Dysmenorrhea

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Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Dysmenorrhea from other Diseases
Epidemiology and Demographics
Risk Factors
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
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Case #1
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sai Rohit Reddy, M.B.B.S.

Synonyms and Keywords: Dysmenorrhoea; menstrual cramps; menorrhalgia; menstrual pain

Classification

The two types of dysmenorrhea are:

• Primary or spasmodic dysmenorrhea
• Secondary or congestive dysmenorrhea

Primary Dysmenorrhea

• Lower abdominal pain that occurs during a menstrual cycle and is not associated with any pelvic pathology
• Usually disappears in women by pregnancy or in late 20's

Secondary Dysmenorrhea

• Lower abdominal pain that occurs during a menstrual cycle and is associated with pathologies inside and outside the uterus
• Usually prevelant over 20's

Pathophysiology

Primary Dysmenorrhea

The pathophysiology of primary dysmenorrhea has not been clearly established for a long period of time. But it is believed to be due to increased prostaglandin and eicosanoid production. The increased prostaglandin production leads to increased myometrial contractibility, inturn leading to ischaemia and hypoxia. As compared to proliferative endometrium, secretory endometrium has been linked to raised progesterone levels. The increase in these hormone levels plays a key effect in prostaglandin production and its consequent effects. Some preliminary studies suggest that an increase in vasopressin levels without an increase in oxytocin is believed to cause stronger uterine contractions leading to decrease in the uterine blood supply.

Secondary Dysmenorrhea

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.

Causes

Primary Dysmenorrhea

• Uterine contractions caused by high prostaglandin concentration, inturn causing shedding of the endometrial lining.

Secondary Dysmenorrhea

• Intramural Causes:
  • Leiomyoma
  • Adenomyosis

• Extrauterine Causes:
  • Endometriosis

• Intrauterine causes:
  • Leiomyomata
  • Polyps
  • IUDs
  • Infection
  • Cervical Stenosis
  • Other cervical lesions

• Other less common causes:
  • Adhesions
  • Ectopic pregnancy
  • Spontaneous abortion
  • Pelvic Inflammatory Disease
  • Pelvic congestion Syndrome
  • Ovarian cysts
  • Allen Masters Syndrome
  • Obstructive malformations of uterine tract
  • Psychogenic
  • Nongynaecological causes

Risk Factors

A number of biological, lifestyle, social and psychological factors have been associated with dysmenorrhea.

• Biological factors such as early age at menarche (<12 years), nulliparity, family history of dysmenorrhea and heavier menstrual flow.
• Psychological factors such as stress, depression and anxiety.
• Lifestyle factors such as smoking, alcohol consumption, physical inactivity, raised BMI levels and inadequate/irregular diet.
• Social factors such as lack of support, education and marital status

However, oral contraceptive pills have been shown to have an inverse effect on the severity of dysmenorrhea.

Natural History, Complications and Prognosis

Although dysmenorrhea has a good prognosis, it is associated with frequent abseentism and poor quality of life, daily living & work productivity.

Diagnosis

History and Symptoms

While taking history of present illness one should ask for complete menstrual history, including age at onset of menses, time between menses, variability in timing, duration and amount of flow, relation of menses to the symptoms, degree of disruption to life, effect on sexual activity, presence of pelvic pain unrelated to menses, nature and severity & response to NSAIDs or acetaminophen.

• Proper medical, surgical, sexual and past history should also be elicited to evaluate further the secondary causes of dysmenorrhea
  • Past medical history should identify endometriosis, adenomyosis, or fibroids. Method of contraception should be also ascertained, specifically IUD use.
  • Past surgical history should identify procedures increasing the risk of dysmenorrhea, such as endometrial ablation and cervical conization.
  • Sexual history should include previous or current history of sexual abuse or any other traumatic events.

Dysmenorrhea has been associated with an increased pain before or during menstruation. It is also associated with a varied number of symptoms such as:

• Nausea and Vomiting
• Fatigue
• Insomnia
• Dizziness
• Diarrhea
• Bloating
• Sweating
• Tremulousness
• Lower back pain
• Urinary frequency

Secondary Dysmenorrhea

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.

Physical Examination

Helps to evaluate the causes of secondary dysmenorrhea. The vulva, vagina and cervix are inspected for lesions and masses protruding through the cervical os. Structures are also palpated to look for a tight cervical os, prolapsed polyp or fibroid, uterine or adnexal mass, thickening of the rectovaginal septum, induration of the cul-de-sac, and nodularity of the uterosacral ligament.

The following findings are of particular concern during a proper physical examination:

• New or sudden-onset pain
• Unremitting pain
• Fever
• Vaginal discharge
• Evidence of peritonitis

Laboratory Findings

Testing should be done to exclude structural gynecologic disorders. Mostly patients should have:

• Pregnancy testing using serum or urine beta hcg
  • Both intrauterine and ectopic pregnancies can be ruled out
• Cervical cultures and NAAT can be done to rule out infectious causes of secondary dysmenorrhea

Ultrasound

Pelvic ultrasonography is highly sensitive to not only exclude pregnancy but also detect pelvic masses such as ovarian cysts, fibroids, endometriosis, uterine adenomyosis. In addition, It aids in visualising lost and abnormally located IUDs.

Other Imaging Findings

• If other tests have been done and the results are inconclusive or the symptoms still persist one can resort to doing the following tests:
  • Hysterosalpingography or sonohysterography that can visualise endometrial polyps, fibroids, or other congenital abnormalities
  • MRI to aid in visualising other congenital abnormalities, or if a surgery is planned, it helps to further define previously identified abnormalities
  • IV pyelography to be used only if a uterine malformation has been identified to be causing dysmenorrhea

Other Diagnostic Studies

If results of all the above tests are inconclusive, laparoscopy or hysteroscopy should be done. Laparoscopy is the most definitive test since it helps to directly examine all of the pelvis, reproductive organs and visualise any abnormalities.

Treatment

Women with primary dysmenorrhea are reassured about the absence of structural gynecologic disorders.

Medical Therapy

Symptomatic treatment of dysmenorrhea includes adequate rest and sleep and regular exercise. In addition, low-fat diet and nutritional supplements, such as omega-3 fatty acids, flaxseed, magnesium, vitamin B1, vitamin E, and zinc, have known to be potentially effective.

Primary Dysmenorrhea

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, a wide range of alternative therapies have been proven effective, including transcutaneous electrical nerve stimulation (TENS), acupuncture, omega-3 fatty acids, transdermal nitroglycerin, thiamine, and magnesium supplements.

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 [1] states "Authors' conclusions: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhea."

Accupuncture 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

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.

Future or Investigational Therapies

Hypnosis is being evaluated as treatment. Other proposed therapies, including acupuncture, acupressure, chiropractic therapy, and transcutaneous electrical nerve stimulation, have not been well-studied but may benefit some patients.

For intractable pain of unknown origin, laparoscopic presacral neurectomy or uterosacral nerve ablation has been efficacious in some patients for as long as 12 months.

Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy

Case Studies

Case #1

Related Chapters

• Premenstrual syndrome (PMS)
• Stress and anxiety
• Pelvic inflammatory disease
• Adenomyosis
• History of sexual or physical abuse
• Leiomyoma
• Ovarian cysts
• Endometriosis

References

• Andreoli, Thomas E., Charles C. J. Carpenter, Robert C. Griggs, and Joseph Loscalzo. CECIL Essentials of Medicine, 6th ed. Saunders, 2004. ISBN 0-7216-0147-2
• Chapman-Smith, David A. "The Chiropractic Profession." NCMIC Group Inc., 2000. ISBN 1-892734-02-8
• Hacker, Neville F., J. George Moore, and Joseph C. Gambone. Essentials of Obstetrics and Gynecology, 4th ed. Elsevier Saunders, 2004. ISBN 0-7216-0179-0
• Jun E (2004). "[Effects of SP-6 acupressure on dysmenorrhea, skin temperature of CV2 acupoint and temperature, in the college students]". Taehan Kanho Hakhoe Chi. 34 (7): 1343–50. PMID 15687775.
• Proctor M, Hing W, Johnson T, Murphy P (2006). "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev. 3: CD002119. PMID 16855988. CS1 maint: Multiple names: authors list (link)
• White A (2003). "A review of controlled trials of acupuncture for women's reproductive health care". J Fam Plann Reprod Health Care. 29 (4): 233–6. PMID 14662058.
• Wright, Jason and Solange Wyatt. The Washington Manual Obstetrics and Gynecology Survival Guide. Lippincott Williams and Wilkins, 2003. ISBN 0-7817-4363-X

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