Australian Doctor 14th June Issue | Page 32

offered any management strategies

( unpublished data from the Long- STEPP co-design survey ).

The physiology of menstruation is more than falling oestrogens and progestogens , followed by menstruation . Appreciating that endometrial shedding is actually an inflammatory process is helpful in terms of understanding the impact of this physiological phenomenon , why it can hurt and why it can exacerbate other pain states as well as a range of other conditions , such as chronic fatigue , asthma , irritable bowel and inflammatory bowel disease . 21

The endometrium that is shed is equivalent to the surface area of a finger and is 4-6mm thick . Although

Suzen A et al . Pediatric Urology Case Reports 2016 / CC BY 4.0 / bit . ly / 3NgPROE

this is a physiological and normal

process , the exact inflammatory

cytokines and prostaglandins

released and activation of white cells

vary in each individual . Many people

will experience nausea , vomiting

, diarrhoea , generalised aches and

pains , headaches and dizziness . 22 Those with chronic conditions —

such as postural orthostatic tachycardia

syndrome , chronic fatigue ,

rheumatoid arthritis , diabetes and

asthma — may have exacerbation of

these and poorer control . Anaphylaxis

at the time of menses has been described . 23 Monthly endometrial shedding is no small event in biological

terms , and while it is completely normal and natural , the process may

Figure 5 . Vaginal polyp .

have significant side effects .

In the past , when women typically

had a later onset of menarche ,

had as many as 10-15 children and

breastfed them all , this process

would have occurred fewer than 50

times in a woman ’ s lifetime . Therefore

, we could consider menses , a bit

like childbirth , as a poorly designed

biological process which also carries

significant risks of mortality to some

individuals , especially those who

cannot access appropriate care and

intervention .

As with all pain conditions , dysmenorrhoea

is influenced by previous

traumatic events that in turn

have effects on the experience of pain . 24 Furthermore , repeated episodes of significant period pain

appear to predispose to the development

of chronic pelvic pain . 25 The process of central sensitisation ( amplification of the pain response ) appears to be potentially triggered by menstruation in some , while in others , central sensitisation triggers more severe period and pelvic pain . 26

Retrograde menstruation , which occurs in more than 90 % of people , is likely to also contribute to dysmenorrhoea in some , potentially more in those with heavy menstrual

22 , 27 bleeding . Exercise , stretches and yoga can

Figure 6 . Rhabdomyosarcoma . A two-year-old child initially saw the GP with a painless genital swelling and no history of trauma . She received two weeks of antibiotics and was referred to a paediatrician , who referred her to a gynaecologist .

all be helpful management modalities . 28 Data are limited on the beneficial effects of diet or supplements ,

there is no evidence to support this . 29 In particular , it is important to note that these hormonal meas-

There are a large variety of oral contraceptive pills available with different hormonal constituents . In

same beneficial impact on reducing pain and bleeding is not achieved . 31

Some patients will have adverse

bleeding itself is not required . It may , however , be difficult to achieve complete amenorrhoea , and patients may

with small sample sizes , poor report-

ures are being offered in the setting

those with migraines with associ-

mood effects using oral , inject-

need to accept that a withdrawal

ing of methodology and inconsist-

of troublesome menses ; final height

ated focal neurological deficit , avoid

able ( depot medroxyprogester-

bleed may sometimes be required

ency ; no studies to date demonstrate

is already determined by the onset

oestrogens and seek neurological

one acetate ) and implant hormonal

to avoid or manage breakthrough

efficacy .

of menarche , and there is no evi-

input . In general , progesterone-only

approaches ( etonogestrel ). These

bleeding .

If simple measures have not

dence of any significant impact of

approaches , including the levonorg-

effects are often related to the spe-

Chronic pelvic pain often devel-

worked , then hormonal approaches

these exogenous hormones — even

estrel-releasing intrauterine system ,

cific progestogen , so acknowledging

ops in the setting of untreated severe

are usually offered , including the

in young adolescents . In studies a

can be used in this cohort . An IUD

the problem and trialling a different

dysmenorrhoea and represents a

combined oral contraceptive pill or

few decades ago , tall girls were given

can be used in a menstruating ado-

progestogen will often help .

missed opportunity to have pre-

progestogen-only options , includ-

oestrogens in an attempt to limit fur-

lescent without undertaking imaging

Skipping a period on the contra-

vented this problem . 25

ing the levonorgestrel intrauterine system . Although many adolescents , their parents and clinicians have concerns regarding the negative impact of hormones on weight ,

ther growth , with doses of 100 µ g / day , 300 µ g / day and 500 µ g / day given with minimal impact on height outcomes . 30 In comparison , oestradiol doses in most contraceptive pills

before insertion because the achievement of menstruation is a good indicator that the uterine size will permit tolerance of an IUD . Although there is a newer , smaller levonorgestrel-re-

ceptive pill is acceptable . The endometrium in young women using the pill continuously is thin because of the progestogenic effect . It is not the bleeding that protects the endo-

Pain

Although endometriosis is often considered a principal cause of severe pelvic pain , there is good evidence in

height and bone mineral density ,

today are 30 µ g / day or 35 µ g / day .