New strategies to treat primary dysmenorrhea

Continuous low-level heat was found to be as effective as ibuprofen in decreasing symptoms.
Continuous low-level heat was found to be as effective as ibuprofen in decreasing symptoms.

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At a glance

  • Primary dysmenorrhea (PD) occurs in women of all ages but usually begins during adolescence.
  • Currently, the best evidence-based treatments for PD are NSAIDs and hormonal contraceptives.
  • Research has shown that heat is better than acetaminophen for pain over an eight-hour period.
  • Positive patient response, overall effectiveness, and relative absence of adverse effects led NIH to recommend the use of acupuncture for the treatment of dysmenorrhea.
Every month, many women experience various symptoms attributable to their menstrual cycle. One of the most common complaints among women is dysmenorrhea. The two types of dysmenorrhea are primary and secondary. Primary dysmenorrhea (PD) is characterized by painful menstrual cramps without any evident pathology.1 Secondary dysmenorrhea is the occurrence of painful menstruation in the presence of a pelvic pathology, such as endometriosis, adenomyosis, or chronic pelvic inflammatory disease (PID).2

PD occurs in women of all ages but usually begins during adolescence, with an estimated prevalence of 40%-50%.1 PD typically presents in the adolescent years roughly six to 12 months after menarche, usually when regular ovulatory cycles are established.3 Overall, PD may affect 40%-90% of women.4 In addition to physical pain, the patient's quality of life is often affected. One in 13 sufferers is incapacitated for one to three days per month, affecting work and school attendance and making dysmenorrhea the leading cause of school absenteeism among adolescents.3,5 Symptoms vary from person to person: may include dizziness and syncope, cramping, nausea, vomiting, diarrhea, headaches, and fatigue; and may last up to 72 hours.3

Many women start treating their pain and discomfort with such pharmacologic therapies as nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives. Because of the major growth and development that occurs during adolescence, many young patients and their parents do not want to rely solely on pharmacologic treatments. Additionally, while the efficacy of pharmacologic treatments is well documented, they still have a 20% to 25% failure rate.6

Many treatments that do not involve pharmaceuticals are available and are good options for both adolescents and adults. The use of complementary and alternative medicine (CAM) has increased in the past decade.7 In one large study, as many as 48% of women reported use of CAM as an alternative to prescription medication or to enhance the effectiveness of their prescription medications.8,9

Providers need to become familiar with the various treatments their patients may use for PD. This review focuses on treatments that women suffering from PD use to alleviate their pain, with an emphasis on CAM.

Pathogenesis

It is believed that PD may be caused by abnormal increased prostanoids (uterine prostaglandins), which lead to abnormal uterine contractions.1 The frequent and prolonged uterine contractions decrease blood flow to the myometrium, resulting in ischemia of the uterus.2

Evidence that the prostanoid secretion is responsible for  PD includes: (1) the similarity between clinical symptoms of PD and the uterine contractions and adverse effects found in prostaglandin-induced abortion and labor; and (2) evidence demonstrating and correlating with the amount of menstrual prostanoids in women with PD compared with normal menstruating women. Also, common symptoms of nausea, vomiting, and diarrhea, found in 60% or more of women who suffer from dysmenorrhea, are similar to the adverse effects of prostaglandins.1

There is some discussion that vasopressin is another factor causing PD, but this speculation remains controversial and not well studied. Theoretically, increased levels of circulating vasopressin during menstruation can produce uterine contractions that reduce blood flow and cause hypoxia.1

Risk factors and clinical manifestations

PD is usually a benign syndrome. Common risk factors include age <30 years, low BMI, smoking, earlier menarche (before age 12 years), longer cycles, heavy menstrual flow, null parity, premenstrual syndrome, sterilization, clinically suspected PID, sexual abuse, and psychosocial symptoms.10 Conversely, women who use oral contraceptives, eat fish, exercise regularly, are married or in a stable relationship, and have higher parity are associated with a reduced risk.2 When treating a woman with chronic menstrual pain, keep these risk factors in mind as an indication of PD. Of course, it is more important to rule out other pathologies first.

 

PD is diagnosed through a detailed patient history and physical exam (Figure 1). Women who seek care for dysmenorrhea will describe intense pain with their menstrual cycle. These patients will complain of pain that is usually centered in the lower abdomen (suprapubic), but the pain may also radiate to the back of the legs or lower back.5 PD only occurs during ovulatory cycles, with pain beginning just before or with the onset of menses and slowly decreasing over 12-72 hours.2 Other common symptoms are nausea, vomiting, diarrhea, fatigue, fever, headache, dizziness, or a flulike feeling.11 Patients will often illustrate their pain by opening and closing their fist, closely mimicking the underlying uterine activity.2 The severity of dysmenorrhea can be classified by a grading system based on pain, symptoms, and impact on daily activities (Table 1), but this system is not mandatory.2


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