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Dysmenorrhea
Dysmenorrhea (or
dysmenorrhoea),
cramps or
painful menstruation, involves menstrual periods that are accompanied by either
sharp, intermittent
pain or dull, aching pain, usually in the pelvis or lower abdomen.
Painful menstruation affects approximately 50% of menstruating women, and 10% are incapacitated for up to 3 days. Painful menstruation is the leading
cause of lost time from school and work among women of childbearing age. This
pain may precede menstruation by several days or may accompany it, and it
usually subsides as menstruation tapers off.
Although some
pain during menstruation is normal, excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities
or require medication. It may coexist with excessively heavy blood loss (menorrhagia).
- Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women (Wright et al. 2003). This type of pain is not related
to any specific problems with the uterus or other pelvic organs.
- Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within
or outside the uterus (for example, pelvic inflammatory disease, leiomyoma, endometriosis, adhesions, adenomyosis, uterine displacement,
or a retroverted uterus). Endometriosis is the most common cause of dysmenorrhea associated with a disease process and is frequently
misdiagnosed.
The incidence of menstrual
pain is greatest in women in their late teens and 20s, then declines with age. Some women experience increased menstrual
pain in their late 30s and 40s as their endocrine systems prepare for menopause by decreasing hormone levels and thus fertility. It does not appear
to be affected by childbearing. An estimated 10 percent to 15 percent of women experience monthly menstrual pain severe enough to prevent normal
daily function at school, work, or home.
Current Research
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Risk Factors
The majority of women will suffer this degree of dysmenorrhea at least once during their reproductive years. Increased risk is associated with
younger age, and past medical history of any of the conditions associated with secondary dysmenorrhea.
- Primary
- Nulliparity (having never given birth)
- Obesity
- Cigarette smoking
- Positive family history
- Secondary:
Primary Dysmenorrhea
Pathophysiology
Primary dysmenorrhea occurs during regular ovulatory cycles. Women with primary dysmenorrhea have increased activity of the uterine muscle with
increased contractility and increased frequency of contractions. Prostaglandins are released during menstruation due to destruction of the endometrial
cells and the resultant release of their contents.
Release of prostaglandins and other inflammatory mediators in the uterus (womb) is thought to be a major factor in primary dysmenorrhea (Wright et al.
2003). Prostaglandin levels have been found to be much higher in women with severe menstrual
pain than in women who experience mild or no menstrual
pain. Drugs which inhibit the production of prostaglandins, such as the non-steroidal anti-inflammatory drugs (NSAIDs) Naproxen, Ibuprofen and Mefenamic
Acid, can provide relief for the discomfort and other associated symptoms of excessive prostaglandin release, such as nausea, vomiting, and headache.
Clinical Features
The cramping associated with dysmenorrhea usually begins a few hours before the start of bleeding and may continue for a few days. The pain is usually
described as being in the lower abdomen, possibly radiating to the thighs and lower back. Other symptoms associated with primary dysmenorrhea are
nausea and vomiting, fatigue, diarrhea, lower backache, and headache.
Treatment
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, are very effective in the treatment of primary dysmenorrhea (Andreoli
et al. 2004). As earlier stated, their effectiveness comes from their ability to inhibit prostaglandin synthesis. However, many NSAIDs can cause
gastrointestinal upset as a side effect. Patients who cannot take most common NSAIDs may be prescribed a cyclo-oxygenase-2 (COX2) inhibitor.
Oral contraceptives are second-line therapy unless a woman is also seeking contraception, then they would become first-line therapy. Oral
contraceptives are 90% effective in improving primary dysmenorrhea and work by reducing menstrual blood volume and suppressing ovulation. It may take
up to 3 months for the oral contraceptives to become effective. Norplant and Depo-provera are also effective since these methods often induce
amenorrhea.
Alternative treatments
For the 10% of patients who do not respond to NSAIDs and/or oral contraceptives, or where use of oral contraceptives is not appropriate, a wide range
of alternative therapies have been proven effective, including transcutaneous electrical nerve stimulation (TENS), omega-3 fatty acids, transdermal
nitroglycerin, thiamine, and magnesium supplements.
In a very small double-blind, placebo-controlled study, guaifenesin reduced primary dysmenorrhea, but the effect was not significant.
Chiropractic care has been an effective treatment approach (Chapman-Smith, 2000). Treating subluxations in the spine may cause the nerves leaving the
spine to be less aggravated and so decrease symptoms of dysmenorrhea, as well as other symptoms such as chronic stomach aches and headaches. However,
the Cochrane Review of 2007-04-19 states
"Authors' conclusions: Overall there is no evidence to suggest that spinal manipulation is effective in
the treatment of primary and secondary dysmenorrhea."
Acupuncture is used to try to treat dysmenorrhea and studies have shown that it "reduced the subjective perception of dysmenorrhea" (Jun 2004).
However, the small number of studies leaves doubt about the effectiveness of acupuncture for gynaecological conditions (White 2003).
Secondary Dysmenorrhea
Pathophysiology
The mechanisms causing the
pain of secondary dysmenorrhea are varied and may or may not involve prostaglandins. Some causes of secondary dysmenorrhea
are
endometriosis, pelvic inflammation, leiomyoma, adenomyosis,
ovarian cysts, and pelvic congestions (Hacker et al. 2004). The presence of an IUD
(intrauterine device) for contraception may also be a potential cause of menstrual pain, although they usually lead to pelvic
pain only around the
time of insertion. Some women also find that use of internally-worn menstrual products, such as tampons and menstrual cups, exacerbate menstrual
cramps and
pain.
Clinical Features
The symptoms of secondary dysmenorrhea vary with the underlying cause, but generally the
pain associated with secondary dysmenorrhea is not limited
to the time around menses as with primary dysmenorrhea. Also, secondary dysmenorrhea is less related to the onset of bleeding in menstruation, is
seen in older women, and is associated with other symptoms like infertility.
Treatment
The most effective treatment of secondary dysmenorrhea is the identification and treatment of the underlying cause of the pain, although the relief
provided by NSAIDs is often helpful.
The first line of treatment is medical (e.g., prostaglandin synthetase inhibitors, hormonal contraception, danazol, progestins). If possible, the
underlying disorder or anatomic abnormality is corrected, thus relieving symptoms. Dilation of a narrow cervical os may give 3 to 6 months of relief
(and allows diagnostic curettage if needed). Myomectomy, polypectomy, or dilation and curettage may be needed. Interruption of uterine nerves by
presacral neurectomy and division of the sacrouterine ligaments may help selected patients. Hypnosis may be useful.
Endometriosis is a common cause of secondary dysmenorrhea. In fact, approximately 24% of women who complain of pelvic pain are subsequently found to
have
endometriosis. This condition is often associated with infertility. If pain relief is the goal, medical options include hormonal contraception,
danazol, progestational agents, and GnRH agonists.
Related Problems
(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Dysmenorrhea)
Dysmenorrhea in Adolescents: Diagnosis and Treatment
Authors: French L.
Department of Family Medicine, University of Toledo, College of Medicine, Toledo, Ohio, USA.
Dysmenorrhea occurs in the majority of adolescent girls and is the leading cause of recurrent short-term school absence in this group. In the vast
majority of cases, a presumptive diagnosis of primary dysmenorrhea can be made based on a typical history of low anterior pelvic
pain coinciding with
the onset of menses and lasting 1-3 days with a negative physical examination. Risk factors for primary dysmenorrhea include nulliparity, heavy menstrual
flow, and smoking. Poor mental health and social supports are other associations. Empiric therapy for primary dysmenorrhea can be initiated without
diagnostic testing. Effective therapies include NSAIDs, oral contraceptives, and pharmacologic suppression of menstrual cycles. In atypical, severe, or
refractory cases, imaging and/or laparoscopy should be performed to investigate secondary causes of dysmenorrhea. The most common cause of secondary
dysmenorrhea is
endometriosis, the treatment of which may include medical and surgical approaches. Pharmacologic treatment of young women with pain
related to
endometriosis is similar to treatment of primary dysmenorrhea but may infrequently include gonadotropin-releasing hormone agonists in severe
refractory cases.
Journal: Paediatr Drugs. 2008;10(1):1-7.
Adapted from PubMed; click here to access full journal article.
Membranous Dysmenorrhea: A Case Series
Authors: Omar HA, Smith SJ.
Division of Adolescent Medicine, Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA. haomar2@ uky.edu
The purpose was to illustrate the variability of hormonal contraception of patients that presented with membranous dysmenorrheal. A case analysis
chart review was completed on six patients referred to a Pediatric Gynecologist in an academic setting. In each case the patient underwent a thorough
pelvic and bimanual exam. Following the initial presentation, each patient continued to be followed on a regular visits. Cases: Two were using the
transdermal contraceptive patch and oral contraceptive, but following the expulsion of decidual cast, they were both placed on depot medroxyprogesterone
acetate (DMPA) without further complications. Three of the six cases were on DMPA prior to the similar occurrence of membranous dysmenorrheal and
following this incident, continued on DMPA without further problems. The final case was on the transdermal patch prior to decidual cast expulsion and
remained on this form of hormonal contraception without further complications. These cases indicate that membranous dysmenorrheal is not limited to
the use of DMPA.
Journal: ScientificWorldJournal. 2007 Nov 26;7:1900-3.
Adapted from PubMed; click here to access full journal article.
Behavioural Interventions for Primary and Secondary Dysmenorrhoea
Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM.
BACKGROUND: Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition with
considerable morbidity. The behavioural approach assumes that psychological and environmental factors interact with, and influence, physiological
processes. Behavioural interventions for dysmenorrhoea may include both physical and cognitive procedures and focus on both physical and psychological
coping strategies for dysmenorrhoeic symptoms rather than modification of any underlying organic pathology. OBJECTIVES: To determine the effectiveness
of any behavioural interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or
conventional medical treatments for example non-steroidal anti-inflammatory drugs (NSAIDs). SEARCH STRATEGY: We searched the Cochrane Menstrual
Disorders and Subfertility Group Trials Register (searched April 2005), Cochrane Central Register of Controlled Trials (CENTRAL on The Cochrane Library,
Issue 2, 2005), MEDLINE (1966 to April 2005), EMBASE (1980 to April 2005), Social Sciences Index (1980 to April 2005), PsycINFO (1972 to April 2005)
and CINAHL (1982 to April 2005) and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials comparing behavioural interventions
with placebo or other interventions in women with dysmenorrhoea. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and
extracted data. MAIN RESULTS: Five trials involving 213 women were included.Behavioural intervention vs control: One trial of
pain management training
reported reduction in pain and symptoms compared to a control. Three trials of relaxation compared to control reported varied results, two trials
showed no difference in symptom severity scores however one trial reported relaxation was effective for reducing symptoms in menstrual sufferers with
spasmodic symptoms. Two trials reported less restriction in daily activities following treatment with either relaxation of pain management training
compared to a control. One trial also reported less time absent from school following treatment wit pain management training compared to a control.
Behavioural intervention vs other behavioural interventions: Three trials showed no difference between behavioural interventions for the outcome of
improvement in symptoms. One trial showed that relaxation resulted in a decrease in the need for resting time compared to the relaxation and imagery.
AUTHORS' CONCLUSIONS: There is some evidence from five RCTs that behavioural interventions may be effective for dysmenorrhoea however results should be
viewed with caution as they varied greatly between trials due to inconsistency in the reporting of data, small trial size, poor methodological quality
and age of the trials.
Journal: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002248.
Adapted from PubMed; click here to access full journal article.
Zinc Treatment Prevents Dysmenorrhea
Authors: Eby GA
George Eby Research, 14909-C Fitzhugh Road, Austin, TX 78736, United States
Primary dysmenorrhea, menstrual cramps in otherwise well women, produces mild to debilitating cramping of the uterus. More than half, and by some
estimates 90% of all American women experience menstrual cramps during the first several days of menstruation. About one in ten women are unable to
perform their normal routine for one to three days each menstrual cycle due to severe uterine cramping. Although the uterus contracts and relaxes
routinely, during menstruation the contractions are much stronger producing
pain and "cramps". Women with dysmenorrhea have high levels of prostaglandins,
hormones believed to cause menstrual cramping. Prostaglandins are believed to temporarily reduce or stop blood supply to the uterus, thus depriving the
uterus of oxygen resulting in contractions and pain. One would expect zinc, like the non-steroidal anti-inflammatory drugs used to treat cramping, to
reduce the production of prostaglandins. Zinc inhibits the metabolism of prostaglandins ruling out this mechanism of action, suggesting erroneously
that zinc deficiency would prevent cramping. However, it is shown by case histories that zinc, in 1-3 30-mg doses given daily for one to four days prior
to onset of menses, prevents essentially all to all warning of menses and all menstrual cramping. One hypothesis for a mechanism of action is that a
precursor (COX-2) or metabolite of prostaglandins causes menstrual cramping and not prostaglandins themselves. Another hypothesis is that zinc has
antioxidant and anti-inflammatory actions in the uterus. Improvement in micro-vessel circulation by zinc may help prevent cramping and pain. In patients
consuming 31 mg of zinc per day, premenstrual tension (PMT) symptoms did not occur, while in patients consuming 15 mg of zinc, PMT symptoms did occur
(P<0.001). Protocols using 30 mg of zinc once to three times a day for one to four days immediately prior to menses to prevent dysmenorrhea are described
and they are recommended for additional study. The side effect from the absence of all warning of pending menses due to zinc treatment was concern of
possible pregnancy. The United States RDA for zinc appears to be too low to optimize women's health and prevent menstrual cramps.
Journal: Med Hypotheses. 2007;69(2):297-301. Epub 2007 Feb 7.
Adapted from PubMed; click here to access full journal article.
Dysmenorrhea in Adolescents and Young Adults: Etiology and Management
Authors: Harel Z
Associate Professor of Pediatrics, Division of Adolescent Medicine/Hasbro Children's Hospital and Department of Pediatrics, Brown University, Providence,
Rhode Island 02903, USA. Zharel@Lifespan.org
Dysmenorrhea is the most common gynecologic complaint among adolescent and young adult females. Dysmenorrhea in adolescents and young adults is usually
primary (functional), and is associated with normal ovulatory cycles and with no pelvic pathology. In approximately 10% of adolescents and young adults
with severe dysmenorrhea symptoms, pelvic abnormalities such as
endometriosis or uterine anomalies may be found. Potent prostaglandins and potent
leukotrienes play an important role in generating dysmenorrhea symptoms. Nonsteroidal anti-inflammatory drugs (NSAID) are the most common pharmacologic
treatment for dysmenorrhea. Adolescents and young adults with symptoms that do not respond to treatment with NSAIDs for 3 menstrual periods should be
offered combined estrogen/progestin oral contraceptive pills for 3 menstrual cycles. Adolescents and young adults with dysmenorrhea who do not respond
to this treatment should be evaluated for secondary causes of dysmenorrhea. The care provider's role is to explain about pathophysiology of dysmenorrhea
to every adolescent and young adult female, address any concern that the patient has about her menstrual period, and review effective treatment options
for dysmenorrhea with the patient.
Journal: J Pediatr Adolesc Gynecol. 2006 Dec;19(6):363-71.
Adapted from PubMed; click here to access full journal article.
Dysmenorrhoea
Authors: Reddish S.
The Jean Hailes Medical Centre for Women's Health, Victoria. sue.reddish@jeanhailes.org.au
BACKGROUND: Menstruation has dual significance for women. From one perspective it defines the start and end of reproductive potential, an affirmation of
womanhood. On the other, just as the ancients observed taboos of menstruation, many women (and men) today are still influenced by outdated negative
messages. OBJECTIVE: This article discusses an approach to assessment and management of dysmenorrhoea that considers the cultural, social and personal
significance of symptoms and management choices. DISCUSSION: Cultural influences, such as a woman's status within society, her life stage, religion,
education and employment, determine whether a woman seeks medical help for menstrual problems, and the personal significance of dysmenorrhoea. Assessment
involves consideration of
pain, associated symptoms, effect on lifestyle and activities of daily living, and a psychosocial and cultural assessment.
Management involves specific treatment of underlying pathology, psychosocial support and individualising treatment according to impact of the pain,
associated symptoms, reproductive stage, cost, and the woman's personal values and attitudes.
Journal: Aust Fam Physician. 2006 Nov;35(11):842-4, 846-9.
Adapted from PubMed; click here to access full journal article.
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