Dysmenorrhea

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Dysmenorrhea
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Dysmenorrhea (dysmenorrhoea or painful periods) is a medical condition of pain during menstruation that interferes with daily activities, as defined by ACOG[1] and others.[2] Still, dysmenorrhea is often defined simply as menstrual pain,[3][4] or at least menstrual pain that is excessive.[5] This article uses the dysmenorrhea definition of menstrual pain that interferes with daily activities, and uses the term menstrual pain as any pain during menstruation whether it is normal or abnormal.

Menstrual pain is often used synonymously with menstrual cramps, but the latter may also refer to menstrual uterine contractions, which are generally of higher strength, duration and frequency than in the rest of the menstrual cycle.[6]

Dysmenorrhea can feature different kinds of pain, including sharp, throbbing, dull, nauseating, burning, or shooting pain. Dysmenorrhea may precede menstruation by several days or may accompany it, and it usually subsides as menstruation tapers off. Dysmenorrhea may coexist with excessively heavy blood loss, known as menorrhagia.

Secondary dysmenorrhea is diagnosed when symptoms are attributable to an underlying disease, disorder, or structural abnormality either within or outside the uterus. Primary dysmenorrhea is diagnosed when none of these are detected.

Signs and symptoms

The main symptom of dysmenorrhea is pain concentrated in the lower abdomen, in the umbilical region or the suprapubic region of the abdomen. It is also commonly felt in the right or left abdomen. It may radiate to the thighs and lower back.

Symptoms often co-occurring with menstrual pain include nausea and vomiting, diarrhea or constipation, headache, dizziness, disorientation, hypersensitivity to sound, light, smell and touch, fainting, and fatigue. Symptoms of dysmenorrhea often begin immediately following ovulation and can last until the end of menstruation. This is because dysmenorrhea is often associated with changes in hormonal levels in the body that occur with ovulation. The use of certain types of birth control pills can prevent the symptoms of dysmenorrhea, because the birth control pills stop ovulation from occurring.

Classification

Dysmenorrhea can be classified as either primary or secondary based on the absence or presence of an underlying cause. Secondary dysmenorrhea is dysmenorrhea which is associated with an existing condition.

Causes of secondary dysmenorrhea

The most common cause of secondary dysmenorrhea is endometriosis, which can be visually confirmed by laparoscopy in approximately 70% of adolescents with dysmenorrhea.[7]

Other causes of secondary dysmenorrhea include leiomyoma,[8] adenomyosis,[9] ovarian cysts, and pelvic congestion.[10]

Pathophysiology of primary dysmenorrhea

During a woman's menstrual cycle, the endometrium thickens in preparation for potential pregnancy. After ovulation, if the ovum is not fertilized and there is no pregnancy, the built-up uterine tissue is not needed and thus shed.

Molecular compounds called prostaglandins are released during menstruation, due to the destruction of the endometrial cells, and the resultant release of their contents.[11] Release of prostaglandins and other inflammatory mediators in the uterus cause the uterus to contract. These substances are thought to be a major factor in primary dysmenorrhea.[12] When the uterine muscles contract, they constrict the blood supply to the tissue of the endometrium, which, in turn, breaks down and dies. These uterine contractions continue as they squeeze the old, dead endometrial tissue through the cervix and out of the body through the vagina. These contractions, and the resulting temporary oxygen deprivation to nearby tissues, are responsible for the pain or "cramps" experienced during menstruation.

Compared with other women, women with primary dysmenorrhea have increased activity of the uterine muscle with increased contractility and increased frequency of contractions.[13]

In one research study using MRI, visible features of the uterus were compared in dysmenorrheic and eumenorrheic (normal) participants. The study concluded that in dysmenorrheic patients, visible features on cycle days 1-3 correlated with the degree of pain, and differed significantly from the control group.[14]

Diagnosis

The diagnosis of dysmenorrhea is usually made simply on a medical history of menstrual pain that interferes with daily activities. However, there is no universally accepted gold standard technique for quantifying the severity of menstrual pains.[15] Yet, there are quantification models, called menstrual symptometrics, that can be used to estimate the severity of menstrual pains as well as correlate them with pain in other parts of the body, menstrual bleeding and degree of interference with daily activities.[15]

Further work-up

Once a diagnosis of dysmenorrhea is made, further work-up is required to search for any secondary underlying cause of it, in order to be able to treat it specifically and to avoid aggravation of a perhaps serious underlying cause.

Further work-up includes a specific medical history of symptoms and menstrual cycles and a pelvic exam.[1] Based on results from these, additional exams and tests may be motivated, such as:

In some cases, laparoscopy may be required.[1]

Management

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving the pain of primary dysmenorrhea.[16] They can have side effects of nausea, dyspepsia, peptic ulcer, and diarrhea.[17] People who are unable to take the more common NSAIDs may be prescribed a COX-2 inhibitor.[18]

Hormonal contraceptives

Although use of hormonal contraception can improve or relieve symptoms of primary dysmenorrhea,[19][20] a 2001 systematic review found that no conclusions can be made about the efficacy of commonly used modern lower dose combined oral contraceptive pills for primary dysmenorrhea.[21] Norplant[22] and Depo-provera[23][24] are also effective, since these methods often induce amenorrhea. The intrauterine system (Mirena IUD) has been cited as useful in reducing symptoms of dysmenorrhea.[25]

Other

A review indicated the effectiveness of use of transdermal nitroglycerin.[26]

Alternative medicine

A number of alternative therapies have been studied in the treatment of dysmenorrhea.

One review found the effectiveness of acupressure, behavioral interventions, thiamine, vitamin E, topical heat, and transcutaneous electrical nerve stimulation is likely while the effects of acupuncture, fish oil, magnets and vitamin B12 is unknown.[27] Spinal manipulation is unlikely to be helpful.[27]

A 2008 systematic review found promising evidence for Chinese herbal medicine for primary dysmenorrhea, but that the evidence was limited by its poor methodological quality.[28]

Behavioral therapies assume that the physiological process underlying dysmenorrhea is influenced by environmental and psychological factors, and that dysmenorrhea can be effectively treated by physical and cognitive procedures that focus on coping strategies for the symptoms rather than on changes to the underlying processes. A 2007 systematic review found some scientific evidence that behavioral interventions may be effective, but that the results should be viewed with caution due to poor quality of the data.[29]

One review found the available evidence for the use of acupuncture to treat dysmenorrhea suggests it may reduce pain, but further research with well designed clinical trials is needed.[30]

Several nutritional supplements have been suggested as effective in treating dysmenorrhea. One review found that Vitamin B1 has been shown to be effective for pain when taken at 100 mg daily based on one large trial. Magnesium supplementation is a promising possible treatment as well, though no strong recommendations can be made for what doses should be used until further trials are completed. There is insufficient evidence to recommend any other herbal or dietary supplement, including omega-3 fatty acids, vitamin E, vitamin B6 among others which have been studied.[31]

Although claims have been made for chiropractic care, under the theory that treating subluxations in the spine may decrease symptoms,[32] a 2006 systematic review found that overall no evidence suggests that spinal manipulation is effective for treatment of primary and secondary dysmenorrhea.[33]

Epidemiology

The prevalence of dysmenorrhea is estimated to be approximately 25% of women.[34] Reports of dysmenorrhea are greatest among individuals in their late teens and 20s, with reports usually declining with age. The prevalence in adolescent females has been reported to be 67.2% by one study[35] and 90% by another.[34] It has been stated that there is no significant difference in prevalence or incidence between races.[34] Yet, a study of Hispanic adolescent females indicated a high prevalence and impact in this group.[36] Another study indicated that dysmenorrhea was present in 36.4% of participants, and was significantly associated with lower age and lower parity.[37] Childbearing is said to relieve dysmenorrhea, but this does not always occur. One study indicated that in nulliparous women with primary dysmenorrhea, the severity of menstrual pain decreased significantly after age 40.[38] A questionnaire concluded that menstrual problems, including dysmenorrhea, were more common in females who had been sexually abused.[39]

A survey in Norway showed that 14 percent of females between the ages of 20 to 35 experience symptoms so severe that they stay home from school or work.[40] Among adolescent girls, dysmenorrhea is the leading cause of recurrent short-term school absence.[41]

References

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    • Mosby's Medical Dictionary, 8th edition.
    • McGraw-Hill Concise Dictionary of Modern Medicine. Copyright 2002
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