Dysmenorrhoea

 

Dysmenorrhoea

Dysmenorrhoea is defined ‘as painful menstruation. It is experienced by 45–95% of women of reproductive age’.

 

Types of dysmenorrhoea:

1.Primary dysmenorrhoea: describes painful periods since onset of menarche and is unlikely to be associated with pathology. There is some evidence to support the assertion that primary dysmenorrhoea improves after childbirth, and it also appears to decline with increasing age.

2.Secondary dysmenorrhoea: describes painful periods that have developed over time and usually have a secondary cause.

 

Aetiology of secondary dysmenorrhoea

Aetiology includes:

• Endometriosis and adenomyosis • Pelvic inflammatory disease

• Cervical stenosis and haematometra (rarely).

History and examination:

Patients will have different ideas as to what constitutes a painful period. For some patients reassurance that the pain may be normal for her will help. For others the ability to alter the menstrual cycle to avoid having a period during key events, for example school examinations or holidays, will be helpful.

To ascertain the actual severity of the pain, the following questions may be useful:

• Do you need to take painkillers for this pain? Which tablets help?

• Have you needed to take any time off work/school due to the pain?

Some primary dysmenorrhoea is associated with flushing and nausea, which may be prostaglandin related. It is important to distinguish between menstrual pain that precedes the period (a vital clue in endometriosis) and pain that only occurs with bleeding. Other important clues about the aetiology include pain that occurs with passage of clots, in which case medication to reduce flow may be effective. Secondary dysmenorrhoea may be associated with dyspareunia or AUB, which may point towards a pathological diagnosis.

An abdominal and pelvic examination should be performed (excepting adolescents). Certain signs associated with endometriosis include a pelvic mass (if an endometrioma is present), a fixed uterus (if adhesions are present) and endometriotic nodules (palpable in the pouch of Douglas or on the uterosacral

ligaments). An enlarged uterus may be found with fibroids. Abnormal discharge and tenderness may be seen with PID.

‘Red flags’ in the expression of dymenorrhoea lead the clinician to suspect serious pathology and include an abnormal cervix on examination, persistent PCB or IMB, which may indicate endometrial or cervical pathology, or a pelvic mass that is not obviously the uterus.

 

What are the symptoms of dysmenorrhea?

·         Cramping in the lower abdomen.

·         Pain in the lower abdomen.

·         Low back pain.

·         Pain radiating down the legs.

·         Nausea.

·         Vomiting.

·         Diarrhea.

·         Fatigue.

 

 

Investigations:

• High vaginal and endocervical swabs.

• TVUSS scan may be useful to detect endometriomas or appearances suggestive of adenomyosis (enlarged uterus with heterogeneous texture) or to image an enlarged uterus.

• Diagnostic laparoscopy: performed to investigate secondary dysmenorrhoea:

• when the history is suggestive of endometriosis;

• when swabs and ultrasound scan are normal, yet symptoms persist;

• when the patient wants a definite diagnosis or wants reassurance that their pelvis is normal.

Discussion about laparoscopy should include risks and the possibility that this investigation may show no obvious causes for their symptoms.

If features in the history suggest cervical stenosis, ultrasound-guided hysteroscopy can be used to investigate further. However, this condition is an infrequent cause of dysmenorrhoea, and this investigation should not be routine. Laparoscopy for primary dysmenorrhoea should not usually be performed.

 

Management:

• Non-steroidal anti-inflammatory drugs (NSAIDs):

Effective in a large proportion of women. Some examples are naproxen, ibuprofen and mefenamic acid.

• Hormonal contraceptives:

 COCP is widely used but, surprisingly, a recent review of randomized controlled trials provides little evidence supporting this treatment as being effective for primary dysmenorrhoea. Progestogens, either oral (desogestrol) or parenteral (medroxyprogesterone, etonogestrel) may be useful to cause anovulation and amenorrhoea.

• LNG-IUS:

There is evidence that this is beneficial for dysmenorrhoea and indeed can be an effective treatment for underlying causes, such as endometriosis and adenomyosis. It is often used as a first-line treatment before laparoscopy.

• Lifestyle changes:

There is some evidence to suggest that a low fat, vegetarian diet may improve dysmenorrhoea. There are suggestions that exercise may improve symptoms by improving blood flow to the pelvis.

• Heat: although this may seem a rather old-fashioned method for helping dysmenorrhoea, there is strong evidence to prove its benefit. It appears to be as effective as NSAIDs.

• GnRH analogues:

This is not a first-line treatment nor an option for prolonged management due to the resulting hypo-oestrogenic state. These are best used to manage symptoms if awaiting hysterectomy or as a form of assessment as to the benefits of hysterectomy. If the pain does not settle with the GnRH analogue, it is unlikely to be resolved by hysterectomy.

• Surgery:

Signs or symptoms of pathology such as endometriosis may warrant surgical laparoscopy to perform adhesiolysis or treatment of endometriosis/drainage of endometriomas.

What is the fastest way to cure dysmenorrhea?

Use a heat patch. Using a heated patch or wrap on your abdomen can help relax the muscles of your uterus.

Massage your tummy with essential oils.

Take a pain reliever.

Exercise. 

Soak in a tub.

Do yoga.

Take supplements.