Dysmenorrhea: Causes, Symptoms, and Effective Management Strategies

                 DYSMENORRHEA (Painfull menstruation)

Definition

Dysmenorrhea literally means painful menstruation.

But a more realistic and practical definition

includes cases of painful menstruation of

sufficient magnitude so as to incapacitate

day-to-day activities.

           Severe Pain during menstruation (DYSMENORRHEA)

Types:

  Primary.          Secondary

             Types of dysmenorrhea

(1) PRIMARY DYSMENORRHEA (Spasmodic)

The primary dysmenorrhea is one where there is no

identifiable pelvic pathology.

Incidence: The incidence of primary dysmenorrhea

of sufficient magnitude with incapacitation is about

15–20 percent. With the advent of oral contraceptives

and non-steroidal anti-inflammatory drugs, there is

marked relief of the symptom.

Causes of pain

 The mechanism of initiation of

uterine pain in primary dysmenorrhea is difficult to

establish. But the following are too often related.

 Mostly confined to adolescents.

 Almost always confined to ovulatory cycles.

 The pain is usually cured following pregnancy

and vaginal delivery.

 The pain is related to dysrhythmic uterine

contractions and uterine hypoxia.

              Causes of dysmenorrhea 

1. Psychosomatic factors.

2. Abnormal anatomical and functional aspect

of myometrium.

3. Imbalance in the autonomic nervous control

of uterine muscle.

4. Role of prostaglandins

5. Role of vasopressin

6. Endothelins

7. Platelet activating factor (PAF)

Patient profile:

 Primary dysmenorrhea is pre-

dominantly confined to adolescent girls. It usually

appears within 2 years of menarche. The mother or

her sister may be dysmenorrheic. It is more common

amongst girls from affluent society.

Clinical features:

 The pain begins a few hours before

or just with the onset of menstruation. The severity

of pain usually lasts for few hours, may extend to

24 hours but seldom persists beyond 48 hours. The

pain is spasmodic and confined to lower abdomen;

          Symptoms of dysmenorrhea 

may radiate to the back and medial aspect of thighs.

Systemic discomforts like nausea, vomiting, fatigue,

diarrhea, headache and tachycardia may be associated.

It may be accompanied by vasomotor changes

causing pallor, cold sweats and occasional fainting.

Rarely, syncope and collapse in severe cases may be

associated.

Treatment: 

General measures include improvement

of general health and simple psychotherapy in terms of

explanation and assurance. Usual activities including

sports are to be continued.

Severe cases: 

™ Drugs ™ Surgery

Drugs: The drugs used are —

 Prostaglandin synthetase inhibitors.

 Oral contraceptives (combined estrogen and

progestogen).

           Medicine of dysmenorrhea 

Prostaglandin synthetase inhibitors (PSI)

These drugs not only reduce the prostaglandin

synthesis (by inhibition of cyclo-oxygenase enzyme)

but also have a direct analgesic effect. Intrauterine

pressure is reduced significantly. Any of the pre-

parations listed in the table can be used orally for 2–3

days starting with the onset of period. The drug should

be continued for 3–6 cycles.

 COMMONLY USED NSAIDs

™ Fenamate group — mefanamic acid 250–500 mg

8 hourly or flufenamic acid 100–200 mg 8 hourly.

™ Propionic acid derivatives — ibuprofen 400 mg 8

hourly or naproxen 250 mg 6 hourly.

™ Indomethacin 25 mg 8 hourly.

Newer drugs NSAIDs inhibit two

different isoforms of the enzyme cyclo-oxygenase:

COX–1 and COX–2. Selective inhibitors of the

enzyme COX-2 may have similar analgesic efficacy

but fewer side effects.

Transdermal use of smooth muscle relaxant gly-

ceryl trinitrate is also used currently.

The suitable cases are—comparatively young

age and having contraindications to ‘pill’. The

contraindications of its use include allergy to aspirin,

gastric ulceration and history of asthma.

Oral contraceptive pills: The suitable candidates

are patients (i) wanting contraceptive precaution,

(ii) with heavy periods and (iii) unresponsive or

contraindications to anti-prostaglandin drugs. The pill

should be used for 3–6 cycles.

Dydrogesterone: It does not inhibit ovulation but

probably interferes with ovarian steroidogenesis. The

drug should be taken from day 5 of a cycle for 20 days.

It should be continued for 3–6 cycles.

Surgery: Transcutaneous electrical nerve stimu-

lation (TENS) has been used to relieve dysmenorrhea.

Results are not better than that of analgesics.

Surgical procedures: Laparoscopic uterine nerve

ablation (LUNA) for primary dysmenorrhea has

not been found beneficial. Laparoscopic presacral

neurectomy is done to cut down the sensory

pathways (via T11–T12) from the uterus. It is not

helpful for adnexal pain (T9

–T10) as it is carried

out by thoracic autonomic nerves along the ovarian

vessels. As such its role in true dysmenorrhea is

questionable.

Dilatation of cervical canal: It is done under anesthesia

for slow dilatation of the cervix to relieve pain by damaging the sensory nerve endings. It is not commonly

done. Late sequela may be cervical incompetence.

SECONDARY DYSMENORRHEA

(Congestive)

Secondary dysmenorrhea is normally considered to

be menstruation — associated pain occurring in the

presence of pelvic pathology.

Causes of pain: The pain may be related to increasing

tension in the pelvic tissues due to pre-menstrual pelvic

congestion or increased vascularity in the pelvic organs.

Common causes of secondary dysmenorrhea:

Cervical stenosis, chronic pelvic infection, pelvic

endometriosis, pelvic adhesions, adenomyosis, uterine

fibroid, endometrial polyp, IUCD in utero and pelvic

congestion. Obstruction due to mullerian malformations

are the other causes.

Patient profile: The patients are usually in their

thirties; more often parous and unrelated to any social

status.

Clinical features: 

The pain is dull, situated in the

back and in front without any radiation. It usually

appears 3–5 days prior to the period and relieves

with the start of bleeding. The onset and duration of

pain depends on the pathology producing the pain.

There is no systemic discomfort unlike primary

dysmenorrhea. The patients may have got some

discomfort even in between periods. There are

symptoms of associated pelvic pathology.

Abdominal and vaginal examinations usually

reveal the offending lesion. At times, the lesion is

revealed by laparoscopy, hysteroscopy or laparotomy

Treatment: 

The treatment aims at the cause rather

than the symptom. The type of treatment depends on

the severity, age and parity of the patient.

Ovarian Dysmenorrhea

Right ovarian vein syndrome: Right ovarian vein

crosses the ureter at right angle. During premenst-

rual period, due to pelvic congestion or increased

blood flow, there may be marked engorgement in the

vein → pressure on ureter → stasis → infection →

pyelonephritis → pain.

CAUSES OF UNILATERAL

DYSMENORRHEA

™ ovarian dysmenorrhea

™ bicornuate uterus

™ unilateral location of pelvic endometriosis

™ small fi broid polyp near one cornu

™ right ovarian vein syndrome

~ thank you for reading ......