Dysmenorrhea (dysmenorrhoea or painful periods) is a
medical condition of pain during menstruation that interferes with daily
activities, as defined by ACOG and others. Still,
dysmenorrhea is often defined simply as menstrual pain, or at least
menstrual pain that is excessive. 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.
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
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.
Other causes of secondary dysmenorrhea include leiomyoma, adenomyosis, ovarian cysts, and pelvic congestion.
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. 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. 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. 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.
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. 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.
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. Based on results from these, additional exams and tests may be motivated,
such as:
- A pap test
- Certain lab tests
- Gynecologic ultrasonography
- In some cases, laparoscopy may be required.
MANAGEMENT
NSAIDs
Non-steroidal
anti-inflammatory drugs (NSAIDs) are effective in relieving the pain
of primary dysmenorrhea. They can have side effects of nausea, dyspepsia, peptic ulcer, and diarrhea. People who are
unable to take the more common NSAIDs may be prescribed a COX-2 inhibitor.
HORMONAL
CONTRACEPTIVES
Although use of hormonal contraception can
improve or relieve symptoms of primary dysmenorrhea, 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. Norplant and Depo-provera are also effective, since these methods often
induce amenorrhea. The intrauterine system
(Mirena IUD) has been cited as useful in reducing symptoms of dysmenorrhea.
OTHER
A review indicated the effectiveness of use of transdermal nitroglycerin.
ALTERNATIVE
MEDICINE
A number of alternative therapies have been studied in the
treatment of dysmenorrhea.
Dark leafy greens are a dietary
source of magnesium, calcium, and countless other micronutrients. These
nutrients are essential for mediating muscle contractions. In Chinese dietary
therapy, dark green vegetables are also considered to be mildly cleansing, which
is what the body needs in a “stagnation” condition. Some greens such as
dandelion greens (very bitter, but very helpful) also have a mild diuretic
effect, which reduces bloating.
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