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月経困難症、月経痛

著者: 岩佐弘一 医療法人イワサクリニック

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2021/02/03
参考ガイドライン:
  1. 日本産科婦人科学会/日本産婦人科医会:産婦人科診療ガイドライン 婦人科外来編 2020 
患者向け説明資料

概要・推奨   

  1. 強い月経痛を訴える若年患者に対しては、まず機能性月経困難症と子宮内膜症などによる器質性月経困難症を疑い鑑別診断を行うことが勧められる(推奨度1)。
  1. 機能性月経困難症の治療として下記のうち適切なものを使用する。
  1. 鎮痛薬(NSAIDsなど)、低用量エストロゲン・プロゲスチン配合薬(LEP)、またはレボノルゲストレル放出子宮内システム(LNG-IUS)を使用する(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
岩佐弘一 : 特に申告事項無し[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

改訂のポイント:
  1. 2014年にレボノルゲストレル放出子宮内システム(LNG-IUS)が、2020年にジエノゲストが月経困難症治療剤として保険適用となった。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 月経困難症とは月経期間中に月経に随伴して起こる病的症状であり、機能性と器質性に大別できる[1]
  1. 下腹痛、腰痛、腹部膨満感、嘔気、頭痛、疲労・脱力感、食欲不振、いらいら、下痢、憂うつの順に多い[1]
  1. 機能性月経困難症の原因は頸管狭小やプロスタグランジン(PG)などの内因性生理活性物質による子宮の過収縮である[2]
  1. 器質性月経困難症は子宮内膜症、子宮腺筋症、子宮筋腫などの器質的疾患に伴う。
  1. 就学・就業など日常生活に多大な支障を来す。就業女性の1/4以上が強い月経痛を訴える。若年女性で月経痛の程度が重い[3]
問診・診察のポイント  
 
  1. 発症時期・年齢、痛みの時期・持続の問診は機能性月経困難症と器質性月経困難症の鑑別上、特に重要である。
  1. 加齢に伴い症状が軽快したか悪化したか、また分娩により症状が軽快したかどうか問診する。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

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文献 

著者: Chooi L Wong, Cindy Farquhar, Helen Roberts, Michelle Proctor
雑誌名: Cochrane Database Syst Rev. 2009 Oct 7;(4):CD002120. doi: 10.1002/14651858.CD002120.pub3. Epub 2009 Oct 7.
Abstract/Text BACKGROUND: Dysmenorrhoea (painful menstrual cramps) is common. Combined OCPs are recommended in the management of primary dysmenorrhoea.
OBJECTIVES: To determine the effectiveness and safety of combined oral contraceptive pills for the management of primary dysmenorrhoea.
SEARCH STRATEGY: We conducted electronic searches for randomised controlled trials (RCTs) in the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials CENTRAL, CCTR, MEDLINE, EMBASE, and CINAHL (first conducted in 2001, updated on 5 November 2008).
SELECTION CRITERIA: RCTs comparing all combined OCPs with other combined OCPs, placebo, no management, or management with nonsteroidal anti-inflammatories (NSAIDs) were considered.
DATA COLLECTION AND ANALYSIS: Twenty three studies were identified and ten were included. Six compared the combined OCP with placebo and four compared different dosages of combined OCP.
MAIN RESULTS: One study of low dose oestrogen and four studies of medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement. For the outcome of pain relief across the different OCPs the pooled OR suggested benefit with OCPs compared to placebo (7 RCTs: Peto OR 2.01 [95% CI 1.32, 3.08]).The Chi-squared test for heterogeneity showed there is significant heterogeneity with an I(2) statistic of 64% and a significant chi-square test (14.06, df=5, p=0.02). A sensitivity analysis removing the studies with inadequate allocation concealment suggested significant benefit of treatment with the pooled OR of 2.99 (95% CI 1.76, 5.07) and heterogeneity no longer statistically significant and I(2) statistic of 0%.Three studies reported adverse effects (Davis 2005; Hendrix 2002; GPRG 1968) The adverse effects were nausea, headaches and weight gain. Two studies reported if women experienced any side effect and no evidence of an effect was found (3 RCTs: OR = 1.45 (95% 0.71, 2.94). There was no evidence of statistical heterogeneity.There were no studies identified that compared combined OCP versus non steroidal anti-inflammatory drugsThere was no evidence of a difference for the pooled studies for 3rd generation pro gestagens (OR = 1.11 (95% CI 0.79 - 1.57)). For the 2nd generation versus 3rd generation the OR was 0.44 (95% CI 0.23-0.84) suggesting benefit of the 3rd generation OCP but this was for a single study (Winkler 2003).
AUTHORS' CONCLUSIONS: There is limited evidence for pain improvement with the use of the OCP (both low and medium dose oestrogen) in women with dysmenorrhoea. There is no evidence of a difference between different OCP preparations.

PMID 19821293  Cochrane Database Syst Rev. 2009 Oct 7;(4):CD002120. do・・・
著者: J Marjoribanks, M L Proctor, C Farquhar
雑誌名: Cochrane Database Syst Rev. 2003;(4):CD001751. doi: 10.1002/14651858.CD001751.
Abstract/Text BACKGROUND: Dysmenorrhoea is a common gynaecological complaint consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs which act by blocking prostaglandin production.
OBJECTIVES: The purpose of this review is to compare all nonsteroidal anti-inflammatory drugs used in the treatment of primary dysmenorrhoea with placebo, with paracetamol and with each other to evaluate their effectiveness and safety.
SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (11 April 2003), Cochrane Central Register of Controlled Trials (1st quarter 2003), MEDLINE (1966-April 2003), and EMBASE (1980 - Week 15 2003). Attempts were also made to identify trials from the National Research Register and the Clinical Trials Register. Citation lists of relevant publications, review articles, abstracts of major scientific meetings and included studies were also searched.
SELECTION CRITERIA: All randomised controlled comparisons of NSAID therapies versus placebo, versus other NSAIDs or versus paracetamol when used to treat primary dysmenorrhoea.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Crossover trial data were presented in additional tables and other data were summarised descriptively.
MAIN RESULTS: In women with dysmenorrhoea, NSAIDs were found significantly more effective for pain relief than placebo (OR 7.91, 95% CI 5.65 to 11.09), though overall adverse effects were also significantly more common (OR 1.52 95% CI 1.09 to 2.12). When NSAIDs were compared with each other or with paracetamol, there was little evidence of the superiority of any individual NSAID with regard to either efficacy or safety. However the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials, most of which were unsuitable for meta-analysis.
REVIEWER'S CONCLUSIONS: NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the most safe and effective for the treatment of dysmenorrhoea.

PMID 14583938  Cochrane Database Syst Rev. 2003;(4):CD001751. doi: 10.・・・
著者: Tasuku Harada, Mikio Momoeda, Yuji Taketani, Hiroshi Hoshiai, Naoki Terakawa
雑誌名: Fertil Steril. 2008 Nov;90(5):1583-8. doi: 10.1016/j.fertnstert.2007.08.051. Epub 2007 Dec 27.
Abstract/Text OBJECTIVE: To evaluate the efficacy of a low-dose oral contraceptive pill (OCP) for patients with dysmenorrhea associated with endometriosis.
DESIGN: A double-blind, randomized, placebo-controlled trial.
SETTINGS: Clinical trial sites in Japan.
PATIENT(S): One hundred patients with dysmenorrhea associated with endometriosis. Most enrolled patients had radiologic evidence of endometriosis rather than surgical diagnosis.
INTERVENTION(S): Patients were randomly assigned to receive either monophasic OCP (ethinylestradiol plus norethisterone) or placebo. Participants used their usual pain medications as needed during the trial.
MAIN OUTCOME MEASURE(S): After four cyclic treatments, we used a zero- to three-point verbal rating scale and a visual analogue scale to measure the severity of disability because of dysmenorrhea in daily life, and the patients' use of analgesics.
RESULT(S): Total dysmenorrhea scores assessed by the verbal rating scale were significantly decreased at the end of treatment in both groups. From the first cycle through the end of treatment, dysmenorrhea in the OCP group was significantly milder than in the placebo group. Nonmenstrual pelvic pain was present at baseline in 24.5% (12 of 49) of the OCP group and 34.0% (16 of 47) of the placebo group. The volume of endometrioma (larger than 3 cm in diameter) was significantly decreased in the OCP group, but not in the placebo group. No serious adverse events related to using OCPs occurred.
CONCLUSION(S): The present study clearly demonstrated for the first time that OCPs could be used to effectively and safely treat pain associated with endometriosis.

PMID 18164001  Fertil Steril. 2008 Nov;90(5):1583-8. doi: 10.1016/j.fe・・・
著者: Philip C Hannaford, Sivasubramaniam Selvaraj, Alison M Elliott, Valerie Angus, Lisa Iversen, Amanda J Lee
雑誌名: BMJ. 2007 Sep 29;335(7621):651. doi: 10.1136/bmj.39289.649410.55. Epub 2007 Sep 11.
Abstract/Text OBJECTIVE: To examine the absolute risks or benefits on cancer associated with oral contraception, using incident data.
DESIGN: Inception cohort study.
SETTING: Royal College of General Practitioners' oral contraception study.
PARTICIPANTS: Directly standardised data from the Royal College of General Practitioners' oral contraception study.
MAIN OUTCOME MEASURES: Adjusted relative risks between never and ever users of oral contraceptives for different types of cancer, main gynaecological cancers combined, and any cancer. Standardisation variables were age, smoking, parity, social class, and (for the general practitioner observation dataset) hormone replacement therapy. Subgroup analyses examined whether the relative risks changed with user characteristics, duration of oral contraception usage, and time since last use of oral contraception.
RESULTS: The main dataset contained about 339,000 woman years of observation for never users and 744,000 woman years for ever users. Compared with never users ever users had statistically significant lower rates of cancers of the large bowel or rectum, uterine body, and ovaries, tumours of unknown site, and other malignancies; main gynaecological cancers combined; and any cancer. The relative risk for any cancer in the smaller general practitioner observation dataset was not significantly reduced. Statistically significant trends of increasing risk of cervical and central nervous system or pituitary cancer, and decreasing risk of uterine body and ovarian malignancies, were seen with increasing duration of oral contraceptive use. Reduced relative risk estimates were observed for ovarian and uterine body cancer many years after stopping oral contraception, although some were not statistically significant. The estimated absolute rate reduction of any cancer among ever users was 45 or 10 per 100,000 woman years, depending on whether the main or general practitioner observation dataset was used.
CONCLUSION: In this UK cohort, oral contraception was not associated with an overall increased risk of cancer; indeed it may even produce a net public health gain. The balance of cancer risks and benefits, however, may vary internationally, depending on patterns of oral contraception usage and the incidence of different cancers.

PMID 17855280  BMJ. 2007 Sep 29;335(7621):651. doi: 10.1136/bmj.39289.・・・

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