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Dysmenorrhea
Dysmenorrhea is the most common gyencologic complaint in adolescent females, affecting more than half of this population. Julie Strickland, MD, Section Chief of Pediatric and Adolescent Gynecology at Children's Mercy, discusses causes, diagnoses and treatment of this painful condition.
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Learn more about Julie Strickland, MD
Julie Strickland, MD
Julie Strickland, MD, is Section Chief of Pediatric and Adolescent Gynecology at Children's Mercy Kansas City and Professor of OB/GYN at the University of Missouri-Kansas City School of Medicine. Dr. Strickland received her medical degree from the University of Missouri-Columbia School of Medicine, where she also completed her residency in Obstetrics and Gynecology.Learn more about Julie Strickland, MD
Transcription:
Dysmenorrhea
Dr. Michael Smith (Host): Dysmenorrhea is the most common gynecologic complaint in adolescent females, affecting more than half of this population. This is Pediatrics in Practice, the podcast from Children’s Mercy. I’m Dr. Mike. My guest is Dr. Julie Strickland. She is the Section Chief of Pediatric and Adolescent Gynecology at Children’s Mercy. Dr. Strickland, can you give us a nice review of what is dysmenorrhea.
Julie Strickland, MD (Guest): Yes, thank you for having me. Dysmenorrhea we often see in adolescent females as they begin their menstrual cycle. It is defined as pain with menstrual functioning. Most commonly, it occurs at the onset or shortly before the onset of the menstrual period and it may last throughout the menstrual cycle, although it is most disabling to adolescents during this first two to three days of their menstrual cycle.
Typically, we see dysmenorrhea occurring after menarche when ovulatory cycles set in.
Host: Right, and is there – when you look at this based on everything you just kind of said there; when you look at a case of dysmenorrhea; is it ever normal? Is there ever a period where you might think well this young girl has just started her menstrual cycles, maybe that does clear up after a few of them? Or is pain during menstrual cycle always something we should worry about?
Dr. Strickland: So, typically, what we see is the first couple periods that a girl has normally are anovulatory, in other words there is no sequence of ovulation and those maybe actually pain free. As girls begin to have more ovulatory cycles, then it is common for there to be some associated symptoms or discomfort with that onset of cyclic functioning. I think a real trick is to figure out when dysmenorrhea is just those minimal symptoms that we can manage easily with over-the-counter medications and modalities and when it really exceeds that and requires us to do more interventions for other disorders which may also appear with cyclic pelvic pain.
Host: I definitely want to get into that, but before we do, I was pretty surprised to see that it could affect close to half of adolescent females. How common actually is dysmenorrhea?
Dr. Strickland: I would say that depending on the criteria that you use for menstrual related pain; I would say the majority of women experience some menstrual related pain so they would fall into that category of dysmenorrhea. So, it’s more common than not. And I think most – when you take a history, most girls that are cycling regularly will tell you that they do have some changes during that time right before when their menstrual period starts.
Host: So, how important is for a general pediatrician for instance who maybe is seeing a patient who is having some complaint of pain during menses; how important is it to really delineate what really is going on? Is dysmenorrhea – maybe this is my question. Is dysmenorrhea really an umbrella term? Are there different types that we kind of need to maybe tease out in our workup?
Dr. Strickland: Absolutely. I think first of all, just the whole concept that as girls begin to enter puberty and begin their menstrual cycle; the real importance of taking a menstrual history, not just that they are having cycles, but what is happening during those cycles is really vital as we look at preventive health. As you mentioned, it is a huge source of discomfort. It is also a huge source of school absences and absences from productivity for young women. So, it is really important that we step back and take that menstrual history. And I think the thing that characterizes the importance of that is really, really asking them about how many days does it last. How incapacitating is it for you? What do you do to relieve that pain? Are you able to relieve the pain? Are there school absences? Is it interfering with your activities of daily life? Are there associated symptoms such as nausea, vomiting, anorexia, changes in bowel habits? Those would all be things that would tend to indicate that maybe you need to look into it further.
So, typically, when we take a history if the person is able – experiences some cyclic discomfort with their periods that she is able to continue with her activities of daily living, that she’s not missing school, that she is able to maybe treat that with over-the-counter NSAIDs in outpatient dosage. Those would all be signs that that’s kind of normal. But when you have any of those other red flags then those would be signs that maybe that’s not so normal and that child may need further evaluation.
Host: Well let’s talk about what that evaluation really looks like. And let’s kind of start – let’s stay within that general practice. What are some of the tests that the general pediatrician or the family physician can do right away to start helping to figure out what really might be going on?
Dr. Strickland: So, I think the first and most important thing is just to listen to what the patient is saying and to see what happens with normal over-the-counter treatments and other modalities such as thermal modalities such as a heating pad, rest, and over-the-counter NSAIDs. So, that would be the first sort of both treatment and tests, so to speak. If that handles the patient’s pain than I really don’t think there is any need for any other tests.
However, if that is not sufficient, then we usually say that we would step up to more pharmacologic doses of NSAIDs, in other words, weight based doses of NSAIDs during menstrual cycle. Again, that’s both a treatment and a test. Because we feel that functional dysmenorrhea should respond to one or two of those things.
In the situation where there isn’t a response, I think stepping back and looking, doing a thorough physical examination along with an external genital examination is really important in that situation because sometimes dysmenorrhea is really triggered by congenital abnormalities both in the opening of the vagina as well as higher up in the uterus. So, that would – we know that that account or 8% of all patients who present with dysmenorrhea. So, a good external genital exam would be the next step. And then perhaps an abdominal pelvic ultrasound would also be helpful to exclude congenital abnormalities that would be contributing.
Host: And so usually if treatment involves surgery, is it going to be one of those congenital situations? Is that normally when surgery is done for dysmenorrhea?
Dr. Strickland: So, when we have patients who have refractory dysmenorrhea, that usually means patients who don’t respond to either nonsteroidal or hormonal suppression. When we have that situation then we think of two things, particularly one is congenital malformation particularly those that obstruct the ability for the menstrual flow to get out of the body. Either the uterus or the vaginal level. And then the other thing that we think about that increasingly we are becoming aware of in young women is the possibility that they may have endometriosis. And both congenital malformations and endometriosis require a surgical diagnosis.
Host: So, in summary, putting this kind of altogether Dr. Strickland, what would you like the general practitioner, the general pediatrician, the nurse practitioner in the community; what would you like for them to know about dysmenorrhea?
Dr. Strickland: I think the thing that is most helpful for us is just knowing that to ask the questions first of all and to go forward with those basic treatments for a very common problem. But to know that when those treatments don’t – when the patient doesn’t respond to those treatments or dysmenorrhea is disrupting that girl’s life; that we would like that to be evaluated and treated early and not late. I think typically, in our culture, many patients don’t really know that that’s a problem. They think that that’s just the normal way that girls are, they have menstrual pain and cramping and that that’s normal. And in reality, we feel that we have great treatments for normal functional dysmenorrhea, and we have great importance at diagnosing those patients who fall out of the normal treatment modalities and we have opportunities to improve their quality of life with good treatments.
Host: Excellent summary. That’s Dr. Julie Strickland, Section Chief of Pediatric and Adolescent Gynecology at Children’s Mercy. Thanks for checking out this episode of Pediatrics in Practice. Please visit www.childrensmercy.org to get connected with Dr. Strickland or any other provider. If you find this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. And be sure to check back soon for the next podcast. I’m Dr. Mike. Thanks for listening.
Dysmenorrhea
Dr. Michael Smith (Host): Dysmenorrhea is the most common gynecologic complaint in adolescent females, affecting more than half of this population. This is Pediatrics in Practice, the podcast from Children’s Mercy. I’m Dr. Mike. My guest is Dr. Julie Strickland. She is the Section Chief of Pediatric and Adolescent Gynecology at Children’s Mercy. Dr. Strickland, can you give us a nice review of what is dysmenorrhea.
Julie Strickland, MD (Guest): Yes, thank you for having me. Dysmenorrhea we often see in adolescent females as they begin their menstrual cycle. It is defined as pain with menstrual functioning. Most commonly, it occurs at the onset or shortly before the onset of the menstrual period and it may last throughout the menstrual cycle, although it is most disabling to adolescents during this first two to three days of their menstrual cycle.
Typically, we see dysmenorrhea occurring after menarche when ovulatory cycles set in.
Host: Right, and is there – when you look at this based on everything you just kind of said there; when you look at a case of dysmenorrhea; is it ever normal? Is there ever a period where you might think well this young girl has just started her menstrual cycles, maybe that does clear up after a few of them? Or is pain during menstrual cycle always something we should worry about?
Dr. Strickland: So, typically, what we see is the first couple periods that a girl has normally are anovulatory, in other words there is no sequence of ovulation and those maybe actually pain free. As girls begin to have more ovulatory cycles, then it is common for there to be some associated symptoms or discomfort with that onset of cyclic functioning. I think a real trick is to figure out when dysmenorrhea is just those minimal symptoms that we can manage easily with over-the-counter medications and modalities and when it really exceeds that and requires us to do more interventions for other disorders which may also appear with cyclic pelvic pain.
Host: I definitely want to get into that, but before we do, I was pretty surprised to see that it could affect close to half of adolescent females. How common actually is dysmenorrhea?
Dr. Strickland: I would say that depending on the criteria that you use for menstrual related pain; I would say the majority of women experience some menstrual related pain so they would fall into that category of dysmenorrhea. So, it’s more common than not. And I think most – when you take a history, most girls that are cycling regularly will tell you that they do have some changes during that time right before when their menstrual period starts.
Host: So, how important is for a general pediatrician for instance who maybe is seeing a patient who is having some complaint of pain during menses; how important is it to really delineate what really is going on? Is dysmenorrhea – maybe this is my question. Is dysmenorrhea really an umbrella term? Are there different types that we kind of need to maybe tease out in our workup?
Dr. Strickland: Absolutely. I think first of all, just the whole concept that as girls begin to enter puberty and begin their menstrual cycle; the real importance of taking a menstrual history, not just that they are having cycles, but what is happening during those cycles is really vital as we look at preventive health. As you mentioned, it is a huge source of discomfort. It is also a huge source of school absences and absences from productivity for young women. So, it is really important that we step back and take that menstrual history. And I think the thing that characterizes the importance of that is really, really asking them about how many days does it last. How incapacitating is it for you? What do you do to relieve that pain? Are you able to relieve the pain? Are there school absences? Is it interfering with your activities of daily life? Are there associated symptoms such as nausea, vomiting, anorexia, changes in bowel habits? Those would all be things that would tend to indicate that maybe you need to look into it further.
So, typically, when we take a history if the person is able – experiences some cyclic discomfort with their periods that she is able to continue with her activities of daily living, that she’s not missing school, that she is able to maybe treat that with over-the-counter NSAIDs in outpatient dosage. Those would all be signs that that’s kind of normal. But when you have any of those other red flags then those would be signs that maybe that’s not so normal and that child may need further evaluation.
Host: Well let’s talk about what that evaluation really looks like. And let’s kind of start – let’s stay within that general practice. What are some of the tests that the general pediatrician or the family physician can do right away to start helping to figure out what really might be going on?
Dr. Strickland: So, I think the first and most important thing is just to listen to what the patient is saying and to see what happens with normal over-the-counter treatments and other modalities such as thermal modalities such as a heating pad, rest, and over-the-counter NSAIDs. So, that would be the first sort of both treatment and tests, so to speak. If that handles the patient’s pain than I really don’t think there is any need for any other tests.
However, if that is not sufficient, then we usually say that we would step up to more pharmacologic doses of NSAIDs, in other words, weight based doses of NSAIDs during menstrual cycle. Again, that’s both a treatment and a test. Because we feel that functional dysmenorrhea should respond to one or two of those things.
In the situation where there isn’t a response, I think stepping back and looking, doing a thorough physical examination along with an external genital examination is really important in that situation because sometimes dysmenorrhea is really triggered by congenital abnormalities both in the opening of the vagina as well as higher up in the uterus. So, that would – we know that that account or 8% of all patients who present with dysmenorrhea. So, a good external genital exam would be the next step. And then perhaps an abdominal pelvic ultrasound would also be helpful to exclude congenital abnormalities that would be contributing.
Host: And so usually if treatment involves surgery, is it going to be one of those congenital situations? Is that normally when surgery is done for dysmenorrhea?
Dr. Strickland: So, when we have patients who have refractory dysmenorrhea, that usually means patients who don’t respond to either nonsteroidal or hormonal suppression. When we have that situation then we think of two things, particularly one is congenital malformation particularly those that obstruct the ability for the menstrual flow to get out of the body. Either the uterus or the vaginal level. And then the other thing that we think about that increasingly we are becoming aware of in young women is the possibility that they may have endometriosis. And both congenital malformations and endometriosis require a surgical diagnosis.
Host: So, in summary, putting this kind of altogether Dr. Strickland, what would you like the general practitioner, the general pediatrician, the nurse practitioner in the community; what would you like for them to know about dysmenorrhea?
Dr. Strickland: I think the thing that is most helpful for us is just knowing that to ask the questions first of all and to go forward with those basic treatments for a very common problem. But to know that when those treatments don’t – when the patient doesn’t respond to those treatments or dysmenorrhea is disrupting that girl’s life; that we would like that to be evaluated and treated early and not late. I think typically, in our culture, many patients don’t really know that that’s a problem. They think that that’s just the normal way that girls are, they have menstrual pain and cramping and that that’s normal. And in reality, we feel that we have great treatments for normal functional dysmenorrhea, and we have great importance at diagnosing those patients who fall out of the normal treatment modalities and we have opportunities to improve their quality of life with good treatments.
Host: Excellent summary. That’s Dr. Julie Strickland, Section Chief of Pediatric and Adolescent Gynecology at Children’s Mercy. Thanks for checking out this episode of Pediatrics in Practice. Please visit www.childrensmercy.org to get connected with Dr. Strickland or any other provider. If you find this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. And be sure to check back soon for the next podcast. I’m Dr. Mike. Thanks for listening.