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Duration depends on the treatment plan; prolonged GnRH agonist therapy generally requires consideration of add-back therapy. Definitive Surgical Treatment • Hysterectomy may be considered in women with severe symptoms who have completed their family, particularly when conservative treatment has failed. • Removal of the ovaries (BSO) is not automatically required and should be individualized. ⸻ 5. Adenomyosis Treatment • Medical treatment can include: • Combined oral contraceptive pill • LNG-IUS (Mirena) • Other hormonal treatments. Definitive Treatment • Hysterectomy is the definitive treatment for adenomyosis in women who have completed their family. Important: Adenomyosis → Hysterectomy WITHOUT routine removal of the ovaries. يعني ما نسوي BSO routinely؛ الـovaries are generally preserved unless there is another indication for removing them. ⸻ 6. Pelvic Congestion Syndrome Clinical Features The patient may present with: • Chronic lower abdominal / pelvic pain • Dyspareunia Characteristic features include: • Pain may be minimal in the morning. • Pain becomes worse as the day progresses, especially in the afternoon/evening. • Pain is aggravated by: • Prolonged standing • Walking • The pain may improve when lying down. Diagnosis There is no single specific diagnostic test. Imaging may demonstrate: • Dilated pelvic veins • Venous congestion around the uterus and adnexa Possible investigations include: • Pelvic ultrasound • Color Doppler • Other venous imaging when required. Treatment Treatment options may include: • Hormonal treatment • Daflon may be used for symptomatic treatment. • Interventional treatment may be considered in selected cases. Definitive Treatment • Hysterectomy may be considered in selected women who have completed their family, although modern management may favor less invasive venous interventions in appropriate patients.

Dysmenorrhea Types There are two types: 1. Primary dysmenorrhea 2. Secondary dysmenorrhea ⸻ 1. Primary Dysmenorrhea Clinical Features • Usually starts within a few years after menarche. • Common in adolescents. • Pain usually starts just before or at the onset of menstruation. • It is usually most severe during the first 1–2 days and improves thereafter. • Associated systemic symptoms may include: • Nausea • Vomiting • Headache • Dizziness • Diarrhea Treatment Non-pharmacological • Warm compresses over the lower abdomen. • Warm fluids. • Exercise may also be helpful. Pharmacological • NSAIDs are first-line treatment.(1*3)for 6months • Examples: • Mefenamic acid (Ponstan) • Ibuprofen (Profen) • NSAIDs should preferably be started 1–2 days before the expected onset of menstruation and continued regularly during the first few days of pain. • They can be used for several cycles; treatment is continued according to the patient’s response rather than routinely prescribing them for exactly 6 months. Supplements • Omega-3 • Vitamin E These may have some benefit in reducing dysmenorrhea, but they are not first-line treatment. ⸻ 2. Secondary Dysmenorrhea Clinical Features • The patient previously had normal, painless menstrual cycles, followed by the development of painful periods. • Pain may: • Start before menstruation • Continue throughout menstruation • Sometimes persist beyond menstruation. • The patient may have chronic pelvic pain. Important Causes • Endometriosis • Adenomyosis • Pelvic congestion syndrome • Fibroids • PID Associated Symptoms Ask about: • Dyspareunia, especially deep dyspareunia • Menorrhagia / heavy menstrual bleeding • Infertility • Abnormal vaginal discharge • Intermenstrual bleeding • Postcoital bleeding Gynecological & Obstetric History If she has previous children, ask about: • Mode of delivery • Previous pregnancy and obstetric history. Ask about the menstrual cycle: • Regular or irregular • Duration • Amount of bleeding • Duration of pain and its relationship to menstruation. Ask about contraception: • IUCD Important: IUCDs, particularly copper IUCDs, can increase menstrual bleeding and may worsen dysmenorrhea. ⸻ Examination General Examination • Perform a general examination. • Look for signs of anemia, especially if there is heavy menstrual bleeding. Abdominal Examination • Perform an abdominal examination. • Look for: • Tenderness • Masses • Organomegaly Pelvic Examination • Perform pelvic examination / PV examination when indicated. • Look for: • Cervical motion tenderness • Uterine tenderness • Adnexal tenderness or masses • Enlarged uterus • Polyp • Other pelvic pathology ⸻ Treatment According to the Cause 1. PID If PID is the cause, treatment should be according to the appropriate PID regimen. Important correction: The regimen mentioned in the lecture of ceftriaxone 2 g IV + doxycycline + metronidazole for 2 weeks is not the standard outpatient regimen for uncomplicated PID. A commonly used regimen is: • Ceftriaxone 1 g IM single dose • Doxycycline 100 mg orally twice daily for 14 days • Metronidazole 500 mg orally twice daily for 14 days Severe PID may require IV therapy and hospital admission. Patients should avoid sexual intercourse until treatment is completed, symptoms have resolved, and sexual partners have been appropriately treated. ⸻ 2. Polyp If the cause is an endometrial polyp: • Polypectomy, usually by hysteroscopic removal. ⸻ 3. Fibroid If the cause is fibroid: • Treatment depends on: • Symptoms • Size and location • Age • Fertility wishes • Whether the patient has completed her family. ⸻ 4. Endometriosis Medical Treatment Initial treatment is usually medical/hormonal, depending on symptoms and fertility wishes. Options include: • Combined oral contraceptive pill • Progestogens • Dienogest (Visanne) • LNG-IUS (Mirena) • GnRH agonists • Goserelin (Zoladex) • Danazol Zoladex (goserelin) is given subcutaneously, commonly as a monthly preparation.

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