Miss Jasmine White is a 32 year old full time student, currently completing her PhD. She leads a busy lifestyle with an active social life. She presents to your pharmacy requesting some advice in regards to her period pain, you notice she has some ibuprofen to purchase. She tells you she is concerned as she has been experiencing pain associated with her recent periods, she has felt some pain between the periods too and has noticed some spotting. Before this recent onset of pain her periods were pain free.

What is dysmenorrhoea?

Dysmenorrhoea is painful cramping, usually in the lower abdomen, occurring shortly before or during menstruation, or both.

What are the two types and causes of dysmenorrhoea?

Dysmenorrhoea may be classified as either primary or secondary. Primary dysmenorrhoea occurs in the absence of any identifiable underlying pelvic pathology. The production of uterine prostaglandins during menstruation is thought to be the cause. Prostaglandin production is controlled by progesterone. Before menstruation begins, progesterone levels drop and this causes endometrial cells to release prostaglandins which stimulates myometrial contractions and ischaemia. Secondary dysmenorrhoea is caused by an underlying pelvic pathology such as endometriosis, fibroids, or endometrial polyps.

Miss White explained earlier that until recently she had pain free periods and has been experiencing pain between her periods as well as some intermenstrual bleeding. For this reason you advise Miss White to make an appointment to see her Doctor, you suspect there may be a secondary cause to her dysmenorrhoea.

What other symptoms may indicate secondary causes of dysmenorrhoea?

Other gynaecological symptoms that may be associated with secondary causes of dysmenorrhoea, include dyspareunia, vaginal discharge, menorrhagia, intermenstrual bleeding, and postcoital bleeding. Some non-gynaecological symptoms that may suggest a secondary cause, may be rectal pain and bleeding which may be associated with endometriosis. A secondary cause is more likely if symptoms start after several years of painless periods.

Miss White returns to your pharmacy with a prescription for naproxen and norethisterone, she has been diagnosed with endometriosis. She is concerned about her long-term fertility and is interested to know why the Doctor prescribed norethisterone.

What is endometriosis?

Endometriosis is the growth of endometrial-like tissue outside the uterus. It mainly affects women of reproductive age and, although its exact cause is unknown, it is an oestrogen-dependent condition and is associated with menstruation. It is typically associated with symptoms such as pelvic pain, painful periods as well as tiredness, and may have a significant physical, sexual, psychological and social impact. Women may also have endometriosis without symptoms, so it is difficult to know how common the disease is in the population.

Aims of treatment

The aim of treatment for endometriosis is to reduce the severity of symptoms, improve the quality of life and to improve fertility, if this is affected.

What are the treatment options for endometriosis?

Management options include drug treatment and surgery. Most drug treatments for endometriosis work by suppressing ovarian function and are contraceptive. Surgical treatment aims to remove or destroy endometriotic lesions. The choice of treatment depends on the woman's preferences and priorities in terms of pain management and fertility.

A short trial (such as 3 months) of paracetamol or an NSAID alone or in combination should be considered for first-line management of endometriosis-related pain. If pain relief is inadequate, consider other forms of pain management and referral for further assessment.

Hormonal treatment (with a combined oral contraceptive or a progestogen) should be offered to women with suspected, confirmed or recurrent endometriosis. Miss White should be informed that hormonal treatment for endometriosis can reduce pain and has no permanent negative effect on subsequent fertility.

When to consider surgery?

Women with suspected or confirmed endometriosis should be asked about their symptoms, preferences and priorities with respect to pain and fertility, to guide surgical decision-making. Excision rather than ablation should be considered to treat endometriomas, taking into account the woman's desire for fertility and her ovarian reserve.

A hysterectomy may be indicated if, for example, the woman has adenomyosis or heavy menstrual bleeding that has not responded to other treatments.

If fertility is a priority, the management of endometriosis-related subfertility should have multidisciplinary involvement with input from a fertility specialist. Women with endometriosis who are trying to conceive should not be offered hormonal treatment, because it does not improve spontaneous pregnancy rates.

The treatment summary for endometriosis in the BNF provides further information.

What is norethisterone? What counselling points would you provide?

Norethisterone is a progesterone, it is a potent inhibitor of ovulation and has weak oestrogenic and androgenic properties. For endometriosis treatment should start on day 5 of the menstrual cycle, taking 10 - 15mg daily for 4 - 6 months or longer. The dose may be increased if spotting occurs and reduced once bleeding has stopped.

You counsel Miss White on how to take norethisterone and some of the side-effects: headache, nausea, vomiting, and dizziness. You tell Miss White if she experiences any changes to her vision, symptoms of thrombosis, onset or aggravation of migraine or the development of a new kind of headache she should stop treatment and seek immediate medical advice.

Some non-drug measures that Miss White could also use to help with the pain involve the application of heat to the area and the use of transcutaneous electrical nerve stimulation (TENS).

The BNF monograph for norethisterone provides further information.

Other sources of information.

Dysmenorrhoea. National Institute for Health and Care Excellence. Clinical Knowledge Summary. May 2014.

Endometriosis: diagnosis and management. National Institute for Health and Care Excellence. NICE guidance 73. February 2017.

This case study is taken from the April 2018 issue of the BNF eNewsletter.