Dysmenorrhea

Alternative names :- Periods - painful (adolescent); Adolescent dysmenorrhea; Menstrual pain - adolescent; Painful menstrual periods - adolescent

Dysmenorrhea is painful menstruation associated with ovulation that isn't related to pelvic disease. It's the most common gynecologic complaint and a leading cause of absenteeism from school (affecting 10% of high school girls each month) and work (an estimate of 140 million work hours lost annually). The incidence peaks in women in their early 20s and then slowly decreases.

Dysmenorrhea can occur as a primary disorder or secondary to an underlying disease. Because primary dysmenorrhea is self-limiting, the prognosis is generally good. The prognosis for secondary dysmenorrhea depends on the underlying disease.

What causes dysmenorrhea?

Although primary dysmenorrhea is unrelated to an identifiable cause, possible contributing factors include:

• hormonal imbalance
• psychogenic factors.

Dysmenorrhea may also be secondary to such gynecologic disorders as:

• endometriosis
• cervical stenosis
• uterine leiomyomas (benign fibroid tumors)
• pelvic inflammatory disease
• pelvic tumors.

The pain of dysmenorrhea probably results from increased prostaglandin secretion in menstrual blood. which intensifies normal uterine contractions. Prostaglandins intensify myometrial smooth muscle contraction and uterine blood vessel constriction. thereby worsening the uterine hypoxia normally associated with menstruation. This combination of intense muscle contractions and hypoxia causes the intense pain of dysmenorrhea. Prostaglandins and their metabolites can also cause GI disturbances. headache. and syncope.

Because dysmenorrhea usually follows an ovulatory cycle. both the primary and secondary forms are rare during the anovulatory cycle of menses. After age 20, dysmenorrhea is generally secondary.

Symptoms of dysmenorrhea

Possible signs and symptoms of dysmenorrhea include sharp, intermittent. cramping. lower abdominal pain, usually radiating to the back. thighs, groin. and vulva. Such pain typically starts with or immediately before menstrual flow and peaks within 24 hours.

Dysmenorrhea may also be associated with signs and symptoms that suggest premenstrual syndrome. including:

• urinary frequency
• nausea
• vomiting
• diarrhea
• headache
• backache
• chills
• abdominal bloating
• painful breasts
• depression
• irritability.

A possible but rare complication of dysmenorrhea is dehydration due to nausea, vomiting. and diarrhea.

Diagnosis information

Differential diagnosis must rule out other causes of pelvic pain, including pregnancy, impending abortion. or various other disorders. Methods used to diagnose dysmenorrhea may include:

• pelvic examination and a detailed patient history to help suggest the cause
• ruling out secondary causes for menses painful since menarche (primary dysmenorrhea)
• tests, such as laparoscopy, hysteroscopy, and pelvic ultrasound. to diagnose underlying disorders in secondary dysmenorrhea.

Treatment of dysmenorrhea

Initial treatment aims to relieve pain and may include:

• analgesics. such as nonsteroidal anti-inflammatory drugs, for mild to moderate pain (most effective when taken 24 to 48 hours before onset of menses) - especially effective due to inhibition of prostaglandin synthesis through inhibition of the enzyme cyclooxygenase
• cyclooxygenase (COX)- 2-specific inhibitors, which recently have been used to relieve the pain of dysmenorrhea
• opioids for severe pain (rarely used) . prostaglandin inhibitors (such as mefenamic add [Ponstel]and ibuprofen [Advil, Motrin]) to relieve pain by decreasing the severity of uterine contractions
• heat applied locally to the lower abdomen (may relieve discomfort in mature women), used cautiously in young adolescents because appendicitis may mimic dysmenorrhea.

For primary dysmenorrhea:

• sex steroids (effective alternative to treatment with antiprostaglandins or analgesics), such as hormonal contraceptives, to relieve pain by suppressing ovulation and inhibiting endometrial prostaglandin synthesis (patients attempting pregnancy should rely on antiprostaglandin therapy)
• psychological evaluation and appropriate counseling due to possible psychogenic cause of persistently severe dysmenorrhea.

Treatment of secondary dysmenorrhea is designed to identify and correct the underlying cause and may include surgical treatment of underlying disorders, such as endometriosis or uterine leiomyomas (after conservative therapy fails).

Special considerations or prevention

Effective management of the patient with dysmenorrhea focuses on relief of symptoms, emotional support, and appropriate patient teaching. especially for the adolescent.

• Obtain a complete history focusing on the patient's gynecologic complaints, including detailed information on symptoms of pelvic disease, such as excessive bleeding. changes in bleeding pattern. vaginal discharge. and dyspareunia (painful intercourse).
• Provide thorough patient teaching, including explanation of normal female anatomy and physiology as well as the nature of dysmenorrhea (depending on circumstances, providing the adolescent patient with information on pregnancy and contraception).
• Take female hormones that prevent ovulation, such as oral contraceptives.
• Encourage the patient to keep a detailed record of her menstrual cycle and symptoms and to seek medical care if symptoms persist.

DIET

• Reduce or discontinue consumption of any caffeine containing beverages or foods.
• You may be prescribed vitamin-B supplements. These help relieve symptoms in some persons.
• Herbal teas may help reduce symptoms of dysmenorrhea for some women.