Dysmenorrhoea is pain or discomfort experienced during or just before a menstrual period.
Types and causes
Primary dysmenorrhoea is common in teenage girls and young women. It usually starts two to three years after menstruation begins, but often diminishes after the age of 25. The exact cause is unknown. One possibility is excessive production of, or undue sensitivity to, prostaglandins, which are hormone-like substances that stimulate spasms in the uterus. Secondary dysmenorrhoea is due to an underlying disorder, such as pelvic inflammatory disease or endometriosis, and usually begins in adult life.
Cramp-like pain or discomfort is felt in the lower abdomen, sometimes accompanied by a dull ache in the lower back. Some women also have nausea and vomiting.
Mild primary dysmenorrhoea is often relieved by analgesic drugs (painkillers). In severe cases, symptoms can usually be relieved by taking oral contraceptives or other hormonal preparations that suppress ovulation. The treatment of secondary dysmenorrhoea depends on the cause of the condition.
Dysmenorrhea in more detail - non-technical
Dysmenorrhea is the occurrence of painful cramps during a woman’s menstrual period. The English word comes from three Greek words that mean ‘‘painful,’’ ‘‘month,’’ and ‘‘flow.’’ Most women experience some discomfort during their periods; however, dysmenorrhea is diagnosed when the pain is so severe as to limit the woman’s normal activities or require medical or surgical treatment.
Dysmenorrhea is by definition a disorder that affects only females of childbearing age. Some studies indicate that the rate of dysmenorrhea is highest among adolescents and young adults, and declines with age. Survey results are highly variable, ranging from 29% in one family practice setting to 90% in a group of Swedish adolescents. One group of researchers reported that 67% of teenagers in their sample reported dysmenorrhea, compared to 27% of women in their 30s. Primary dysmenorrhea is the leading cause of recurrent short term absence from school among adolescent American girls. In the workplace, dysmenorrhea causes 600 million missed work hours in the United States each year and an economic loss of $2 billion.
Secondary dysmenorrhea is more common in older women than in teenagers; in general, women who experience dysmenorrhea for the first time after age 25 have secondary dysmenorrhea.
As far as is known as of 2012, race or ethnicity is not a risk factor for dysmenorrhea.
Women with dysmenorrhea describe the pain in their abdomens as variously shooting, stabbing, burning, sharp, throbbing, or nauseating. Dysmenorrhea may precede the onset of the woman’s period by several days, or accompany it. It usually subsides as the woman’s flow tapers off.
In some women, dysmenorrhea is accompanied by unusually heavy blood loss—a condition known as menorrhagia.
The likelihood that a woman will have painful cramps increases if she:
- has a family history of painful periods
- leads a stressful life smokes
- has never borne a child is below 20 years of age
- began puberty before age 11 has heavy periods
- doesn’t get enough exercise
- drinks large quantities of beverages containing caffeine (coffee, tea, cola, energy drinks)
- has attempted to lose weight rapidly
- has pelvic inflammatory disease (PID)
- has a history of sexual abuse
Causes and symptoms
Dysmenorrhea is called ‘‘primary’’ when there is no specific abnormality, and ‘‘secondary’’ when the pain is caused by an underlying gynecological problem. It is believed that primary dysmenorrhea occurs when prostaglandins, hormone-like substances produced by uterine tissue, trigger strong muscle contractions in the uterus during menstruation. However, the level of prostaglandins does not seem to correlate with how strong a woman’s cramps are. Some women have high levels of prostaglandins and no cramps, whereas other women with low levels have severe cramps. This is why experts assume that cramps must also be related to other causes, such as diets, genetics, stress, and different body types, in addition to prostaglandins. The first year or two of a girl’s periods are not usually very painful. However, once ovulation begins, the blood levels of the prostaglandins rise, leading to stronger contractions.
Symptoms of dysmenorrhea include a dull, throbbing cramping in the lower abdomen that may radiate to the lower back and thighs. In addition, some women may experience nausea and vomiting; diarrhea or constipation; hypersensitivity to lights, sounds, or odors; general irritability and fatigue; heavy sweating; or dizziness. Cramps usually last for two or three days at the beginning of each menstrual period. Many women often notice their painful periods disappear after they have their first child, probably due to the stretching of the opening of the uterus or because the birth improves the uterine blood supply and muscle activity, although other women do not notice a change in their level of menstrual discomfort after childbirth.
To read about fibroids and pain see: fibroid pain
A doctor should perform a thorough pelvic exam and take a patient history to rule out any underlying condition that could cause unusually painful cramps. The patient history will include such information as the patient’s age at the time of her first period, family history of painful periods, sexual activity (if any), method of contraception used (if any), number of children, the regularity of the menstrual cycle, the cycle’s length, date of the last menstrual period, and duration and amount of menstrual flow.
An office examination of the patient’s abdomen is usually sufficient in adolescents who have not been sexually active. Women who are sexually active should have a pelvic examination.
There are no laboratory tests that can be used to diagnose primary dysmenorrhea; however, the doctor may order a blood test to rule out a systemic infection, or take a smear of the cervix to evaluate the patient for a sexually transmitted disease. If the abdominal and pelvic examinations suggest secondary dysmenorrhea, an ultrasound of the pelvis is the next step in evaluating endometriosis or ovarian cysts as possible causes of the dysmenorrhea. Other imaging studies that can be used include CT scans and MRIs.
The doctor may recommend either a hysteroscopy or a laparoscopy to check for such causes of secondary dysmenorrhea as fibroids, ovarian cysts, endometriosis, or an ectopic pregnancy. In a hysteroscopy, the doctor inserts a thin lighted tube called an endoscope into the uterine cavity. The doctor can remove a small sample of uterine tissue for biopsy as well as examining the interior of the uterus visually. In a laparoscopy, the doctor makes small incisions in the skin of the abdomen and inserts an endoscope with a small camera lens. Laparoscopy can also be used for surgical removal of endometriomas, which are a type of cyst formed when endometrial tissue grows inside the ovaries rather than in the uterus. In extreme cases, the doctor may recommend a hysterectomy—surgical removal of the entire uterus. A qualified physician is required in order to fit a woman with the Mirena (an intrauterine device described below). The woman’s cervix must be dilated before insertion; the process is uncomfortable, and some doctors use a local anesthetic to reduce discomfort.
Several over-the-counter medications can lessen or completely eliminate the pain of primary dysmenorrhea. Most popular are the nonsteroidal anti-inflammatory drugs (NSAIDs), which prevent or decrease the formation of prostaglandins. These include aspirin, ibuprofen (Advil), and naproxen (Aleve). For more severe pain, prescription-strength ibuprofen (Motrin) is available. These drugs are usually begun at the first sign of the period and taken for a day or two. Although NSAIDs are effective in providing short-term relief from cramps, some researchers think that long-term use of these medications increases the risk of side effects, particularly diarrhea and peptic ulcer.
If an NSAID is not available, acetaminophen (Tylenol) (paracetamol in UK) may also help ease the pain. Heat applied to the painful area may bring relief, and a warm bath twice a day also may help.
Hormonal therapy is another approach to dysmenorrhea that works for many women, although it involves prescription medications rather than over-the-counter pain relievers. Birth control pills and Depo-Provera, an injected contraceptive thatmust be given every 3months, work by preventing ovulation. Depo-Provera is also given as a treatment for endometriosis as well as contraception.
Studies of a drug patch containing glyceryl trinitrate to treat dysmenorrhea suggest that it also may help ease pain. This drug has been used in the past to ease preterm contractions in pregnant women. One common side effect of the patch, however, is headache.
In 2002, an intrauterine device (IUD) was introduced to help eliminate the pain of menstrual cramps related to endometriosis. The IUD, known as Mirena, is approved for use in the United States as a contraceptive. The device works by releasing small amounts of progestin (a hormone) as well as preventing a fertilized egg from implanting in the lining of the uterus. Mirena cannot, however, be used by women with a history of pelvic inflammatory disease, current gonorrhea or chlamydia infection, or cervical or breast cancer.
There are two drugs that can be given to completely suppress menstrual periods—danazol (Danocrine) and leuprolide acetate (Lupron). These are generally regarded as treatments of last resort for secondary dysmenorrhea that is not helped by other medications. Both Danocrine and Lupron are expensive drugs with severe side effects.
There are a variety of alternative therapies for dysmenorrhea. As of 2012, however, most of these have not been well studied.
The following dietary or lifestyle changes may help prevent or treat menstrual pain:
- Increased dietary intake of foods such as fiber, calcium, soy foods, fruits and vegetables.
- Decreased consumption of foods that exacerbate PMS. They include caffeine, salt and sugar.
- Quitting smoking. Smoking has been found to worsen cramps.
- Taking daily multi-vitamin and mineral supplements that contain high doses of magnesium and vitamin B6 (pyridoxine), and flaxseed or fish oil supplements. Recent research suggests that vitamin B supplements, primarily vitamin B6 in complex, magnesium, calcium, zinc, vitamin E, and fish oil supplements (omega-3 fatty acids) also may help relieve cramps.
An herbalist may recommend one of the following herbal remedies for menstrual pain:
- Chasteberry (Vitex agnus-castus) for women who also experience breast pain, irregular periods, and ovarian cysts.
- Dong quai (Angelica sinensis) for women with typical menstrual pain.
- Licorice (Glycyrrhiza glabra) for abdominal bloating and cramping.
- Black cohosh (Cimifuga racemosa) for relief of menstrual pain as well as mood swing and depression.
Several yoga positions are popular as methods to ease menstrual pain. In the ‘‘cat stretch’’ position, the woman rests on her hands and knees, slowly arching the back. The pelvic tilt is another popular yoga position, in which the woman lies with knees bent, and then lifts the pelvis and buttocks. Exercise may be a way to reduce the pain of menstrual cramps through the brain’s production of endorphins, the body’s own painkillers.
Acupuncture and Chinese herbs are other popular alternative treatments for cramps. There are particular formulas depending on the pattern of imbalance.
Aromatherapy and massage may ease pain for some women.
Transcutaneous electrical nerve stimulation (TENS) has been touted as a safe and practical way to relieve the pain of dysmenorrhea. It works by using electrodes to stimulate nerve fibers.
Some women find relief through visualization, concentrating on the pain as a particular color and gaining control of the sensations. Others find that imagining a white light hovering over the painful area can actually lessen the pain for brief periods.
Simply changing the position of the body can help ease cramps. The simplest technique is assuming the fetal position with knee pulled up to the chest while hugging a heating pad or pillow to the abdomen. Also, orgasm can make a woman feel more comfortable by releasing tension in the pelvic muscles.
Dysmenorrhea is a treatable condition with a goodto- excellent prognosis in most women. As noted above, most adolescents with primary dysmenorrhea outgrow their painful cramps as they enter their 20s and 30s. Older women with secondary dysmenorrhea usually do well after surgery to remove fibroids or endometriomas; some of these procedures can be done in outpatient surgical clinics. A complete hysterectomy is usually done as an inpatient procedure, but most women recover without complications.
Most of the causes of secondary dysmenorrhea cannot be prevented as of 2012. However, avoidance of caffeine, alcohol, and sugar prior to the onset of the period, and NSAIDs taken a day before the period begins may eliminate cramps for some women with primary dysmenorrhea.
Dysmenorrhea - technical
Dysmenorrhea or colicky pain in the lower abdomen and pelvis around the time of menses is a common condition that disturbs the lives and families of the women who suffer from it. Severe pain and discomfort often lead to absenteeism from work or school, resulting in an overall reduction in productivity and enormous economic loss.
Dysmenorrhea can be classified as primary or secondary, depending on its cause. Secondary dysmenorrhea results from a known pathologic process occurring within the pelvis. Primary dysmenorrhea does not have an anatomic cause.
Because many women seek help for this disorder, the physician should be sensitive to the concerns of each patient and provide a treatment that is specific to each patient's needs. The goal of therapy is to enable the patient to resume her daily life without the fear of being disabled by pain.
The prevalence of primary dysmenorrhea is between 40% and 90%, with an average of 75%. It occurs predominantly in women younger than 25 years.
Primary dysmenorrhea results from tissue hypoxia and ischemia. An elevation in the basal tone of the uterus, combined with an increase in contraction strength and frequency, leads to vasospasm and a reduction in uterine blood flow. (1) Increased levels of prostaglandin, leukotrienes, and vasopressin are responsible for these alterations. (2) It is important to note that this abnormality in prostaglandin production occurs only in endometrial tissue that has been exposed to both estrogen and progesterone.
Diagnosis of primary dysmenorrhea is based on patient history; results of physical examination are usually normal. Symptoms characteristically begin within 6 to 12 months after menarche, as ovulatory cycles become established. The pain occurs only during ovulatory cycles and lasts about 48 to 72 hours each month. In most patients, the pain starts a few hours before menstruation or at the onset of menstruation.
The degree of pain suffered is variable, but fewer than 15% of women with primary dysmenorrhea have severe pain. Patients with severe pain may also experience other symptoms, such as nausea, vomiting, dizziness, and diarrhea.
Treatment of primary dysmenorrhea includes nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, and transcutaneous electrical nerve stimulation (TENS). (3) Other nonpharmacologic approaches that may be effective are the use of a lower abdominal heating pad, (4) supplemental vitamin B1 (100 mg daily) or magnesium (400 mg daily), (5) and a low-fat vegetarian diet. (6)
NSAIDs inhibit the action of cyclooxygenase and prevent the conversion of arachidonic acid into prostaglandins (PGs). NSAIDs significantly alleviate pain in approximately 75% of patients. The fenamates (e.g., mefenamic acid) are considered the best choice of NSAIDs because they act as antiprostaglandins, preventing both the production of PGs and the binding of the PG to its receptor. (7,8) Therapy with NSAIDs should be discontinued if adverse side effects occur. (9) Definitive research on the use of cyclooxygenase-2 (COX-2) inhibitors (e.g., celecoxib [Celebrex] in dysmenorrhea has not been completed, but these agents seem promising for this purpose.
If NSAIDs are ineffective or poorly tolerated, the next step is the use of combined estrogen-progestin oral contraceptives. In a normal menstrual cycle, the progesterone level increases after ovulation and steadily decreases during the luteal phase. As the level of progesterone decreases, lysosomal enzymes within the endometrial cells are released, causing an increase in the production of PGs. Oral contraceptives prevent fluctuations of endogenous progesterone levels, reducing the amount of pain and symptoms associated with primary dysmenorrhea.(10) Regular-cycle oral contraceptives are not usually effective for treatment of primary dysmenorrhea; continuous oral contraceptives are preferable. Many patients consider continuous oral contraceptives unnatural but are willing to compromise by taking long-cycle contraceptives, so that they have three or four menses a year.
If neither NSAIDs nor oral contraceptives alone alleviate primary dysmenorrhea, the two can be used together. If combination therapy also fails, the patient should be reevaluated and a diagnostic workup initiated for secondary dysmenorrhea.
The pain associated with secondary dysmenorrhea is the direct result of a pathologic process. Unlike primary dysmenorrhea, secondary dysmenorrhea varies with regard to the patient's age at onset and the causative condition. Some of the conditions that can cause secondary dysmenorrhea include endometriosis, adenomyosis, pelvic adhesions and infection, pelvic congestion, cervical stenosis, psychological stress, and psychological disturbances.
Endometriosis is the presence of endometrial glands and stroma outside the uterus [see: Endometriosis]. Approximately 7% of women in the United States suffer from this disorder. Endometriosis causes intra-abdominal hemorrhage, fibrosis, and adhesion formation. Consequently, dyspareunia, infertility, and pelvic pain occur. (11)
The pain usually begins 2 to 3 days before menses and worsens during menstruation. Tender nodules along the uterosacral ligament, a posteriorly fixed uterus, and enlarged cystic ovaries are characteristic findings; however, results of physical examination are often normal. Definitive diagnosis requires direct visualization during laparoscopy, with or without a tissue biopsy.
Treatment may entail either medical intervention or surgery. Oral contraceptives, intramuscular injection of leuprolide acetate depot, oral danazol, or high-dose progestins (oral or intramuscular) are all beneficial in suppressing the endometrial implants and relieving the symptoms of pain.
Adenomyosis is the presence of ectopic endometrial glands and stroma in the myometrium of the uterus. Unlike the ectopic glands in endometriosis, the ectopic glands in adenomyosis do not undergo monthly cyclical changes.
Symptoms of adenomyosis classically include dysmenorrhea and menorrhagia (heavy menstrual bleeding). As the disease progresses, so does the dysmenorrhea. On physical examination, the uterus is soft, globular, and uniformly enlarged. Typically, the uterus is tender just before and during menstruation.
Diagnostic aids include pelvic sonography, magnetic resonance imaging, and hysterosalpingography. Unfortunately, most cases go undiagnosed until histologic evaluation is made at the time of a hysterectomy.
Treatment starts with medical suppression of ovarian function and culminates in hysterectomy if symptoms do not abate. Thermal balloon ablation of the endometrium, which is an effective treatment for some patients with dysmenorrhea from other causes, (12) does not work in adenomyosis.
When menstrual flow is impeded at the level of the internal cervical os, intrauterine pressure increases and pelvic pain occurs. A narrow or stenotic os may be a congenital abnormality or the result of trauma, infection, or surgery.
The diagnosis of cervical stenosis should be considered in women who have a history of hypomenorrhea and severe pelvic pain during menses or if the diameter of the external cervical os is less than 5 mm.
During the physical examination, the physician should attempt to pass a uterine sound into the endometrial cavity. Inability to document a clear passage through the cervical canal warrants further investigation. Diagnostic workup with hysterosalpingography may reveal a narrow cervical canal.
Treatment consists of dilating the cervical canal with laminaria tents or performing a formal dilatation and curettage (D and C) under anesthesia. These procedures have limited therapeutic benefit and need to be repeated frequently. Complete resolution of symptoms typically occurs with pregnancy and vaginal delivery, which therefore is considered the ultimate therapy.
Pelvic inflammatory disease
Most pelvic infections are caused by Chlamydia, Neisseria gonorrhoeae, and mixed microbial organisms. Pelvic anatomy is often distorted as a consequence of dense adhesion formation. During menstruation, adhesion edema and venous congestion result in severe pelvic pain and discomfort. This pain may eventually become chronic.
Patients at risk for pelvic inflammatory disease (PID) include current or past users of intrauterine devices (IUDs) and women with more than one sexual partner. The workup includes cervical cultures, endometrial biopsy, and pelvic sonography.
Treatment of the dysmenorrhea associated with PID includes NSAIDs for pain management and antibiotics for acute infection. Surgery can be offered to patients with chronic pain and to those with a known tubo-ovarian abscess or hydrosalpinx. Although lysis of adhesions can be performed, results are usually poor because recurrence is high.
Pelvic congestion syndrome
Engorgement and thrombosis of the pelvic veins are another cause of dysmenorrhea. (13) The pooling of blood in the pelvic vasculature results in a burning and throbbing pain. The pain is characteristically worse at night and after prolonged periods of standing. Bimanual examination often reveals a uterus that is mildly enlarged and tender to the touch. The diagnosis of pelvic congestion syndrome is made almost exclusively during laparoscopic evaluation. Although the underlying cause of pain is not well understood, treatment often entails NSAIDs and psychological therapy. New treatment approaches that utilize uterine artery embolization show promising results. Hysterectomy should be reserved for patients who do not respond to other therapeutic modalities.
Other causes of chronic pelvic pain
Also see: pelvic pain
Secondary dysmenorrhea can also be caused by psychological problems, including stress, tension, and abnormal conditioned behavior. For these patients, resolution of symptoms is best achieved through lifestyle and behavior modification. Chronic pelvic pain, rather than acute pain, is more common among women with psychological disorders.
Patients who have pain for more than 6 months are considered to have chronic pelvic pain. In addition to a gynecologic cause of the pelvic pain, the physician should always consider other causes. The basic workup should include gastrointestinal, urologic, musculoskeletal, and psychological evaluations. Once a diagnosis has been established, treatment should focus on correcting the underlying disorder. Treatment should be initiated with medical therapy. If this fails, more aggressive treatment can be attempted, including presacral neurectomy or a laparoscopic uterine nerve ablation (LUNA) procedure. (14,15,16)
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