What is dysmenorrhea?

Causes and Symptoms

Dysmenorrhea is classified into primary and secondary dysmenorrhea. In primary dysmenorrhea, no organic cause of the menstrual pain
is found, although multiple theories exist in the medical literature as to why pain occurs. Dysmenorrhea is associated with a number of psychological symptoms, including depression, irritability, and insomnia, although it is not clear whether these psychological symptoms are causes or effects.

Secondary dysmenorrhea is painful menstruation that occurs in the setting of a known pelvic disease, such as endometriosis
or adenomyosis; an infection such as endometritis, Pelvic inflammatory disease (PID), or a sexually transmitted disease; or anatomic abnormalities, such as uterine fibroids, ovarian cysts, or developmental abnormalities of the uterus, cervix, or vagina. Other potential factors include inflammatory bowel disease (IBD), use of a copper intrauterine device (IUD), and scar tissue from surgery.

The symptoms of dysmenorrhea involve dull lower abdominal pain or cramping at the midline. The discomfort may radiate to the lower back or thighs. It can be associated with a number of other symptoms, most commonly nausea and vomiting or fatigue. Dysmenorrhea can occur up to one to two days before the onset of menstrual flow and usually lasts for forty-eight to seventy-two hours. The most severe pain usually occurs on the first day of menstrual flow.

Treatment and Therapy

Treatment is recommended if dysmenorrhea interferes with the activities of daily living. The two most common treatments are hormones and nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is particularly effective and commonly prescribed in doses of 600 and even 800 milligrams every six hours, which exceeds the over-the-counter limits of 400 milligrams every six hours. Ibuprofen should never be taken on an empty stomach or by women with gastric conditions that are contraindications to the drug. In women who do not desire pregnancy, combined hormonal contraception, either in the form of birth control pills, patches, vaginal rings, or hormone-containing IUDs, are an effective method of controlling dysmenorrhea, as they can reduce the volume of blood flow. A progestin-only birth control injection or implant may also be effective. If combined hormonal contraception is utilized, dosing in a continuous or extended fashion can help to reduce symptoms.

In women nearing menopause, hormones that artificially induce menopause can serve as a bridge until natural menopause occurs. In women with primary dysmenorrhea whose symptoms do not improve after six to twelve months of medical treatment, laparoscopy may be considered to search for organic causes of pain.

In secondary dysmenorrhea, the treatment of any underlying pelvic disease may ameliorate the symptoms. For instance, anatomic abnormalities may be amenable to surgery. Endometriosis may be treated with hormones or removal procedures.

Pain from either primary or secondary amenorrhea is often responsive to prostaglandin synthetase inhibitors, such as ibuprofen. These drugs decrease the levels of prostaglandins (which cause uterine cramping) in the menstrual blood. Patients with psychological symptoms accompanying their dysmenorrhea may benefit from psychological counseling and therapy. In cases of dysmenorrhea that resist standard treatment, a number of alternate treatments have been tried, with varying levels of success. They include nonspecific analgesics (such as opiates), acupuncture, and even surgical procedures such as presacral neurectomy, the interruption of the nerves going to the uterus. Relaxation techniques, application of heat (such as through a heating pad or hot shower), and exercise provide relief to some women.

Bibliography

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American College of Obstetricians and Gynecologists. "Dysmenorrhea: Frequently Asked Questions." American Congress of Obstetricians and Gynecologists, July 2012.

Golub, Sharon. Periods: From Menarche to Menopause. Newbury Park, Calif.: Sage, 1992.

Kasper, Dennis L., et al., eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill, 2012.

Minkin, Mary Jane, and Carol V. Wright. The Yale Guide to Women’s Reproductive Health: From Menarche to Menopause. New Haven, Conn.: Yale University Press, 2003.

Shannon, Diane W., and Andrea Chisholm. "Painful Menstrual Periods." Health Library, September 27, 2012.

Stenchever, Morton A., et al. Comprehensive Gynecology. 5th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.

Mackay, H. Trent. "Gynecologic Disorders." In Current Medical Diagnosis and Treatment 2013, edited by Maxine A. Papadakis, Stephen J. McPhee, and Michael W. Rabow. 52d ed. New York: McGraw-Hill, 2013.