Diagnosis of pubertal dysmenorrhea

During examination, pale skin, constricted pupils, and decreased heart rate are noted.

It should be noted that most girls currently have mixed vegetative-emotional reactions. Quite rarely, but the most severe menstruation occurs in asthenic girls with psychopathic personality traits (hypochondria, resentment and tearfulness, bouts of irritability and aggressiveness, followed by depression and apathy, feelings of anxiety and fear, disturbances in the depth and duration of sleep, intolerance to sound, olfactory and taste stimuli).

Every second girl suffers from neuropsychiatric, every fifth girl suffers from cephalgic or crisis form of premenstrual syndrome.

During an objective examination, attention is paid to multiple manifestations of connective tissue dysplasia syndrome:

• skin:
• vascular network on the chest, back, limbs due to thin skin.

Increasing skin elasticity (painless pulling by 2-3 cm in the area of the back of the hand, forehead):

• hemorrhagic manifestations (ecchymosis and petechiae during pinch or tourniquet tests);
• intradermal ruptures and stretch marks (striae);
• tissue paper symptom (areas of shiny, atrophied skin remaining at the sites of abrasions, wounds, chicken pox);
• bone tissue:
• chest deformity (funnel-shaped, keel-shaped);
• spinal pathology (scoliosis, kyphosis, lordosis, flat back);
• limb pathology (arachnodactyly, joint hypermobility, limb curvature, flat feet);
• cardiovascular system:
• mitral valve prolapse;
• varicose veins (functional insufficiency of valves, impaired blood flow);
• organs of vision:
• myopia.

In the management of patients with dysmenorrhea, diagnostic techniques that allow the recognition of the disease, the mask of which is painful menstruation, are of great clinical significance.

Non-steroidal anti-inflammatory drug test

NSAIDs have an antiprostaglandin effect. The main mechanism of action of NSAIDs is to block the synthesis and activity of cyclooxygenases type 1 and/or 2, which facilitate the conversion of arachidonic acid into eicosanoids. In addition to the direct effect on prostaglandin synthesis, these drugs increase the level of endogenous compounds that reduce pain sensitivity (endorphins).

The NSAID test makes it possible to choose the most rational ways of subsequent examination of patients.

Taking the drug according to a certain scheme helps not only to relieve the symptoms of dysmenorrhea, but also to diagnose with a high degree of reliability the gynecological disease that caused this pathology. The patient is asked to independently assess the severity of pain sensations on a 4-point system against the background of a five-day intake of NSAIDs, where 0 points is the absence of pain, and 3 points is the most severe pain. For a more accurate assessment of the analgesic effect of NSAIDs, decimal values are provided. You can also use the classic visual analog scale with divisions from 0 to 10 points.

When very irritating but still bearable pain sensations appear, close to the maximum, the patient notes the initial indicators on the pain intensity scale. On the first day of the test, the dynamics of pain changes are assessed 30, 60, 120 and 180 minutes after taking the first tablet, and then every 3 hours before taking the next tablet until sleep. In the following 4 days, the patient should take the drug 1 tablet 3 times a day and assess the severity of pain once in the morning. Along with consistently filling out the pain scale, the patient simultaneously records data on the tolerability of the drug and the characteristics of the vegetoneurotic and psychoemotional manifestations of dysmenorrhea. It is advisable to make a medical assessment of the analgesic effect of the drug on the 6th day of the test.

A rapid decrease in the severity of pain and associated manifestations of dysmenorrhea in the first 3 hours after taking the drug with the preservation of the positive effect in the following days allows us to speak with a high degree of reliability about primary dysmenorrhea caused by functional hyperprostaglandinemia. Such test results allow us to limit the range of examination of patients to the analysis of EEG data and the determination of psycho-emotional personality traits.

The persistence and, in some cases, intensification of pain on the 2nd-3rd day of heavy menstruation, followed by a decrease in its intensity by the 5th day of the test, is more typical for patients with dysmenorrhea caused by genital endometriosis.

In the case where, after taking the first pill, the girl indicates a natural decrease in the intensity of pain, and upon further testing, notes the persistence of painful sensations until the end of taking the drug, an inflammatory disease of the pelvic organs can be assumed to be the main cause of dysmenorrhea.

The absence of an analgesic effect of NSAIDs throughout the entire test, including after the first tablet, suggests a deficiency or depletion of the analgesic components of the system. A similar condition is observed in cases of genital defects associated with impaired menstrual blood flow, as well as in cases of dysmenorrhea caused by leukotriene or endorphin metabolism disorders.

Laboratory diagnostics and instrumental methods

If secondary dysmenorrhea is suspected, it is necessary to perform an ultrasound of the pelvic organs in the first and second phases of the menstrual cycle or an MRI of the genital organs, and also refer the patient to the hospital for diagnostic hysteroscopy or laparoscopy in accordance with the presumptive diagnosis.

It is advisable to include echocardiography and determination of magnesium levels in blood plasma in the examination of girls with dysmenorrhea. According to the data obtained, 70% of patients with pubertal dysmenorrhea are diagnosed with severe hypomagnesemia.

An important diagnostic step is determining the level of estrogen and progesterone in the days preceding the expected menstruation (on the 23rd-25th day with a 28-day menstrual cycle).

Patients with mild dysmenorrhea usually have a normal estradiol and progesterone ratio. Electroencephalographic data indicate a predominance of general cerebral changes with signs of dysfunction of the mesodiencephalic and striopallidal structures of the brain.

In patients with moderate dysmenorrhea, the steroid profile is characterized by the classic variant of NLF - normal production of estradiol and reduced secretion of progesterone in the 2nd phase of the menstrual cycle. EEG data help to detect multiple manifestations of overstimulation of the sympathetic tone of the autonomic nervous system with general cerebral changes and signs of dysfunction of the mid-stem structures of the brain.

In patients with severe dysmenorrhea, the estradiol level exceeds the standard parameters, and the progesterone content may correspond to the norms of the luteal phase of the menstrual cycle. In the clinic of dysmenorrhea, in addition to pain, signs of the parasympathetic influence of the autonomic nervous system predominate, manifested on the EEG by general cerebral changes with signs of dysfunction of the diencephalic-stem structures of the brain.

Differential diagnostics

Endometriosis is one of the most common causes of dysmenorrhea. With external endometriosis, the pain is aching, often radiating to the sacrum and rectum. Attacks of very severe pain are often accompanied by the development of an "acute abdomen", nausea, vomiting and short-term loss of consciousness. With internal endometriosis (adenomyosis), pain usually occurs 5-7 days before menstruation, increases in intensity by the 2nd-3rd day, and then gradually decreases in intensity by the middle of the cycle. The amount of blood lost progressively increases. Endometriosis is also characterized by a slight increase in body temperature during menstruation, an increase in ESR. In girls who have sexual relations, dyspareunia is a pathognomonic sign.

Dysmenorrhea may be one of the earliest symptoms of malformations of the uterus and vagina, accompanied by a unilateral delay in the outflow of menstrual blood (closed accessory horn of the uterus or vagina). Characteristic signs: the onset of dysmenorrhea with menarche, a progressive increase in pain both in severity and duration with a maximum of their intensity after 6-12 months, maintaining the same localization and irradiation of pain from month to month.

Dysmenorrhea may be due to congenital insufficiency of the pelvic vascular system, better known as varicose veins of the pelvic veins or ovarian vein syndrome. However, there is an opinion that the hemodynamic disturbance in the venous system of the uterus is the result of psychopathic or mental disorders in predisposed individuals.

One of the rare causes of dysmenorrhea is a defect in the posterior leaflet of the broad ligament of the uterus (Alain-Masters syndrome).

In the genesis of pain syndrome, manifested by transient or permanent dysmenorrhea, an important role can be played by functional or endometrioid ovarian cysts, as well as fixed disruption of the topography of the genitals due to the adhesion process.

Dysmenorrhea caused by inflammatory diseases of the internal genital organs of non-specific and tuberculous etiology has significantly different features.

In chronic salpingitis of non-tuberculous etiology, aching or pulling pain occurs 1-3 days before the onset of menstruation and intensifies during the first 2-3 days. Menometrorrhagia is often associated. A detailed survey of the patient allows us to clarify that menstruation did not become painful immediately after menarche; its appearance was preceded by hypothermia or previous inflammation of various localizations, and similar pains also occur outside of menstruation. In inflammatory processes, the tension of adhesions formed between the peritoneum of the uterus and adjacent organs is important. Inflammation, starting in one section of the genital tract, spreads to other areas. As a result, various combinations of such forms as salpingo-oophoritis, endometritis, tubo-ovarian formations, pelviocellulitis, pelvioperitonitis are possible.

Dysmenorrhea caused by chronic genital tuberculosis has more specific symptoms. General malaise, increased frequency of attacks of aching unmotivated abdominal pain without clear localization (especially in spring or autumn), painful menstruation with menarche, menstrual cycle disorders such as hypomenorrhea, opsomenorrhea, amenorrhea or metrorrhagia are characteristic. These disorders are caused by the effect of tuberculosis toxins on the regulating sexual centers and the neutralization of sex hormones.

Dysmenorrhea often accompanies a condition called appendicular-genital syndrome. It is believed that every third girl simultaneously with acute appendicitis develops inflammation of the uterine appendages (most often catarrhal salpingitis, less often - perio-oophoritis and purulent salpingitis, even less often - oophoritis). Thus, in 33% of cases of appendicitis, the prerequisites for the formation of appendicular-genital syndrome are created.

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