Sickle Cell Information Center Guidelines

Edited by James Eckman, M.D. and Allan Platt, PA-C

Dysmenorrhea by Hiba Tamim, MD

Pain before and during the menstrual period is common in sickle cell patients. This can be problematic in that patients often confuse this pain with sickle pain episodes and may expect relief with narcotic analgesics. Young patients and those approaching menopause may also have pain episodes that appear to be precipitated by menstruation or the premenstrual syndrome. Secondary dysmenorrhea must be excluded.

Present Illness. Define the pain, relationship to menstrual period, associated breast enlargement and tenderness, diarrhea, nausea, or vomiting. Determine sexual activity, presence of discharge, dyspareunia, or pain on defecation.

Past Medical History Determine onset of menstruation, menstrual irregularity, previous pregnancies, exposure to venereal disease, and past venereal infections.

• Vital Signs. Temperature.
• Abdomen. Abdominal tenderness, CVA tenderness, masses, hepatosplenomegaly.
• Pelvic. Presence of cervical discharge. Pain on cervical motion. Adenexal tenderness. Ovarian and uterine size, masses, or fullness in cul-de-sac.

Minimum Lab. CBC with differential and reticulocyte count. Urinalysis, beta HCG, and erythrocyte sedimentation rate.

Additional Lab. Endocervical smears and culture of discharge, Pap smear, and laparoscopy may be indicated. Ultra sound, CT or other studies may be indicated if masses or enlarged uterus or ovaries are present and pregnancy is excluded.

Primary Dysmenorrhea.Common among women <25 years of age (40-90%). Occurs in young women and those approaching menopause during ovulatory cycles. Diagnosed after causes of secondary dysmenorrhea are excluded.Colicky in nature. The increased prostaglandin production causes increase in uterine tone and a decrease in uterine blood flow.

Pelvic Inflammatory Disease. History of sexual activity, discharge fever, and dyspareunia. Physical findings of fever, cervical discharge, and tenderness, or tender tubal mass. White count and erythrocyte sedimentation rate are elevated. Cervical smear and cultures may be diagnostic.

Endometriosis. Occurs later in life. Pain is often more, prolonged, lasting after the period and is more diffuse. Diagnosis is established by laparoscopy.

Endometrial Polyps. Prolapsing polyps which block menstrual flow can be diagnosed by pelvic examination.

Leiomyoma. Diagnosis is apparent on bimanual exam which shows irregular uterine enlargement with a negative beta HCG.

Treatment

Primary Dysmenorrhea. Because the syndrome is likely caused by liberation of prostaglandins, most patients respond to treatment with non-steroidal antiinflammatory medications which inhibit prostaglandin synthesis. Ibuprofen 400 - 800 mg q 8 hours is effective, Naproxen 250 mg q 8 hours has been used also. Diuretics are added without proven benefit if fluid retention is prominent. Birth control pills are given to suppress ovulation in refractory cases. Depo-Provera may benefit patient that have pain episodes precipitated by menstruation. This use is not established.

Pelvic Inflammatory Disease Patients are admitted for prolonged treatment with intravenous antibiotics active against gonorrhea, chlamydia, anaerobic, and facultative gram negative organisms. Regiments include doxycycline 100 mg IV q 12 hours with cefoxitin 2 gm IV q 8 hours for four days followed by doxycycline 100 mg PO bid for a total of 14 days; or clindamycin, 900 mg IV q 8 hours with gentamycin 2 mg/kg IM then 1.5 mg/kg IV q 8 hours for 2 to 4 days followed by doxycycline 100 mg PO bid or clindamycin 450 mg PO qid for a total of 10 -14 days.

Endometriosis. Medical treatment consists of OCP, danazol, depomederoxyprogesterone acetate (DMPA), and gonadotropin-releasing hormone (GnRH) agonists. Failures require surgery.

Endometrial Polyps. Surgical removal.

Leiomyoma. Surgical removal by myomectomy or hysterectomy.

Nursing Considerations:

 Discuss diagnosis, explain any scheduled procedures or surgeries with patient including their impact on child-bearing

 Assess the adolescent’s knowledge of the menstrual cycle, STDs, and coping mechanisms

 Teach patient about normal menstrual cycle as needed, emphasizing safe sex and different methods of contraception

 Teach adolescents the importance of annual pelvic exam, pap smear and self breast exam

 Inform patients to report any abnormal bleeding, increased or foul-smelling vaginal discharge, pelvic pain or fever immediately

 Explain to patient that menstrual pain responds well to non narcotic and should not require the use of narcotics

 Inform patient that infections may recur unless patient’s sexual partner is examined and treated

 Identify emotional problems, discuss lifestyle changes that may alleviate problems, refer them to psychological counseling as needed

Prevention of complications requires education about separating the pain of menstruation from sickle pain episodes. Pelvic inflammatory disease is prevented by abstinence, condoms during sex, and early treatment of infections.

Young females approaching menarche need education about the normal menstrual cycle and menstruation. They are educated to separate the pain of menstruation from sickle pain episodes and use NSAIDs rather than narcotics for this former. Patients must also obtain accurate information about the prevention of sexually transmitted diseases.

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Beach RK. Relieving the pain of menstrual cramps. Contemp. Pediatr. 3:115- , 1986.

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Peterson HB, Galaid EI, Zenilman. Pelvic inflammatory disease: Review of treatment options. Rev. Infect. Dis 12:S656-S664.

Zhang WY, Li Wan Po A. Efficacy of minor analgesics in primary dysmenorrhoea: a systemic review. Br. J. Obstet. Gynaecol. 105:780-789, 1998.

Schroeder B, Sanfilippo JS. Dysmenorrhea and pelvic pain in adolescents. Pediatr. Clin. North Amer. 46:555-571, 1999.

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Copyright © 1997 Sickle Cell Information Center
Last modified: October 08, 2000