonpharmacologic and pharmacologic interventions for patients with dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding.
Identify the desired therapeutic outcomes for patients with dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding.
Design a monitoring plan to assess the safety and effectiveness of pharmacotherapy for dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding.
Problems related to the menstrual cycle are common among women of reproductive age. The most common menstruation-related disorders include dysmenorrhea, amenorrhea, anovulatory bleeding, and abnormal uterine bleeding. These disorders can negatively affect quality of life, reproductive health, and productivity; they may also lead to adverse long-term health consequences, such as increased risk for osteoporosis with amenorrhea.
Dysmenorrhea is pelvic pain, generally described as painful cramping, occurring during or just prior to menstruation. Primary dysmenorrhea occurs with normal pelvic anatomy and physiology, whereas secondary dysmenorrhea is associated with underlying pelvic pathology.1
Epidemiology and Etiology
Dysmenorrhea is the most commonly reported menstrual complaint, with more than one-half of menstruating women reporting pain for at least 1 or 2 days each month.2 Of women with dysmenorrhea, around 51% report limited daily activities or missing work or school.3 Risk factors include irregular or heavy menses, age less than 30, menarche prior to age 12, body mass index (BMI) less than 20 kg/m2, history of sterilization or sexual abuse, and smoking.1,4 Causes of secondary dysmenorrhea may include endometriosis, pelvic inflammatory disease (PID), uterine or cervical polyps, and uterine fibroids.4-5
In primary dysmenorrhea, elevated arachidonic acid levels in the menstrual fluid lead to increased concentrations of prostaglandins and leukotrienes in the uterus. This induces uterine contractions, stimulates pain fibers, reduces uterine blood flow, and causes uterine hypoxia.3
Desired treatment outcomes (Figure 49–1) are reduction of pelvic pain, improved quality of life, and fewer missed days from school and work.
Treatment algorithm for dysmenorrhea. (CHC, combination hormonal contraceptive; IUD, intrauterine device; MPA, medroxyprogesterone acetate; NSAID, nonsteroidal anti-inflammatory drug.) (Data from Umland EM, Klootwyk J. Menstruation-related disorders. In: Pharmacotherapy: A Pathophysiologic Approach, 9th ed. New York, NY: McGraw-Hill, 2014, with permission.)