Dysmenorrhea

Dysmenorrhea
Synonyms Dysmenorrhoea, painful periods, menstrual cramps
Specialty Gynecology
Symptoms Pain during menstruation, diarrhea, nausea[1][2]
Usual onset Within a year of the first menstrual period[1]
Duration Less than 3 days[1]
Causes No underlying problem, uterine fibroids, adenomyosis, endometriosis[3]
Diagnostic method Pelvic exam, ultrasound[1]
Similar conditions Ectopic pregnancy, pelvic inflammatory disease, interstitial cystitis, chronic pelvic pain[1]
Treatment Heating pad, medication[3]
Medication NSAIDs such as ibuprofen, hormonal birth control, IUD with progestogen[1][3]
Prognosis Often improves with age[2]
Frequency 20% to 90% (women of reproductive age)[1]

Dysmenorrhea, also known as painful periods, or menstrual cramps, is pain during menstruation.[1][2] It usually begins around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea, or nausea.[1]

In young women painful periods often occur without an underlying problem. In older women it is more often due to an underlying issues such as uterine fibroids, adenomyosis, or endometriosis.[3] It is more common among those with heavy periods, irregular periods, whose periods started before twelve years of age, or who have a low body weight.[1] A pelvic exam in those who are sexually active and ultrasound may be useful to help in diagnosis.[1] Conditions that should be ruled out include ectopic pregnancy, pelvic inflammatory disease, interstitial cystitis, and chronic pelvic pain.[1]

Dysmenorrhea occurs less often in those who exercise regularly and those who have children early in life.[1] Treatment may include the use of a heating pad.[3] Medications that may help include NSAIDs such as ibuprofen, hormonal birth control, and the IUD with progestogen.[1][3] Taking vitamin B or magnesium may help.[2] Evidence for yoga, acupuncture, and massage is insufficient.[1] Surgery may be useful if certain underlying problems are present.[2]

Dysmenorrhea is estimated to occur in 20% to 90% of women of reproductive age.[1] It is the most common menstrual disorder.[2] Typically it starts within a year of the first menstrual period.[1] When there is no underlying cause often the pain improves with age or following having a child.[2]

Signs and symptoms

The main symptom of dysmenorrhea is pain concentrated in the lower abdomen or pelvis.[1] It is also commonly felt in the right or left side of the abdomen. It may radiate to the thighs and lower back.[1]

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 after 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 they stop ovulation from occurring.

Causes

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.

The most common cause of secondary dysmenorrhea is endometriosis, which can be visually confirmed by laparoscopy in approximately 70% of adolescents with dysmenorrhea.[4]

Other causes of secondary dysmenorrhea include leiomyoma,[5] adenomyosis,[6] ovarian cysts, and pelvic congestion.[7]

Unequal leg length might hypothetically be one of the contributors, as it may contribute to a tilted pelvis, which may cause lower back pain,[8] which in turn may be mistaken for menstrual pain, as women with lower back pain experience increased pain during their periods.

Other skeletal abnormalities, such as scoliosis (sometimes caused by spina bifida) might be possible contributors as well.

Mechanism

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.[9] 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.[10] 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.[11]

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.[12]

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.[13] 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.[13]

Further work-up

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

Further work-up includes a specific medical history of symptoms and menstrual cycles and a pelvic exam.[2] Based on results from these, additional exams and tests may be motivated, such as:

Management

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving the pain of primary dysmenorrhea.[14] They can have side effects of nausea, dyspepsia, peptic ulcer, and diarrhea.[15][14] People who are unable to take the more common NSAIDs may be prescribed a COX-2 inhibitor.[16]

Hormonal birth control

Use of hormonal birth control may improve symptoms of primary dysmenorrhea.[17][18] A 2009 systematic review however found limited evidence that the birth control pill, containing low doses or medium doses of oestrogen, reduces pain associated with dysmenorrhea.[19] In addition, no differences between different birth control pill preparations were found.[19]

Norplant[20] and Depo-provera[21][22] are also effective, since these methods often induce amenorrhea. The intrauterine system (Mirena IUD) may be useful in reducing symptoms.[23]

Other

A review indicated the effectiveness of transdermal nitroglycerin.[24]

Alternative medicine

There is insufficient evidence to recommend the use of any herbal or dietary supplements for treating dysmenorrhea, including, melatonin, vitamin E, fennel, dill, chamomile, cinnamon, damask rose, rhubarb, guava, and uzara.[1][25] Further research is recommended to follow up on weak evidence of benefit for: fenugreek, ginger, valerian, zataria, zinc sulphate, fish oil, and vitamin B1. A 2016 review found that evidence of safety is insufficient for all dietary supplements.[25]

There is some conflicting evidence in the scientific literature, including:

One review found thiamine and vitamin E to be likely effective.[26] It found the effects of fish oil and vitamin B12 to be unknown.[26]

Reviews found tentative evidence that ginger powder may be effective for primary dysmenorrhea.[27][28]

Another review found Vitamin B1 to be effective. Magnesium supplementation are a promising possible treatment.

A 2008 review found promising evidence for Chinese herbal medicine for primary dysmenorrhea, but that the evidence was limited by its poor methodological quality.[29]

Procedures

Acupuncture: A 2016 Cochrane review found that the randomized controlled trials (RCTs) of acupuncture treatments for dysmenorrhea are of low quality and concluded that it is unknown if acupuncture or acupressure is effective for treating symptoms of primary dysmenorrhea.[30] There are also concerns of bias in study design and in publication, insufficient reporting (few looked at adverse effects), and that they were inconsistent.[30] There are conflicting reports in the literature, including one review which found that acupressure, topical heat, transcutaneous electrical nerve stimulation, and behavioral interventions are likely effective.[26] It found the effect of acupuncture and magnets to be unknown.[26]

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.[31]

Spinal manipulation does not appear to be helpful.[26] 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

Dysmenorrhea is estimated to affect 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

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Osayande, AS; Mehulic, S (1 March 2014). "Diagnosis and initial management of dysmenorrhea.". American family physician. 89 (5): 341–6. PMID 24695505.
  2. 1 2 3 4 5 6 7 8 9 10 11 American College of Obstetricians and Gynecologists (Jan 2015). "FAQ046 Dynsmenorrhea: Painful Periods" (PDF). Retrieved 26 June 2015.
  3. 1 2 3 4 5 6 "Menstruation and the menstrual cycle fact sheet". Office of Women's Health. December 23, 2014. Retrieved 25 June 2015.
  4. ↑ Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D'Hooghe TM (2013). "Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: A systematic review". Human Reproduction Update. 19 (5): 570–582. PMID 23727940. doi:10.1093/humupd/dmt016.
  5. ↑ Hilário SG, Bozzini N, Borsari R, Baracat EC (2008). "Action of aromatase inhibitor for treatment of uterine leiomyoma in perimenopausal patients". Fertil. Steril. 91 (1): 240–3. PMID 18249392. doi:10.1016/j.fertnstert.2007.11.006.
  6. ↑ Nabeshima H, Murakami T, Nishimoto M, Sugawara N, Sato N (2008). "Successful total laparoscopic cystic adenomyomectomy after unsuccessful open surgery using transtrocar ultrasonographic guiding". J Minim Invasive Gynecol. 15 (2): 227–30. PMID 18312998. doi:10.1016/j.jmig.2007.10.007.
  7. ↑ Hacker, Neville F., J. George Moore, and Joseph C. Gambone. Essentials of Obstetrics and Gynecology, 4th ed. Elsevier Saunders, 2004. ISBN 0-7216-0179-0
  8. ↑ Cooperstein R, Lew M (2009). "The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature". J Chiropr Med. 8: 107–18. PMC 2732247 Freely accessible. PMID 19703666. doi:10.1016/j.jcm.2009.06.001.
  9. ↑ Lethaby, Anne; Duckitt, Kirsten; Farquhar, Cindy (2013-01-31). "Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding". The Cochrane Database of Systematic Reviews (1): CD000400. ISSN 1469-493X. PMID 23440779. doi:10.1002/14651858.CD000400.pub3.
  10. ↑ Wright, Jason and Solange Wyatt. The Washington Manual Obstetrics and Gynecology Survival Guide. Lippincott Williams and Wilkins, 2003. ISBN 0-7817-4363-X
  11. ↑ Rosenwaks Z, Seegar-Jones G (October 1980). "Menstrual pain: its origin and pathogenesis". J Reprod Med. 25 (4 Suppl): 207–12. PMID 7001019.
  12. ↑ Kataoka M, Togashi K, Kido A, Nakai A, Fujiwara T, Koyama T, Fujii S (2005). "Dysmenorrhea: evaluation with cine-mode-display MR imaging--initial experience". Radiology. 235 (1): 124–31. PMID 15731368. doi:10.1148/radiol.2351031283.
  13. 1 2 Wyatt KM, Dimmock PW, Hayes-Gill B, Crowe J, O'Brien PM (2002). "Menstrual symptometrics: A simple computer-aided method to quantify menstrual cycle disorders". Fertility and Sterility. 78 (1): 96–101. PMID 12095497. doi:10.1016/s0015-0282(02)03161-8.
  14. 1 2 Marjoribanks, Jane; Ayeleke, Reuben Olugbenga; Farquhar, Cindy; Proctor, Michelle (2015-07-30). "Nonsteroidal anti-inflammatory drugs for dysmenorrhoea". The Cochrane Database of Systematic Reviews (7): CD001751. ISSN 1469-493X. PMID 26224322. doi:10.1002/14651858.CD001751.pub3.
  15. ↑ Rossi S, editor. Australian Medicines Handbook 2006. Adelaide: Australian Medicines Handbook; 2006. ISBN 0-9757919-2-3
  16. ↑ Chantler I, Mitchell D, Fuller A (2008). "The effect of three cyclo-oxygenase inhibitors on intensity of primary dysmenorrheic pain". Clin J Pain. 24 (1): 39–44. PMID 18180635. doi:10.1097/AJP.0b013e318156dafc.
  17. ↑ Archer DF (November 2006). "Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives". Contraception. 74 (5): 359–66. PMID 17046376. doi:10.1016/j.contraception.2006.06.003.
  18. ↑ Harel Z (December 2006). "Dysmenorrhea in adolescents and young adults: etiology and management". J Pediatr Adolesc Gynecol. 19 (6): 363–71. PMID 17174824. doi:10.1016/j.jpag.2006.09.001.
  19. 1 2 Wong, CL; Farquhar, C; Roberts, H; Proctor, M (7 October 2009). "Oral contraceptive pill for primary dysmenorrhoea.". The Cochrane database of systematic reviews (4): CD002120. PMID 19821293.
  20. ↑ Power J, French R, Cowan F (2007). Power, Jo, ed. "Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy". Cochrane Database Syst Rev (3): CD001326. PMID 17636668. doi:10.1002/14651858.CD001326.pub2.
  21. ↑ Glasier, Anna (2006). "Contraception". In DeGroot, Leslie J.; Jameson, J. Larry (eds.). Endocrinology (5th ed.). Philadelphia: Elsevier Saunders. pp. 2993–3003. ISBN 0-7216-0376-9.
  22. ↑ Loose, Davis S.; Stancel, George M. (2006). "Estrogens and Progestins". In Brunton, Laurence L.; Lazo, John S.; Parker, Keith L. Goodman & Gilman's The Pharmacological Basis of Therapeutics (11th ed.). New York: McGraw-Hill. pp. 1541–1571. ISBN 0-07-142280-3.
  23. ↑ Gupta HP, Singh U, Sinha S (2007). "Laevonorgestrel intra-uterine system--a revolutionary intra-uterine device". J Indian Med Assoc. 105 (7): 380, 382–5. PMID 18178990.
  24. ↑ Morgan PJ, Kung R, Tarshis J (2002). "Nitroglycerin as a uterine relaxant: a systematic review". J Obstet Gynaecol Can. 24 (5): 403–9. PMID 12196860.
  25. 1 2 Pattanittum, Porjai; Kunyanone, Naowarat; Brown, Julie; Sangkomkamhang, Ussanee S.; Barnes, Joanne; Seyfoddin, Vahid; Marjoribanks, Jane (2016-03-22). "Dietary supplements for dysmenorrhoea". The Cochrane Database of Systematic Reviews. 3: CD002124. ISSN 1469-493X. PMID 27000311. doi:10.1002/14651858.CD002124.pub2.
  26. 1 2 3 4 5 Latthe PM, Champaneria R, Khan KS (Feb 21, 2011). "Dysmenorrhoea". Clinical evidence. 2011. PMC 3275141 Freely accessible. PMID 21718556.
  27. ↑ Daily, James W.; Zhang, Xin; Kim, Da Sol; Park, Sunmin (2015-12-01). "Efficacy of Ginger for Alleviating the Symptoms of Primary Dysmenorrhea: A Systematic Review and Meta-analysis of Randomized Clinical Trials". Pain Medicine (Malden, Mass.). 16 (12): 2243–2255. ISSN 1526-4637. PMID 26177393. doi:10.1111/pme.12853.
  28. ↑ Chen, Chen X.; Barrett, Bruce; Kwekkeboom, Kristine L. (2016-05-05). "Efficacy of Oral Ginger (Zingiber officinale) for Dysmenorrhea: A Systematic Review and Meta-Analysis". Evidence-Based Complementary and Alternative Medicine. 2016: 1–10. ISSN 1741-427X. PMC 4871956 Freely accessible. PMID 27274753. doi:10.1155/2016/6295737.
  29. ↑ Zhu X, Proctor M, Bensoussan A, Wu E, Smith CA (2008). Zhu, Xiaoshu, ed. "Chinese herbal medicine for primary dysmenorrhoea". Cochrane Database Syst Rev (2): CD005288. PMID 18425916. doi:10.1002/14651858.CD005288.pub3.
  30. 1 2 Smith, Caroline A.; Armour, Mike; Zhu, Xiaoshu; Li, Xun; Lu, Zhi Yong; Song, Jing (2016-04-18). "Acupuncture for dysmenorrhoea". The Cochrane Database of Systematic Reviews. 4: CD007854. ISSN 1469-493X. PMID 27087494. doi:10.1002/14651858.CD007854.pub3.
  31. ↑ Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM (2007). Proctor, Michelle, ed. "Behavioural interventions for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev (3): CD002248. PMID 17636702. doi:10.1002/14651858.CD002248.pub3.
  32. ↑ Chapman-Smith D (2000). "Scope of practice". The Chiropractic Profession: Its Education, Practice, Research and Future Directions. West Des Moines, IA: NCMIC. ISBN 1-892734-02-8.
  33. ↑ Proctor ML, Hing W, Johnson TC, Murphy PA (2006). Proctor, Michelle, ed. "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev. 3 (3): CD002119. PMID 16855988. doi:10.1002/14651858.CD002119.pub3.
  34. 1 2 3 eMedicine > Dysmenorrhea By Andre Holder, Laurel D Edmundson and Mert Erogul. Updated: Dec 31, 2009
  35. ↑ Sharma P, Malhotra C, Taneja DK, Saha R (2008). "Problems related to menstruation amongst adolescent girls". Indian J Pediatr. 75 (2): 125–9. PMID 18334791. doi:10.1007/s12098-008-0018-5.
  36. ↑ Banikarim C, Chacko MR, Kelder SH (2000). "Prevalence and impact of dysmenorrhea on Hispanic female adolescents". Arch Pediatr Adolesc Med. 154 (12): 1226–9. PMID 11115307. doi:10.1001/archpedi.154.12.1226.
  37. ↑ Sule ST, Umar HS, Madugu NH (2007). "Premenstrual symptoms and dysmenorrhoea among Muslim women in Zaria, Nigeria". Ann Afr Med. 6 (2): 68–72. PMID 18240706. doi:10.4103/1596-3519.55713.
  38. ↑ Juang CM, Yen MS, Horng HC, Cheng CY, Yuan CC, Chang CM (2006). "Natural progression of menstrual pain in nulliparous women at reproductive age: an observational study". J Chin Med Assoc. 69 (10): 484–8. PMID 17098673. doi:10.1016/S1726-4901(09)70313-2.
  39. ↑ Vink CW, Labots-Vogelesang SM, Lagro-Janssen AL (2006). "[Menstruation disorders more frequent in women with a history of sexual abuse]". Ned Tijdschr Geneeskd (in Dutch and Flemish). 150 (34): 1886–90. PMID 16970013.
  40. ↑ "Mozon: Sykemelder seg på grunn av menssmerter". Mozon. 2004-10-25. Retrieved 2007-02-02.
  41. ↑ French L (2008). "Dysmenorrhea in adolescents: diagnosis and treatment". Paediatr Drugs. 10 (1): 1–7. PMID 18162003. doi:10.2165/00148581-200810010-00001.
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