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Updated 13 February 2013

Dysmenorrhoea

Dysmenorrhoea is described as menstrual pain that is severe enough to limit a woman’s normal activities and requires medical attention.

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 Summary

  • Dysmenorrhoea, also known as painful menstruation or periods, is one of the most common health care problems in women during their reproductive years. It is also one of the main causes of absenteeism from school or work, and affects the quality of women’s lives.
  • Approximately 30–50% of all women suffer from dysmenorrhoea during their menstrual periods.
  • Depending on the cause, painful menstruation is traditionally classified as primary or secondary dysmenorrhoea. Primary dysmenorrhoea, also called menstrual cramps, is related to prostaglandins, certain hormones that are produced naturally in the body. Secondary dysmenorrhoea is the occurrence of pelvic pain, together with menstruation, due to a disease within the pelvis.
  • Primary dysmenorrhoea is more common in younger women and can present in teenagers within three years of their menarche (first menstrual period).
  • Secondary dysmenorrhoea can occur at any age and is related to a number of medical conditions.

Definition

Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhoea is described as menstrual pain that is severe enough to limit a woman’s normal activities, requiring medical attention. Most women experience dysmenorrhoeaat some time during their lives. During menstrual periods, the pain a woman is suffering can be so severe that she is unable to carry on with her normal activities. She may also experience other symptoms such as nausea, vomiting, heart palpitations, sweating and headache.

Different types

Two types of dysmenorrhoea are distinguished, namely:

  • Primary dysmenorrhoea
  • Secondary dysmenorrhoea

Primary dysmenorrhoea

Primary dysmenorrhoea is pain during menstruation where there is no underlying disease or disorder of the uterus (womb) or in the pelvis. It is characterised by a cramping lower abdominal pain that may radiate to the lower back and upper thighs, sometimes described as similar to labour pains.  The pain usually starts few hours before, or with the start of the menses and is usually most intense the first and second day.

Prevalence

Most women suffer from primary dysmenorrhoea. It occurs mainly in young women in their teens to late twenties. It is also more common in women who have never had children. Pregnancy and childbirth, with the associated increase and stretching of uterine muscle fibres, often cause an end to primary dysmenorrhoea.

Risk Factors for primary dysmenorrhoea
  • Heavy menstrual flow both in duration and flow
  • Young age, <20yrs
  • Never having been pregnant
  • First menstruation started <12yrs
  • Smoking
  • Overweight and obesity
  • Underweight
  • Strong family history  (mother and sisters having dysmenorrhoea)
  • High levels of stress, anxiety and depression
Cause

The real causative mechanism for primary dysmenorrhoea is not known, but it appears that a major role is played by a group of hormones called prostaglandins, which are present in various body tissues, including the uterus (womb). Prostaglandins influence the tension and constriction of muscles of the uterus and of blood vessels, which not only cause menstrual cramps but may also be responsible for general symptoms like headache, nausea and vomiting. As there is less blood circulation and oxygenation to the uterus, waste products such as carbon dioxide and lactic acid may accumulate, which in turn intensifies the pain and discomfort. The uterine contractions that occur during menstruation help expel the shed inner lining of the uterus (endometrium). Women with severe dysmenorrhoea have higher levels of prostaglandins, which results in more frequent and forceful uterine contractions.

Prostaglandins are made inside the tissue from precursors such as fatty acids, which increase after ovulation. Research has shown that women, who do not ovulate, do not experience cramps, and primary dysmenorrhoea can be treated by inhibiting ovulation with oral contraceptives. This has led to the conclusion that an imbalance of oestrogens and progesterone, the main hormones of the menstrual cycle, may play a role.

Secondary dysmenorrhoea

Secondary dysmenorrhoea is painful menstruation that occurs in the presence of an underlying disorder or pelvic pathology. The symptoms and the patterns of pain will depend on the underlying cause.

Rarely a personality factor with a conditionedbehaviour or psychosexual disorder may be present. This is sometimes referred to as psychogenicdysmenorrhoea, which is attributed to an unpleasant sexual experience or a lack of information about menstruation and sexuality, combined with negative attitudes towards sex.

Prevalence

Secondary dysmenorrhoea most frequently occurs in women in their late thirties or forties. For these women, menstruation may unexpectedly become painful after years of pain-free menstrual periods. Secondary dysmenorrhoea, however, is less prevalent than primary dysmenorrhoea.

Cause

An underlying cause should be considered if a woman does not respond to standard treatment for suspected primary dysmenorrhoea. Non-gynaecological disorders may also present with cyclic pelvic pain, for example irritable bowel syndrome (spastic colon) and interstitial cystitis (painful bladder syndrome).

The cause of secondary dysmenorrhoea can be situated inside the cavity, in the muscle layer and outside the uterus.

  • Extrauterine(outside the uterus)
    • Endometriosis
    • Pelvic inflammatory disease
    • Pelvic congestion syndrome
    • Adhesions
    • Structural abnormalities of the genital tract
  • Intramural (within the muscle layer of the uterus)
    • Adenomyosis
    • Fibroids/ leiomyomata
  • Intrauterine (within the cavity of the uterus)
    • Submucous fibroids (fibroids projecting into the uterine cavity)
    • Polyps
    • Intrauterine device
    • Cervical stenosis
    • Infection

Endometriosis
Endometriosis is the main cause of secondary dysmenorrhoea and may be present with a false diagnosis of primary dysmenorrhoea. The main symptom is pain which may start several days before and then become worse during menstruation. Furthermore, the patient can suffer from pain during sexual intercourse (dyspareunia) and may present with infertility.

The term "endometriosis" refers to tissue similar to the endometrium that is implanted and growing outside the uterine cavity (so-called ectopic or out-of-place endometrium). Ectopic endometrium can develop at any area in the pelvic cavity, including the fallopian tubes, the ovaries and even the intestines. If endometrial tissue appears within the muscle wall of the uterus, the condition is referred to as adenomyosis. At the onset of menstruation, bleeding from ectopic endometrial implants becomes trapped, leading to the formation of blood-containing cysts, which expand and cause pain.

During absence of menstruation, no expansion occurs, and this is the reason why pregnancy helps for endometriosis. However, women who suffer from endometriosis are more likely to become infertile due to the scarring and other structural damage caused by the disease in the reproductive tract.

Pelvic inflammatory disease (PID)
This serious infection may involve the uterus and fallopian tubes, initially without and later within the ovaries and other pelvic structures. Symptoms include fever, chills, back pain, an abnormal vaginal discharge, and pain during or after intercourse and spotting. PID requires quick diagnosis and medical treatment to prevent scarring of the reproductive organs with subsequent infertility. If PID recurs and becomes chronic, it can cause the formation of adhesions of the pelvic organs with associated menstrual pain.

Fibroid tumours of the uterus (also calledmyomasor leiomyomata)
These tumours develop as excessive growth of the uterine muscle tissue and are most prevalent in women in their reproductive years. They are benign and their growth isoestrogen-dependent. This means that they can become larger during pregnancy with the increased production ofoestrogens, and also that they shrink after menopause when oestrogen levels decrease. The tumours may increase the size of the uterus to that of a pregnant woman. Fibroids can cause menstrual cramps and can be responsible for additional pain when they press against the bladder and bowel (causing frequent urination and bowel symptoms), or when they become so large that they outgrow their own blood supply. Apart from menstrual cramps and pelvic pain, fibroid tumours can cause excessive menstrual bleeding.

Endometrial polyps
Polyps, which develop from the endometrium, may fill the uterine cavity in the same way as a submucosal fibroid which has grown beneath the endometrial lining (or: mucosa). The uterine muscles contract around these tumours, trying to expel them, hereby causing labour-like contraction pains. The doctor will identify polyps and submucosal fibroids by ultrasonography or by looking inside the uterine cavity with an endoscope (hysteroscopy).

Structural abnormalities of the genital tract
This refers to the very rare condition of a congenital defect, for example, when the uterus is malformed and has a horn. This horn may be lined with endometrium but may not have a connection with the uterine cavity. During periods, the menstrual blood is trapped inside the horn with a similar effect to endometriosis.

Pelvic congestion syndrome
This refers to the engorgement of blood vessels within the pelvic cavity. When examined by the doctor with laparoscopy (inspection of the organs inside the abdomen through an endoscope), varicose veins are visible at the pelvic side walls and in the ligaments attached to the uterus.

Cervical stenosis
If the cervical canal, which links the uterine cavity to the vagina, is severely narrowed, menstrual flow is inhibited, causing a build-up of shed endometrium and blood inside the uterus with subsequent cramps. The stenosis (narrowing) may be congenital or due to infection or trauma of the cervix following previous operations. The condition may improve after pregnancy and vaginal delivery.

When to see a doctor

Whether you suffer from primary or secondary dysmenorrhoea, always call your health professional when:

  • Menstrual pain is so severe that it disrupts your life
  • Menstrual periods always hurt
  • Over-the-counter medications do not provide relief
  • Unexplained symptoms accompany painful periods
  • If your period is a week or two later than expected and you are bleeding heavily (you may have a miscarriage)
  • If your period is a few weeks later than expected and you have severe pain on one side (it may indicate an ectopic pregnancy)

Diagnosis

When seeking medical attention, patients who report cyclic pain during menstruation may have other diseases such as appendicitis, ectopic pregnancy and ovarian cysts, which all have to be differentiated from conditions which cause dysmenorrhoea. Another possible misdiagnosis can occur when patients are thought to have primary dysmenorrhoea while they are actually suffering from secondary dysmenorrhoea due to endometriosis.

Primary or secondary dysmenorrhoea can only be diagnosed after:

  • A thorough medical history has been taken. The health professional will enquire about the patient’s menstrual history, such as:
  • The quantity of menstruation (was the amount of bleeding with the last menstrual period normal or excessive?)
  • Time pattern of menstrual periods (does the patient have periods at regular intervals?)
  • Self-treatment (how effective were home remedies?)
  • Other symptoms
  • A thorough physical examination, which includes a gynaecological examination. If the patient is a virgin, digital palpation through the vagina will be replaced by a rectal examination.

Other diagnostic tests that may be performed include:

  • Abdominal or transvaginal ultrasound scan of the pelvic organs
  • Hysteroscopy with or without dilatation of the cervix (looking into the uterus with a thin fibre-optic endoscope which can be attached to a video-camera)
  • Laparoscopy (looking into the abdomen with a similar endoscope)
  • Blood tests and cultures (to rule out sexually transmitted diseases such as gonorrhoea, syphilis or chlamydia infections)

Treatment

Home remedies

Treatment for primary dysmenorrhoea focuses on pain relief. Women who suffer from primary dysmenorrhoea are usually advised to relieve menstrual cramps with the following home remedies:

  • Increase intake of magnesium, calcium, vitamin B-1, vitamin B-6 and vitamin E
  • The modern western diet with high levels of omega-6 fatty acids contributes to higher levels of prostaglandins which cause the painful menstrual cramps. A diet containing omega-3 fatty acids such as fish and fish-oil helps restore the balance. The richest dietary source of omega-3 fatty acids is found in flax oil.
  • Heat (with a warm bath/shower or a hot water bottle, applied to the lower abdomen)
  • Relaxation techniques, supported by deep breathing and light abdominal massage with stroking fingers
  • Exercise, such as waist-bending, pelvic rock exercises and walking
  • Drinking warm beverages may be helpful.

Medication/ pharmacological methods

Whether or not to use medication and what type of treatment should be administered is best decided by a doctor who will diagnose and differentiate between primary and secondary dysmenorrhoea. For primary dysmenorrhoea, the following drugs have been used successfully, some of which are available as over-the-counter medicines:

  • Several non-steroidal anti-inflammatory drugs (NSAIDs) are beneficial in the management of menstrual cramps. Their mode of action is inhibiting the production and release of prostaglandins. There are different types of NSAIDs available such as: mefenamic acid (Ponstan®), naproxen (Naprosyn®), and ibuprofen (Nurofen® Ibumed®). The response to these drugs can vary and some women may only find relief by switching from one type of brand to another one after one or two menstrual cycles. These medicines are taken from the beginning of the period through the first two to three days. Taking them with food can minimise side-effects such as nausea and diarrhoea. Usually, NSAIDs become effective within 30-60 minutes, and it is not necessary to start two to three days before the period as it was previously customary. Since there are certain contraindications for NSAIDs (e.g. stomach ulcer and others), advice on these drugs for treating dysmenorrhoea needs to be obtained from a health professional.
  • Aspirin, also used for alleviating primary dysmenorrhoea, is not recommended since it is not strong enough in the usual dosage to reach sufficient anti-prostaglandin activity.
  • Oral contraceptives (OCs) or the “pill” are effective for treating primary dysmenorrhoea. Their mode of action is the inhibition of ovulation and the reduction of menstrual flow. For women who suffer from primary dysmenorrhoea and who require contraception, using OCs is the first-line treatment.
  • Extended-cycles with oral contraceptives. An alternative method of use of the “pill” is to drink the placebo tablets that induce a withdrawal bleed once every 9 weeks (i.e. after drinking only the active pills of 3 packets) instead of monthly cycles. This is known as tricycling. Even longer extended-cycles have been used. Extended-cycles have been associated with less dysmenorrhoea than monthly cycles, but can result in breakthrough spotting/ bleeding.
  • Other hormonal therapies/contraception that induce amenorrhoea (absence of menstruation) can be used, such as intramuscular injectable depotmedroxyprogesterone acetate (Petogen® or Depo Provera®), or the levonorgestrel intrauterine system (Mirena®).

For secondary dysmenorrhoea, medication is aimed at the underlying disease:

  • For pelvic inflammatory disease, antibiotics will be prescribed. The choice of antibiotics is influenced by the detection of specific micro-organisms at the laboratory from culture specimens of the patient.
  • For endometriosis, a number of drugs are available including NSAIDs to inhibit prostaglandin production by ectopic endometrium, and continuous treatment with different hormone regimens to induce amenorrhoea.

Non-pharmacological methods

  • Transcutaneous electrical nerve stimulation (TENS) is the use of a device placed over the skin which uses electrical current to stimulate nerves. This stimulates endorphins from the peripheral nerves and spinal cord and also results in a lower perception of painful uterine signals. High frequency TENS has been found to be effective for dysmenorrhoea, but less so than medication
  • Complementary or alternative medicine (e.g. acupuncture). There is little current evidence to support these methods.
  • Spinal manipulation offered by physiotherapists, osteopaths or chiropractors has not been found to be effective for relief of dysmenorrhoea.
  • Behavioural interventions include ways to alter the woman’s perception and response to the pain. Examples of these are hypnotherapy, imagery, coping strategies and relaxation techniques. There is no strong evidence to prove their efficacy.

Surgery

This may be necessary in women who cannot obtain adequate pain relief or control, and is especially indicated in secondary dysmenorrhoea to remove endometriotic cysts, polyps, adhesions and fibroids. There are various methods of surgery, depending on the underlying condition. This can be done either via laparoscopy, laparotomy (open incision into the abdomen) or hysteroscopy. A hysterectomy (surgical removal of uterus) may be indicated in cases of adenomyosis and large fibroids.  A hysterectomy with or without the removal of the ovaries should be considered only as a last resort for endometriosis, as it is a condition which is situated outside the uterus (ectopic sites). Removing the uterus solely because of endometriosis will not guarantee relief of symptoms.

Interruption of the sensory nerves supplying the uterus can be performed by means of a presacral neurectomy or laparoscopic uterosacral nerve ablation (LUNA), meaning the cutting of the nerves, which run in the uterosacral ligaments (in the ligaments from the uterus to the sacrum bone of the pelvis). There is limited evidence that LUNA offers relief for primarydysmenorrhoea. However, LUNA does not appear to be effective for women suffering from chronic pelvic pain and endometriosis. Presacral neurectomy has been found to be effective in those with midline abdominal pain but not for those with pain in the right and/ or left sides of the pelvis. The benefits of LUNA and presecral neurectomy appear to decline with time and therefore are not routinely recommended. These operations are very rarely performed and only in patients with severe dysmenorrhoea who do not respond satisfactorily to other medical and/or surgical treatment. They should only be performed by a highly experienced surgeon.

Reviewed by Prof B. Schaetzing, MD, FCOG (SA), FRCOG, PhD. Part-time Consultant, Dept of Obstetrics & Gynaecology, Faculty of Health Sciences, University of Stellenbosch

Updated by Dr Judith Kluge,MB ChB, FCOG (SA), MRCOG. Dept of Obstetrics & Gynaecology, Tygerberg Academic Hospital, University of Stellenbosch, December 2010

 
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