Dysmenorrhea

Clinical Presentation of Dysmenorrhea

Primary dysmenorrhea (sometimes called functional dysmenorrhea) is pain that occurs in the absence of pelvic disease and is more common as compared to secondary dysmenorrhea, which occurs secondary to a pelvic condition such as endometriosis or uterine fibroids.

Primary dysmenorrhea is the more common of the two conditions and results from the action of prostaglandins on the uterus during ovulatory cycles. Prostaglandins contribute to dysmenorrhea in two ways. They cause the uterus to contract, which leads to painful cramping, and they decrease blood flow to the myometrium, which contributes to lactic acid buildup and additional pain.

Primary dysmenorrhea affects as many as 50% of women during their childbearing years. It occurs at a higher rate in younger women who have not born children. As age and parity increase, the incidence of primary dysmenorrhea decreases. Risk factors that increase the severity of symptoms include earlier age at menarche, long and/or heavy menstrual flow, smoking, and a family history of the condition (Smith & Kaunitz, 2013).

Clinical Manifestations

Primary Dysmenorrhea

Primary dysmenorrhea is usually associated with ovulatory cycles, hence begins within six months to two years after menarche, however, it may occasionally accompany anovulatory cycles, especially if heavy bleeding and clots are present.

The major symptoms of primary dysmenorrhea consist of severe intermittent cramping in association with constant pain in the lower abdomen, which may radiate to the lower back or upper thighs. General malaise, fatigue, dizziness, nausea and vomiting, diarrhea, and headache frequently accompany the spasmodic cramping.

The symptoms typically begin several hours prior to the onset of menstruation and continue for one to three days. The severity of the disorder depends upon the severity of menstrual pain, presence of systemic symptoms, and impact on daily activities.

Secondary Dysmenorrhea

Secondary dysmenorrhea usually develops years after menarche and can occur with anovulatory cycles and this may be associated with uterine and pelvic pathology such as intrauterine contraceptive device (IUCD), endometriosis, pelvic inflammatory disease (PID), cervical stenosis, a submucosal fibroid or an endometrial polyp. The pain often begins 1–2 weeks prior to menses and persists until a few days after the cessation of the bleeding.

Approach to Diagnosis

History

A complete menstrual history, onset and duration of cramps, presence of nausea, vomiting, diarrhea, back pain, dizziness, or headache during menstruation, impact of symptoms on daily activities, medication taken for pain relief and their perceived effectiveness and sexual history should be taken.

In adolescents with dysmenorrhea from menarche that progresses steadily, obstructive genital tract abnormalities or endometriosisOpens in new window should be considered. Adolescents with history of pelvic infections may develop adhesions that result in pelvic pain, especially during menstruation.

Physical Examination

A pelvic examination is generally not required in adolescents presenting with typical symptoms of primary dysmenorrhea. However, if the history is suggestive of an organic disease or any congenital malformation of the genital tract, or if the patient does not respond to the conventional therapy of primary dysmenorrhea, a complete pelvic examination is indicated or a rectoabdominal examination is advised if the patient is virgin to exclude adnexal tenderness and masses. It is not uncommon to detect an abdominal lump in cases of Müllerian anomalies.

Treatment

Primary dysmenorrhea may result in significant school absence and lost productivity, so aggressive and evidence-based treatment is warranted. The most effective treatment have been nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives (birth control pills) given alone or in combination. NSAIDs, such as ibuprofen, naproxen, and meclofenamate, reduce symptoms by lowering prostaglandin levels and relieving pain.

In randomized trials, approximately 70–90 % of patients have effective pain relief. NSAIDs should be started at the onset of menses and continued for the first one to two days of the menstrual cycle or for the usual duration of crampy pain. However, with severe symptoms, NSAIDs should be started one to two days prior to the onset of menses. Adequate rest, sleep, hot fomentation, acupuncture and regular exercise may help in some women.

If NSAIDs do not control symptoms after two to three cycles, a trial of oral contraceptive (OCPs) may be indicated. OCPs reduce menstrual pain by eliminating ovulation and by thinning the endometrial lining; thus leading to reduced synthesis of prostaglandins.

In severe cases, extended cycle OCP regimens (e.g., 84 active pills, followed by 7 placebos) may be used to eliminate menses. In a sexually active female, OCPs may be considred the first line of therapy because they serve a dual purpose: prevention of both pregnancy and dysmenorrheal. If there is no relief with either NSAIDs or OCPs, both can be prescribed simultaneously.

In case of secondary dysmenorrheal, treatment of the underlying cause is very important. Dilation of a narrow cervical os may give 3–6 months of relief (and allows diagnostic curettage if needed). Other surgical measures (e.g., myomectomy, polypectomy, or dilation and curettage) may be needed in some patients. But these are usually not required for adolescent girls. Presacral neurectomy and division of the sacrouterine ligaments may help selected patients.

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