On examination, the paleness of the skin, the narrowing of the pupils, and the decrease in heart rate are noted.
It should be noted that most girls are currently discovering mixed vegetative-emotional reactions. Rarely, but most heavily menstruation occurs in asthenicized girls with psychopathic personality traits (hypochondria, touchiness and tearfulness, attacks of irritability and aggressiveness, alternating with depression and apathy, feelings of anxiety and fear, violation of the depth and duration of sleep, intolerance of sound, olfactory and taste stimuli ).
Every second girl suffers a neuropsychic, every fifth girl has a cephalgic or a crisis form of premenstrual syndrome.
At objective research pay attention to plural displays of a syndrome of a dysplasia of a connecting fabric:
- skin integument:
- a vascular network on the chest, back, limbs due to thin skin.
Increase of skin extensibility (painless pulling by 2-3 cm in the area of the rear of the hand, forehead):
- hemorrhagic manifestations (ecchymosis and petechiae in cases of pinch or tourniquet);
- intradermal ruptures and stretch marks (striae);
- a symptom of tissue paper (areas of abrasions, wounds, chicken pox left at the sites of shiny, atrophied skin);
- bone tissue:
- deformation of the chest (funnel-shaped, keeled);
- pathology of the spine (scoliosis, kyphosis, lordosis, flat back);
- pathology of extremities (arachnodactyly, hypermobility of joints, curvature of limbs, flat feet);
- of cardio-vascular system:
- mitral valve prolapse;
- varicose veins (functional failure of the valves, violation of blood flow);
- organs of vision:
In the management of patients with dysmenorrhea, diagnostic methods are of great clinical importance, which make it possible to recognize a disease whose mask was painful menstruation.
A sample with non-steroidal anti-inflammatory agents
NSAIDs have an anti-prostaglandin effect. The main mechanism of action of NSAIDs is the blocking of the synthesis and activity of type I and / or 2 cyclooxygenases that promote the conversion of arachidonic acid to eicosanoids. In addition to direct action on the synthesis of prostaglandins, these agents increase the level of endogenous compounds that reduce pain sensitivity (endorphins).
The trial with NSAIDs 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 remove the manifestations of dysmenorrhea, but also with a high degree of reliability to diagnose the gynecological disease that caused this pathology. The patient is offered to evaluate the severity of painful sensations on a 4-point system on the background of a five-day NSAID intake, where 0 points are absence of pain, and 3 points are the maximum pain. Decimal values are provided for a more accurate estimate of the analgesic effect of NSAIDs. You can also apply a classic visual analogue scale with a division of divisions from 0 to 10 points.
When there are very irritating, but still bearable pain, close to the maximum, the patient marks the initial indicators on the scale of pain intensity. On the first day of the test, the dynamics of pain change is evaluated after 30, 60,120 and 180 minutes after taking the first tablet, and then every 3 hours before taking the next pill before bedtime. In the next 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 the consistent filling of the pain scale, the patient simultaneously records the data on the tolerability of the drug and the features of the vegetoneurotic and psychoemotional manifestations of dysmenorrhea. It is advisable to make a medical evaluation of the analgesic effect of the drug on the 6th day of the test.
Rapid reduction in the severity of pain and concomitant manifestations of dysmenorrhea in the first 3 hours after taking the drug with the preservation of a positive effect in the following days allows us to speak with high degree of certainty about primary dysmenorrhea caused by functional hyperprostaglandinemia. Such test results allow to limit the spectrum of examination of patients with the analysis of EEG data and the definition of psychoemotional personality traits.
The preservation, and in some cases, the intensification of pain on the 2-3rd day of profuse menstruation and the subsequent weakening of their intensity by the 5th day of the test is more typical for patients with dysmenorrhea due to genital endometriosis.
In the case when after taking the first pill the girl indicates a regular decrease in the intensity of pain, and with further performance of the sample notes the preservation of painful sensations until the end of the drug intake, as an underlying cause of dysmenorrhea, one can assume an inflammatory disease of the pelvic organs.
The absence of an anesthetic effect of NSAIDs throughout the whole sample, including after the first tablet, suggests the insufficiency or exhaustion of the analgesic components of the system. A similar condition is observed in the genitalia, associated with a violation of outflow of menstrual blood, as well as with dysmenorrhea due to impaired metabolism of leukotrienes or endorphins.
Laboratory diagnostics and instrumental methods
If suspicion of secondary dysmenorrhea is suspected, ultrasound of the pelvic organs should be performed in the first and second phases of the menstrual cycle or MRI of the genital organs, and sent to the hospital for diagnostic hysteroscopy or laparoscopy in accordance with the presumptive diagnosis.
In the complex of examination of girls with dysmenorrhea, it is advisable to include Echocardiography and the determination of the level of magnesium in the blood plasma. According to the data obtained, 70% of patients with pubertal dysmenorrhea are diagnosed with pronounced hypomagnesemia.
An important diagnostic step is the determination of the level of estrogens and progesterone in days preceding the expected menstruation (on the 23rd-25th day with a 28-day menstrual cycle).
In patients with mild degrees of dysmenorrhea, usually a normal ratio of estradiol and progesterone. Electroencephalographic data indicate a predominance of cerebral changes with signs of dysfunction of mesodiencephalic and striopallidal brain structures.
In patients with moderate dysmenorrhea, the steroid profile is characterized by a classical version of NLP, the normal production of estradiol and reduced progesterone secretion in the 2nd phase of the menstrual cycle. EEG data help to detect multiple manifestations of the over-stimulation of the sympathetic tone of the autonomic nervous system with cerebral changes and signs of dysfunction of the mid-stem brain structures.
In patients with severe dysmenorrhea, the level of estradiol exceeds the regulatory parameters, and the content of progesterone may correspond to the norms of the lutein phase of the menstrual cycle. In the clinic of dysmenorrhea, in addition to pain, signs of parasympathetic influence of the autonomic nervous system, which are manifested in the EEG by general cerebral changes with signs of dysfunction of the brain's diencephalic structures, predominate.
Endometriosis is one of the most common causes of dysmenorrhea. With external endometriosis, the pain is aching, often radiating to the area of the sacrum and rectum. Often seizures of very severe pain are accompanied by the development of a picture of the "acute abdomen", nausea, vomiting and short-term loss of consciousness. With internal endometriosis (adenomyosis), pain occurs, usually 5-7 days before menstruation, increase in intensity by day 2-3, and then gradually decrease in intensity by the middle of the cycle. Progressively increases the amount of blood lost. For endometriosis is also characterized by a slight rise in body temperature during menstruation, an increase in ESR. In girls who have sexual relations, the pathognomonic sign is dyspareunia.
Dysmenorrhea can serve as one of the earliest symptoms of malformations of the uterus and vagina, accompanied by a one-sided delay in the outflow of menstrual blood (closed additional horn of the uterus or vagina). Characteristic signs: the onset of dysmenorrhea with menarche, the progressive increase in pain both in severity and duration with a maximum of their intensity after 6-12 months, the preservation of the same localization and irradiation of pain from month to month.
Dysmenorrhea may be due to congenital insufficiency of the vasculature of the pelvic organs, better known as varicose veins of the pelvic veins or ovarian vein syndrome. However, there is an opinion that the violation of hemodynamics in the venous system of the uterus is the result of psychopathic or mental disorders in predisposed people.
One of the rare causes of dysmenorrhea is the defect of the posterior leaf of the broad ligament of the uterus (Alain-Masters syndrome).
In the genesis of pain syndrome manifested by transient or persistent dysmenorrhea. An important role may play functional or endometrioid ovarian cysts, as well as a fixed violation of the topography of the genital organs due to the adhesive process.
Dysmenorrhea caused by inflammatory diseases of the internal genital organs of nonspecific and tubercular etiology has significantly different features.
In chronic salpingitis of non-tuberculous etiology, a painful or traumatic character occurs 1-3 days before the onset of menstruation and increases in the first 2-3 days. Frequently accompanied by menometrorrhagia. A detailed interview with the patient makes it possible to clarify that menstruation became painful not immediately after menarche; their appearance was preceded by hypothermia or transferred inflammation of different locations, and similar pains also occur outside menstruation. In inflammatory processes the tension of adhesions formed between the peritoneum of the uterus and adjacent organs is important. Inflammation, starting in one of the sections of the genital tract, spreads to other areas. As a result, different combinations of such forms as salpingo-oophoritis, endometritis, tubo-ovarian formations, pelvic-cellulitis, pelvioperitonitis are possible.
For dysmenorrhea caused by chronic genital tuberculosis, other characteristics are more specific. Characterized by general malaise, frequent attacks of aching unmotivated pain in the abdomen without a clear localization (especially in the spring or autumn season), painful menstruation with menarche, menstrual irregularities in the type of hypomenorrhea, opsoniformes, amenorrhea, or metrorrhagia. These disorders are caused by the impact of tuberculosis toxins on the regulating sexual centers and neutralization of sex hormones.
Dysmenorrhea often accompanies a condition called appendicular-genital syndrome. It is believed that every third girl at the same time with acute appendicitis, there is inflammation of the uterine appendages (most often catarrhal salpingitis, less often periophoritis and purulent salpingitis, and even less often oophoritis). Thus, in 33% of cases of appendicitis prerequisites are created for the formation of appendicular-genital syndrome.
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