【病例学习第10期】Menstrual Pain（痛经）

From Pharmacy Times(www.pharmacytimes.com)
Thanks to the author Craig I. Coleman, PharmD(Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.)

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Menstrual Pain

PN comes to the counter seeking advice with his 14-year-old daughter who has been experiencing dull pain in her lower abdomen. PN brings aspirin, ibuprofen, and acetaminophen to the counter and asks which is best for his daughter. The daughter mumbles something about her friend using Midol and wonders if that would be better. Upon questioning by the pharmacist, the daughter states that her period started yesterday and that this “crampy” pain is worse during the first 2 days of her period. She also notes that she is not sexually active and that similar symptoms have occurred right around the time of her period for the last 4 months.

What advice should the pharmacist provide?


ANSWER
Based upon her symptoms (continuous, dull pain and cramping occurring at the onset of menstruation and lasting up to 72 hours), the daughter is likely suffering from primary dysmenorrhea. Although the exact cause of primary dysmenorrhea is unclear, it is thought to be associated with elevated prostaglandin levels, which cause strong uterine contractions, significant vasoconstriction, and pain. Whereas primary dysmenorrhea can be treated with aspirin, acetaminophen, or nonsteroidal antiinflammatory drugs, the latter class is most efficacious, likely as a result of its superior ability to inhibit arachidonic acid production of prostaglandins. In addition, aspirin should not be used in patients <18 years of age, due to the risk of Reye’s syndrome. Therefore, ibuprofen 200 to 400 mg every 4 to 6 hours (maximum: 1200 mg/day) taken on a schedule (not as needed) would be the best choice for this patient. Nonpharmacologic recommendations may include topical heat and regular exercise.

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PN的14岁小女儿感到下腹部隐痛，他们一起来到柜台进行用药咨询。PN带了阿司匹林、布洛芬和对乙酰氨基酚，他想知道哪一种药最适合于他的女儿。这个女孩说了一些她的朋友使用Midol（一种止痛药，主要成份布洛芬）的情况，并且想知道是否这个药的疗效更好。药师进一步询问了她的病情，女孩说她的经期从昨天开始，经期开始2天腹痛较重。她说没有过性生活，且相似的症状前四个月的经期也出现过。

答案

根据女孩的症状(持续的、隐痛、在月经开始时出现、持续72小时)描述，女孩应该是原发性痛经。尽管原发性痛经的确切病因不清楚，但是它与前列腺素水平升高有关，前列腺素可使大血管及子宫强烈收缩，而引起疼痛。虽然阿司匹林、对乙酰氨基酚或者非甾体抗炎药都可以治疗原发性痛经，但后一类最有效，这可能与其抑制花生四烯酸，从而减少前列腺素的生成有关。另外，阿司匹林不能用于18岁以下患者，它可能引起“雷尔氏综合征”。因此，对于这位患者最好的选择是，布洛芬200-400mg，每隔4-6小时按时服用（必要时）。建议可以局部加热并且经常锻炼。

PN 带着他14岁的女儿----一个下腹疼痛的女孩来到药店。PN带来了阿司匹林，布洛芬和对乙酰氨基酚，问哪种适合他女儿。根据药师的提问，他女儿说她的例假从昨天开始，而这种“绞痛”在刚开始的两天更严重。她也讲到她并不觉得性激动，而同样的症状大概在最近4个月例假期都有发生。
根据她的症状（持续的，钝痛和绞痛在例假一开始就出现且持续到72小时），这个女孩儿似乎得了原发性痛经。虽然原发性痛经的确切原因还不明，但它与前列腺水平的升高有关。前列腺水平升高导致子宫收缩，明显的血管收缩，和痛苦发生。治疗原发性痛经可以用阿司匹林，对乙酰氨基酚和非甾体类抗炎药，最后一种是比较有效的，因为此类药最显著的功能就是阻断花生四烯酸，使前列腺素不能生成。而且，为了预防雷氏综合征，阿司匹林不用于18岁以下。所以，布洛芬200-400mg，q4--6h（最大每日不超过1200mg）按时服用（而不是按需服用），这是对这个病人最好的选择。药师建议不适用于局部发热和常规运动的情况。

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