Dysmenorrhea

A review of the clinical features, diagnosis and management of primary and secondary dysmenorrhea updates some old views. Dysmenorrhea is painful menstruation, either cramps with no visible cause, primary dysmenorrhea, or secondary to specific pelvic pathology. Primary dysmenorrhea occurs in as many as 50% of young women, only in ovulatory cycles, and usually limited to the first 48 or 72 hours of menstruation. Secondary dysmenorrhea can be caused by any of a dozen or so disorders such as endometriosis, pelvic inflammatory disease, IUDs, irregular cycles or infertility problems, ovarian cysts, adenomyosis, uterine myomas or polyps, intrauterine adhesions or cervical stenosis. Psychological factors are now known not to cause dysmenorrhea, only to add to the reactive component of the pain. The pain is due to uterine cramps, hypoxia or ischemia, due to overproduction of prostaglandins, leukotrienes or vasopressin. Thus, primary dysmenorrhea can be treated with oral contraceptives if the women wishes to take pills for contraception and they are not contraindicated, or with non-steroidal antiinflammatory agents for the full 72 hours after pain begins. Calcium channel-blockers are also used on a research basis; transcutaneous electrical nerve stimulation is sometimes effective. If these treatments are not effective, investigation for causes of secondary dysmenorrhea is indicated, preferably for laparoscopy.     

Dysmenorrhea

Affecting over 50% of menstruating women, dysmenorrhea results in absenteeism and economic loss. In primary dysmenorrhea there is no macroscopically identifiable pelvic pathology. In secondary dysmenorrhea gross pelvic pathology in present. With primary dysmenorrhea, the pain is suprapubic, spasmodic, lasts for 48–72 h and is most severe during the first or second day of menstruation. Characteristically, dysmenorrhea starts at or shortly after menarche. The pathophysiology in primary dysmenorrhea is due to increased and/or abnormal uterine activity because of the excessive production and release of uterine prostaglandins. Treatment with many non-steroidal anti-inflammatory drugs (NSAIDs) that are prostaglandin synthetase inhibitors will produce relief from dysmenorrhea and a concomitant decrease in menstrual fluid prostaglandins. For those desiring oral contraception or who cannot use NSAIDs, the oral contraceptive pill will relieve dysmenorrhea by suppressing endometrial growth, thus resulting in a decrease in the menstrual flow as well as in menstrual fluid prostaglandins. Laparoscopy is needed if a pelvic abnormality is detected on examination or if medical treatment for up to 6 months is unsuccessful.In secondary dysmenorrhea, relief is obtained when the pelvic pathology is treated. Dysmenorrhea and menorrhagia due to intrauterine contraceptive devices are controlled with NSAIDs.     

Correlates of Dysmenorrhea

A study was conducted to explore the relationship of demographic variables, gynecologic history variables, and menstrual attitudes to three measures of dysmenorrhea derived from the Menstrual Distress Questionnaire. One hundred ninety-three women, 18 to 35 years old, from five neighborhoods in a large, metropolitan city comprised the sample population. The strongest correlates found were attitudes toward menstruation, though associations between dysmenorrhea and items reflecting traditional/feminist dimensions were absent. Further precision in defining dysmenorrhea and a comprehensive, health-oriented approach to dealing with menstrual distress is indicated. Recommendations about the nurse's role in counseling dysmenorrheic women and promoting more positive menstrual attitudes are discussed.     

Dysmenorrhea: contemporary perspectives

Dysmenorrhea affects up to 80% of reproductive age women, in many cases causing sufficient pain to dramatically affect social and occupational roles. The prevalence varies across ethnic groups, which in part may reflect varying cultural attitudes toward women and menstruation. Key identified risk factors for dysmenorrhea include age of menarche, body mass, dietary habits, associated uterine bleeding disorders, comorbid pelvic pathology, and psychosocial problems. While much of the focus on the pathogenesis of dysmenorrhea has focused on aberrant inflammatory mediators in the uterine environment, recent studies using experimental quantitative sensory testing suggest central processing of pain is enhanced in many of these women as well, similar to both irritable bowel syndrome and painful bladder syndrome, which are closely related visceral pain disorders. The mainstays of treatment include nonsteroidal antiinflammatories and combined oral contraceptives; although only the former has extensive level I evidence to support its efficacy. Surgical treatments (presacral neurectomy or uterosacral nerve ablation) appear to be beneficial in a subset of women, but are associated with small, but serious, risks of visceral or vascular injury. Complementary and alternative treatments such as vitamin B1 and magnesium supplementation have not been studied as extensively but show some promise as well. In particular, treatments targeting central aberrations in pain processing, as used in chronic pain management, may prove beneficial as a more multidimensional approach to this common malady is accepted in our field.     

Dysmenorrhea and cold exposure

As part of a health study undertaken at the request of the employees of eight Quebec poultry slaughterhouses, 213 women workers and 105 housewives responded to a self-administered questionnaire on menstruation. The prevalence of dysmenorrhea among the workers was determined for the last menstrual period and compared with that in the reference group, consisting of full-time housewives married to male slaughterhouse workers. The women slaughterhouse workers had a significantly higher prevalence of dysmenorrhea (73.2%) than the housewives (52.5%) (alpha less than 0.001). This difference was analyzed with respect to factors reported to be related to dysmenorrhea--age, parity, oral contraceptive use and menstrual regularity. Forty-four slaughterhouse workers took sick leave during their last menstrual cycle. The relationship between the prevalence of dysmenorrhea, sick leave and cold exposure at the workplace was examined. Among the workers the prevalence of dysmenorrhea and sick leave increased with increasing cold exposure (alpha less than 0.05 and less than 0.02, respectively). An analysis of the relationship of dysmenorrhea to cold exposure with respect to age, parity, oral contraceptive use and menstrual regularity revealed that factors usually associated with a lower frequency of dysmenorrhea do not apply to women working in a cold environment. These findings indicate that cold exposure influences the menstrual process.     

Dysmenorrhea among Japanese women.

OBJECTIVE: To investigate the epidemiology of dysmenorrhea in Japanese women of menstrual age. METHODS: A prospective cohort study was conducted using a health diary in a sample representative of Japanese women. Information on health care use was also collected. RESULTS: Among 823 enrolled participants (age range, 18-51 years), dysmenorrhea (mean duration 1.75 days; range 1-5 days) was reported in 15.8% (95% CI, 13.3-18.3) during the 1-month study period. Common associated symptoms included headache (10.77%), back pain (6.92%), and fatigue (5.38%). No participant with dysmenorrhea visited a physician, while 51.5% of the women used self-medication, and 7.7% used complementary/alternative medicine. CONCLUSION: Dysmenorrhea is common in Japanese women. In our study, about half used self-medication, while some preferred complementary/alternative medicine. Dysmenorrhea is significantly associated with younger age and employment status.     

Dysmenorrhea and Endometriosis in Transgender Adolescents

Study ObjectiveTo study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes.DesignA retrospective review.SettingBoston Children's Hospital.ParticipantsTransmasculine persons younger than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020.InterventionsNot applicable.Main Outcome MeasuresAn electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes.ResultsDysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20 months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies.ConclusionTo our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.     

Dysmenorrhea in pediatric and adolescent gynaecology

Dysmenorrhea is the most common problem in pediatric and adolescent gynaecology and it reaches approximately 20-90% of adolescents and young adult females. Dysmenorrhea in adolescent girls is usually primary and is associated with normal ovulatory cycles and with no pelvic pathology. Secondary dysmenorrhea, associated with some pelvic pathology, constitutes approximately 10% of the cases and its most frequent reasons are: endometriosis, pelvic inflammatory disease, congenital mullerian anomalies and ovarian cysts. Prostaglandins and leukotriens play a significant role in etiopathogenesis of the primary dysmenorrhea. The therapy of the primary dysmenorrheal in adolescent girls involves: nonsteroidal anti-inflammatory drugs for at least 3 months, combined with oral contraceptives for at least 3-6 menstrual cycles, as well as dietary supplementation, other alternative therapies (vitamins, herbal remedies, acupuncture, TENS) and surgical treatment Secondary causes of dysmenorrhea should be considered in adolescents with dysmenorrhea who do not respond to the treatment. The role of the pediatric and adolescent gynaecologist is to diagnose the reason of symptoms, educate the patient, review effective treatment options as well as to restore normal daily functioning.     

Dysmenorrhea: treatment with an antiprostaglandin.

Painful menses, one of the most frequent gynecologic complaints, is incapacitating for many women. It has recently been proposed that increased endometrial prostaglandin production and prostaglandin-induced myometrial contractility may be responsible for dysmenorrhea. In this prospective, double-blind, 3-way, crossover study, relief of pain by an antiprostaglanding drug, ibuprofen (400 mg), was compared with propoxyphene (64 mg) and placebo in 22 women with severe primary dysmenorrhea. Ibuprofen was significantly more effective in 18 patients when compared to the other 2 treatment regimens (P less than 0.001), while propoxyphene was superior to placebo in 13 patients (P less than 0.05). Prostaglandin E and F synthesis rates in endometrial biopsy specimens taken on the second day of treatment in 2 patients during each treatment cycle were lowest during ibuprofen in one case but showed no definite pattern in the second.     

The Effects of a Dysmenorrhea Support Program on University Students Who Had Primary Dysmenorrhea: A Randomized Controlled Study

Study ObjectiveThis study aims to determine the results of a cognitive-behavioral approach in a dysmenorrhea support program that covers the symptoms, acquaintance, and attitudes toward menstruation of university students who had primary dysmenorrhea.Design and SettingThis randomized controlled, prospective, experimental study was carried out in a nursing school using a pretest-posttest design.ParticipantsA total of 682 female nursing students and 584 volunteers from the 2017-2018 academic year participated in a study of the prevalence of primary dysmenorrhea (94.0%). Study subjects were first-year female nursing students who scored severe on a visual analog scale for primary dysmenorrhea. As a result of the analysis, 80 female nursing students were assigned to study and control groups. A total of 60 students, 29 in the study group and 31 in the control group, completed the study.InterventionThe study group participated in a 6-session cognitive-behavioral approach in a dysmenorrhea support program. No intervention was administered to the control group. The control group and the study group were followed by using data collection forms during three menstrual cycles.Outcome MeasuresThe Participant Introductory Form (PIF), Dysmenorrhea Follow-up Form (DFF), Dysmenorrhea Information Form (DIF), Functional and Emotional Dysmenorrhea Scale (FEDS), Visual Analog Scale (VAS), and Menstrual Attitude Questionnaire (MAQ) were used to measure outcomes.ResultsIn the case of primary dysmenorrhea, the use of nonpharmacological methods was higher in the study group than in the control group. In the third cycle, although the rate of analgesics use was 20.7% in the study group, it was 50% in the control group. Primary dysmenorrhea symptoms, pain levels, and analgesic use decreased. No change was observed in the attitude toward menstruation.ConclusionA cost-effective, reliable, cognitive-behavioral approach−based dysmenorrhea support program can be used to relieve symptoms, decrease the use of analgesics, and increase knowledge about primary dysmenorrhea.     

Rates of Anovulation in Adolescents and Young Adults with Moderate to Severe Primary Dysmenorrhea and Those without Primary Dysmenorrhea

Study Objective

To evaluate rates of presumptive anovulation in eumenorrheic adolescents and young adults with moderate to severe primary dysmenorrhea and those without primary dysmenorrhea.