Dysmenorrhea
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and Keywords: Dysmenorrhoea; menstrual cramps; menorrhalgia; menstrual pain ==Overview==Sai Rohit Reddy, M.B.B.S.
Historical Perspective
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
Differentiating Dysmenorrhea from other Diseases
Epidemiology and Demographics
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
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.
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
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
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.
- 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
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
Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies
Case Studies
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. Unknown parameter
|month=ignored (help) - 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