Dysmenorrhea

14April 2023

What is Dysmenorrhea?

It is a condition where a female experiences pain during her menstrual cycle. It is the most common gynaecological problem and is experienced among45-93%of menstruating women.

About 13-51 % of individuals miss out on their regular work/school routine resulting in absenteeism at least once due to mild pain, while 5-14 % of the women are more frequently absent due to more severe pain.

What are the types of Dysmenorrhea ?

There are two types of Dysmenorrhea:

Primary Dysmenorrhea:
Second Dysmenorrhea

	Primary Dysmenorrhea	Secondary Dysmenorrhea
What	Recurrent menstrual pain without an organic disease	Menstrual pain associated with an identifiable disease in the reproductive organ of the woman.
Cause	Hyper-production of uterine prostaglandins	Conditions that can cause Secondary Dysmenorrhea include: o Endometriosis o Adenomyosis o Uterine Fibroids o Infection
Nature of Pain	The pain: o Varies between mild to severe. o Usually reduces in intensity as the age increases. o can stop entirely if you have had a baby o Generally starts either 1 or 2 days prior to when the menstrual bleeding starts or on the day it starts. o Pain is in the lower abdomen, back or thighs.	The pain begins early in the menstrual cycle and lasts longer than common menstrual cramps.
How long does the pain last	Typically lasts 12 to 72 hours and may co-occur with: o Nausea o Vomiting o Fatigue o Diarrhoea	The pain can get worse as the menstrual period continues and it may not go away after the period ends. Generally, it is not accompanied by nausea, vomiting, fatigue, or diarrhoea.

What is the leading cause of Primary Dysmenorrhea (pain of menstrual cramps)?

Hyper-production of uterine prostaglandins causes contractions in the uterus leading to menstrual cramps. The uterus is the organ in the lower body of a woman where a baby grows. It contracts during the menstrual cycle. However, at the time of menstruation, it contracts even more strongly. As the contractions of the uterus strengthen, there is increased pressure on the nearby blood vessels. This pressure cuts off the oxygen supply to the muscle tissue of the uterus. The momentary loss of oxygen supply in the muscle leads to pain.

How doesSecondary Dysmenorrhea cause menstrual cramps?

A disease in a woman’s reproductive organs can lead to menstrual pain.

Conditions that can cause secondary Dysmenorrhea include:

Endometriosis: Endometrium is the tissue lining of the uterus. In Endometriosis, this tissue is found outside the womb.
Adenomyosis: lining of on the walls of the uterus grows into the muscle of the uterus.
Pelvic Inflammatory Disease: this is an infection wherein the bacteria starts growing in the uterus and eventually spreads to other reproductive organs.
Cervical Stenosis: The opening of the uterus contracts.
Uterine Fibroids: In this condition, benign tumours (non-cancerous) grow on the inner wall of the uterus.

What are the risk factors associated with Dysmenorrhea?

The severity of Dysmenorrhea is associated with the following:

Duration of menstrual flow
Younger average menarche
Smoking
Obesity
Alcohol consumption

A lot of mental pressure can also lead to Dysmenorrhea. Therefore if a woman is suffering from high levels of stress, depression or anxiety, then the chances of her being afflicted with Dysmenorrhea are highly likely.

There is a noticeable improvement in Primary Dysmenorrhea when a woman:

Is in the third decade of her reproductive life.
Has given birth to a child.

However, it is still unclear how the underlying disease alters the prognosis of secondary Dysmenorrhea.

What are the common symptoms of Dysmenorrhea?

Some of the common symptoms of Dysmenorrhea include:

Pain in the abdomen (can be either severe or dull).
Pressure in the abdomen
Pain in inner thighs, hips and lower back.

How would your doctor detect if you may have Dysmenorrhea?

Primary Dysmenorrhea – patient interview process:

Physical examination coupled with medical history examination is sufficient for the diagnosis of Primary Dysmenorrhea.
The doctor may ask you about the following:
- When did the pain start?
- How long does the pain last?
- What all body parts are affected by the pain?
- What are the characteristics of the pain you feel?
- Any other aggravating or relieving factors that you may have noticed.
Generally,Primary Dysmenorrhea starts 6 to 12 months after the first menstrual cycle.
Lower abdominal pain or pelvic pain is usually associated with the onset of menstrual flow. The pain lasts for 8 to 72 hours.

Secondary Dysmenorrhea –patient interview process:

Secondary Dysmenorrhea can occur any time after the first menstrual cycle. It can come up as a new symptom when the woman is in her 30s or 40s due to the development of an underlying medical condition.

To identify the underlying medical condition, the doctor may ask you whether you have noticed any of the following gynaecological symptoms:

Dyspareunia
Menorrhagia
Post-coital bleeding
Intermenstrual bleeding

Your doctor might enquire about the following conditions, as they might implicate Secondary Dysmenorrhea:

Did you have Dysmenorrhea during the first two cycles after menarche (first menstrual cycle)?
When was the first occurrence of Dysmenorrhea after you reached the age of 25?
Did you have a delayed onset of Dysmenorrhea without any history of pain with menstruation?
Have you had heavy menstrual flow and/or irregular cycles?

Note: Don’t forget to share all the crucial details of your family’s patient history with your doctor. This information could be essential in differentiating between primary and secondary dysmenorrhea.

For example: Endometriosis in first degree relatives.

Alert: You should immediately consult your doctor, if:

You have severely unusual menstrual cramps or cramps, and/or;
Your cramps last longer than 2 or 3 days.

You can get proper treatments for primary and secondary menstrual cramps. Therefore, in the case of the alerts mentioned above, it is essential to get a check-up.

How do you test for Dysmenorrhea?

Your doctor will ask you to delineate your symptoms and menstrual cycles.
You will receive a pelvic exam:
1. Used to examine the following in a woman’s body:

Uterus (womb)
Fallopian tubes (or oviducts, carry eggs to the womb/uterus from the ovary)
Bladder (the sac that holds the urine)
Cervix (connects the vagina and the uterus)
Ovaries (glands that produce eggs)
Rectum (chamber connecting the colon to the anus)
1. Pelvic exam procedure step by step:
Change from personal clothes to a gown (given to you by your doctor/nurse)
Share details about your health concerns
Lie on your back
Your doctor will press down on the lower stomach and feel the organs.
Your doctor/nurse will then help you get in position for speculum exam:
- A speculum is inserted into your vagina.
- The speculum is opened to check-up the widened vagina and the cervix.
With your knees bent you will have to place your feet in holders called stirrups.
Your doctor will then perform a Pap Smear:
- Use a plastic spatula to collect samples from your cervix.
- A fluid sample is taken from the vagina to check for infection.
The speculum is removed.
Your doctor will then perform a manual exam:
- One or two fingers placed inside the vagina and the other hand gently press down on the area that the doctor is checking.
- Your doctor will note the changes in the size and shape of the organs if any.
You may also get a rectal exam:
- Your doctor will insert a gloved finger into your rectum to detect potential tumours or abnormalities.

Based on the test results conducted thus far, if secondary Dysmenorrhea is suspected, you may have to undergo further tests.
Based on medical problems(if any) that the test results implicate, your doctor will recommend possible treatments.

Alert: Immediately contact your healthcare provider, if you use tampons and you are noticing any of the following symptoms:

Fever over 102 degrees Fahrenheit
Vomiting
Diarrhoea
Dizziness, fainting or near fainting
Rashes that look like sunburn

These symptoms indicate Toxic Shock Syndrome, a life-threatening illness.

A comparison of the diagnosis for primary and secondary Dysmenorrhea:

Primary Dysmenorrhea	Secondary Dysmenorrhea
Starts shortly after the first menstrual cycle.	Can start any time after the first menstrual cycle (generally after 25 years of age).
Examinations and tests don’t result in any abnormal findings.	Pelvic abnormality could be diagnosed in the physical examination.
Symptoms include headache, vomiting, back and thigh pain, headache, diarrhoea and nausea.	Other gynaecological symptoms may occur
Abdominal pain lasts for 9-72 hours	Duration and intensity of pain vary.

What is the best treatment for Dysmenorrhea?

Dysmenorrhea has a significant impact on the quality of life and the general well-being of women. However, very few women seek treatment. This is because of the common misconception that treatment would not help.

The treatments for Dysmenorrhea attempt at curing the physiological mechanisms that underlie menstrual pain (like prostaglandin production). This goal of these treatments is to:

Decrease pain
Alleviate symptoms

You can follow the below-mentioned measures to get relief from mild Dysmenorrhea:

Possible medications (to be consumed only after consulting with your doctor):
- Simple Analgesics: e.g., aspirin, paracetamol are right medicines to start with.
- Non-steroidal anti-inflammatory drugs (NSAIDs): On average,65%of women get pain relief with NSAIDs.
- Ibuprofen, when the bleeding or cramping starts. Or any other anti-inflammatory medication (the recommended dosage is higher than what is available over-the-counter)
- Pain relievers, such as aspirin, acetaminophen
Herbal Medication and dietary supplements:
Vitamin B1: Based on one study consumption of 100mg of Thiamine or Vitamin B-1 for two months cured Dysmenorrhea in 87% of the people. Thiamine, therefore, can be an efficient cure against Dysmenorrhea.
Fish oil: Even though the efficacy of fish oil is yet to be substantiated by more evidence, fish oil capsules (containing omega 3 fatty acids) can potentially decrease the pain
Vitamin B6 supplements and magnesium: When taken together, these can potentially decrease pain. However, these need to be backed by further clinical trials.
Oral Contraceptives: These are prescribed to alleviate the pain and can be considered for women who want to avoid pregnancy.
Surgery: If all treatments fail to work, your doctors may suggest surgery. The type of surgery depends on the source of the pain. In some cases, fibroids can be removed if they are causing the pain. It is possible to remove the Endometriosis tissue during surgery. However, they may return after the surgery. Therefore it offers short term relief from pain. Your doctor may recommend you to take hormonal birth control or other medications to delay or completely stop the pain from returning.

Alert: Hysterectomy is a major surgical procedure in which the uterus is removed. It is the last resort of the healthcare providers. This is recommended only if :

o All other treatments have failed

o The pain is very critical

o Heavy menstrual bleeding

Avoid:
- Caffeine-containing food
- Smoking
- Alcohol consumption
For pain in your lower back and abdomen:
- Place a heating pad or hot water bottle.
- Massage
Rest as much as possible, don’t strain yourself too much.
Exercise regularly. Studies have so far not confirmed that physical activity can provide complete protection against Dysmenorrhea. However, there is a strong hypothesis that suggests exercising can reduce the effects.

Can I permanently get rid of Dysmenorrhea?

With proper choice of treatments, both primary and secondary Dysmenorrhea can be treated.

Reference:

By -
Dr. Ruchika Singh

14-April-2023

Dysmenorrhea

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