Dysmenorrhoea, also known as painful
menstruation, 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.
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Approximately 30–50% of all women suffer from
dysmenorrhoea during their menstrual periods.
According to 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.
What is dysmenorrhoea?
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 and is requiring medical
attention. Most women experience dysmenorrhoea 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 palpitation,
sweating and headache. Usually, the pain starts at the beginning of the
period lasting for a few hours, but in some women it may continue for
several days.
Different types of dysmenorrhoea
Two types of dysmenorrhoea are distinguished, namely:
primary dysmenorrhoea, and
secondary dysmenorrhoea.
Primary dysmenorrhoea
Primary dysmenorrhoea is pain during menstruation
for which no organic cause can be found. It is characterised by sharp
pains or cramps which present as spasmodic or colicky sensation, sometimes described as labour-like
pain.
Prevalence
Most women suffer from primary dysmenorrhoea. It occurs mainly in young women
in their early teens (who have just started to menstruate) 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 muscles
fibres, often cause an end to primary dysmenorrhoea in many women.
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. 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. The constricting and tightening of the muscles are responsible for the sharp pains that are sometimes felt in the inner thighs and lower abdomen. 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.
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 characterised by
pain, usually felt more to one side, which occurs at the time of
menstruation, the pain being secondary due to an organic cause.
Rarely, a
personality factor with a conditioned behaviour or psychosexual disorder may be present. This is sometimes referred to as psychogenic dysmenorrhoea, 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
The doctor will establish the organic disorder, which may occur at any
age, by taking a detailed history and performing a medical examination. An
organic cause should also be considered if a woman does not respond to standard treatment for suspected primary dysmenorrhoea. The organic cause may be an underlying disease or structural abnormality inside or outside the uterus, such as:
Endometriosis
Pelvic inflammatory disease
Fibroid tumours of the uterus
Endometrial polyps
Structural abnormalities of the genital tract
Pelvic congestion syndrome
Cervical stenosis
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 becoming worse during menstruation. Furthermore, the
patient can suffer from pain during sexual intercourse and may present with
infertility.
The
term "endometriosis" refers to the endometrium (the inner lining of the uterus), and the disease
is characterised by implants of endometrium (so-called ectopic or out-of-place endometrium) growing
outside the uterine cavity. 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, all
endometrial tissue irrespective of location, starts to bleed. While blood
from the uterine cavity lining can leave the body through the cervix and vagina, bleeding
from endometrial implants at all ectopic (out-of-place)
sites becomes trapped leading to the formation of
blood-containing cysts. With each menstruation these cysts 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 which the disease causes in the reproductive tract. In
advanced cases of endometriosis, a hysterectomy with removal of the implant
areas even including the ovaries may become necessary.
Pelvic inflammatory disease (PID)
This serious infection may involve the
uterus and fallopian tubes, initially without and later with the ovaries and
other pelvic structures. Symptoms include fever, chills, back pain, an
abnormal vaginal discharge, 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 called myomas or
leiomyomas)
Such 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 is oestrogen-dependent. This means that they can
become larger during pregnancy with the increased production of oestrogens, 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 (sometimes necessitating a hysterectomy).
Endometrial polyps
Polyps which develop from the
endometrium, may fill the uterine cavity in the same way like 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 like
endometriosis.
Pelvic congestion syndrome
This refers to 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 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)
How is it treated?
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:
A diet with increased intake of magnesium, calcium,
vitamin B-1 and omega-3 fatty acid containing food such as fish and
fish-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
Whether or not to use a 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 sometimes customary in the past. 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) are up to 90%
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.
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 (absence of menstruation).
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. A hysterectomy may be indicated in cases of advanced endometriosis or large fibroids.
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). 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.
Reviewed by Prof B. Schaetzing, MD, FCOG(SA), FRCOG, PhD. Part-time Consultant, Dept of Obstetrics & Gynaecology, Faculty of Health Sciences, University of Stellenbosch.
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