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The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms A cytologic smear of the cervix and vaginal pool should be taken If available, transvaginal sonography (TVS) should be used to measure endometrial thickness A measurement of 5 mm or less indicates a low likelihood of hyperplasia or endometrial cancer, although up to 4% of endometrial cancers may be missed with sonography If the thickness is greater than 5 mm or there is a heterogeneous appearance to the endometrium, endocervical curettage and endometrial biopsy or D&C preferably with hysteroscopy should be performed
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Endometrial biopsy or D&C may be curative Simple endometrial hyperplasia calls for cyclic progestin therapy (medroxyprogesterone acetate, 10 mg/d, or norethindrone acetate, 5 mg/d) for 21 days of each month for 3 months A repeat endometrial biopsy should be performed If endometrial hyperplasia with atypical cells or carcinoma of the endometrium is found, hysterectomy is necessary
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Complex endometrial hyperplasia with atypia is present Hysteroscopy is indicated
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Bertone-Johnson ER et al Calcium and vitamin D intake and risk of incident premenstrual syndrome Arch Intern Med 2005 Jun 13;165(11):1246 52 [PMID: 15956003] Kroll R et al Treatment of premenstrual disorders J Reprod Med 2006;51:359 370 [PMID: 16734319]
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or by passing a sound or curette over the uterine cavity during D&C Cervical stenosis may result from induced abortion, creating crampy pain at the time of expected menses with no blood flow; this is easily cured by passing a sound into the uterine cavity after administering a paracervical block
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DYSMENORRHEA 1 Primary Dysmenorrhea
Primary dysmenorrhea is menstrual pain associated with ovulatory cycles in the absence of pathologic findings The pain usually begins within 1 2 years after the menarche and may become more severe with time The frequency of cases increases up to age 20 and then decreases with age and markedly with parity Fifty to 75 percent of women are affected at some time and 5 6% have incapacitating pain
Treatment
A Specific Measures
Periodic use of analgesics, including the NSAIDs given for primary dysmenorrhea, may be beneficial, and oral contraceptives may give relief, particularly in endometriosis Danazol and GnRH agonists are effective in the treatment of endometriosis (see below)
B Surgical Measures
If disability is marked or prolonged, laparoscopy or exploratory laparotomy is usually warranted Definitive surgery depends on the degree of disability and the findings at operation
Clinical Findings
Primary dysmenorrhea is low, midline, wave-like, cramping pelvic pain often radiating to the back or inner thighs Cramps may last for 1 or more days and may be associated with nausea, diarrhea, headache, and flushing The pain is produced by uterine vasoconstriction, anoxia, and sustained contractions mediated by prostaglandins The pelvic examination is normal between menses; examination during menses may produce discomfort, but there are no pathologic findings
When to Refer
Standard therapy fails to relieve pain Suspicion of pelvic pathology, such as endometriosis
French L Dysmenorrhea Am Fam Physician 2005 Jan 15;71 (2):285 91 [PMID: 15686299] Proctor M et al Diagnosis and management of dysmenorrhoea BMJ 2006 May 13;332(7550):1134 8 [PMID: 16690671]
Treatment
NSAIDs (ibuprofen, ketoprofen, mefenamic acid, naproxen) are generally helpful Drugs should be started at the onset of bleeding to avoid inadvertent drug use during early pregnancy Medication should be continued on a regular basis for 2 3 days Ovulation can be suppressed and dysmenorrhea usually prevented by oral contraceptives, depot-medroxyprogesterone acetate, or levonorgestrel-releasing IUD For women who do not wish to use hormonal contraception, other therapies that have shown at least some benefit include local heat; thiamine, 100 mg/d orally; vitamin E, 200 units/d orally from 2 days prior to and for the first 3 days of menses; and high-frequency transcutaneous electrical nerve stimulation
VAGINITIS
ESSENTIALS OF DIAGNOSIS
Vaginal irritation Pruritus Pain Unusual discharge
2 Secondary Dysmenorrhea
Secondary dysmenorrhea is menstrual pain for which an organic cause exists It usually begins well after menarche, sometimes even as late as the third or fourth decade of life
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