KEYWORDS: ..월경곤란증은 젊은 여성에서 병원을 찾는 가장 흔한 원인이며, 청소년 시절 엔 학교 결석의 원인, 나중엔 직장 결근의 원인에 많은 부분을 차지한다. ..Prevalence : 20~90% (젊은 여성의 15%에서는 심각한 증상을 호소하며 이는 사회활동의 제약을 가져온다.) Pathogenesis I. Prostaglandin : Prostaglandins in the menstrual fluid, which causes uterine contraction and pain. II. Vasopressin : Vasopressin may play a role by increasing uterine contractility and causing ischemic pain as a result of vasoconstriction. III. Endometriosis : The relationship between endometriosis and dysmenorrhea is not clear. → Endometriosis may be asymptomatic, or it may be associated with pelvic pain that is not limited to the menstrual period and the low anterior pelvis. But an observational study of women undergoing laparoscopy for infertility supported a relationship between dysmenorrheal and the severity of endometriosis. ..Age < 20 years ..Attempts to lose weight ..Depression/Anxiety ..Disruption of social networks ..Heavy menses ..Nulliparity ..Smoking Dysmenorrhea 483 The Root of ambulatory care 1. Complete menstrual history 2. Family history of dysmenorrheal 3. Sexual history, including method of contraception 4. Description of pain : - Onset → 6 to 18months after menarche in the teens and early twenties and declines with increasing age/begins 1 to 2 hours before menstrual flow and lasts 1 to 2days : Primary dysmenorrhea → Either with the first menstrual cycles after menarche (congenital) or much later, usually after age 25/begins a few days before menstrual flow and lasts longer : Secondary dysmenorrhea - Pattern → A diffuse, dull ache centered in the midline lower abdomen, just above the pubis, often radiation to the lower back and/or anterior thighs : Primary dysmenorrhea → Atypical, sometimes chronic, and varies in description and temporal relationships depending on the etiology : Secondary dysmemorrhea (Endometriosis the pain is often deep and aching and may radiate to the rectum or the perineum.) 5. Associated symptoms such as nausea, vomiting, diarrhea, headache, dizziness, or fatigue : often associated with primary dysmenorrhea. 6. Limitation of daily activities 7. Previous treatment attempts and results 8. Risk factors increasing duration, severity, and occurrence of dysmenorrhea include early age at menarche and long menstrual periods : Smoking and alcohol increase the length and duration of dysmenorrhea. ..생리전 증후군에서 동반되는 통증은 대개 유방통과 복부 팽만감이 하복통 보다 흔하고, 통증이 생리주기 전에 시작되고 생리가 시작된 후 급히 해소 된다. - If secondary dysmenorrhea suspected 1. Pelvic ultrasonography 2. Exploratory laparoscopy : diagnostic test for endometriosis 3. Hysteroscopy : abnormalities in the uterus such as polyps, adhesions, tumors, and congenital malformations. Key questions Key tests Key treatments Dysmenorrhea - Life style modification 1. Low-fat vegetarian diet : decrease duration and intensity of dysmenorrhea 2. Aerobic exercise : not clear 3. Smoking cessation : not been studied - Primary dysmenorrhea 1. NSAIDs : 통증이 시작되기 직전이나 직후에 복용하고, 생리주기가 규칙적이라면 생리예 정일 하루 전에 복용/약제의 개인별 반응이 다양할 수 있으므로 1~2월경 주기 동안 효과 가 없으면 다른 종류의 NSAIDs를 고려한다. ..Naxen-F.. 500mg 1T, initial 500mg qd, maintenance 250mg tid-qid ..Carol-F.. 200/185mg 1T, 1-2T qid (daily maximun 6T/day) 2. Oral contraceptives : 피임을 원하고 복용의 특별한 금기사항(심혈관질환, 뇌혈관질환, 간질환, 정맥혈전 등)이 없다면 1차약제로 사용할 수 있으나, 일반적으로 효과가 나타나는 데 3개월 정도가 걸리므로 초반에는 NSAIDs와 병합투여하는 것이 효과적이다. 3. Alternative medicine : 10%의 환자에서는 NSAIDs나 oral contraceptives같은 약물 치 료에도 불구하고 지속적인 통증을 호소하며, 이 경우 고려해 볼 수도 있다. ..Thiamine 100mg daily - In East Indian women ..Vitamin E 2500IU daily ..Omega 3 fatty acids 2g daily of a fish oil supplement ..Japanese herbal remedy toki-shakuyaku-san ..Acupuncture & Acupressure ..Transcutaneous electric nerve stimulation (TENS) ..Heated patch 4. Surgical therapy : refractory, severe dysmenorrhea ..Hysterectomy ..Laparoscopic uterine nerve ablation/presacral neurectomy ..Naxen-F.. - Naproxen ..Carol-F.. - Ibuprofen/Arginine ..Warning women to start NSAIDs treatment only with onset of menstrual flow will help prevent potential teratogenic effects of NSAIDs used during pregnancy. 485 The Root of ambulatory care ..An intravaginal contraceptive is more effective and associated with fewer side effects than the same agent in an oral form. 참고 문헌 Stephen Paul : Dysmenorrhea, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 510-513 고희정 : 월경곤란증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1312-1315 Linda French, M.D. : Dysmenorrhea. A journal of the American Family Physicains 2005 ; 71(2) :285- 291, 292