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Dysmenorrhoea

Dysmenorrhoea or painful menstruation is a state of unpleasant cramping sensation of uterine origin ( Clinmedjournals.org )

 

Most commonly reported menstrual disorder in women It is thought that more than 1/2 of women who menstruate have pain for 1-2 days each month Prevalence estimates vary from 45 % to 95 % Severe pain affects 2% to 29 % It is the most common gynaecological condition in women regardless of age and nationality

 

Primary dysmenorrhoea- Pain with no obvious pathological pelvic disease Seen in younger women with estimates ranging from 67 % to 90 % in those aged 17-24 yrs Crampy pain in the lower abdomen before or during the menstruation

 

Secondary dysmenorrhoea – It is a consequence of the presence of pelvic pathology Typically affects women in their 30s and 40s Endometriosis is one of the commonest reason for secondary dysmenorrhoea

 

Primary dysmenorrhoea – current understanding indicates an excessive or imbalanced amount of prostanoids and possibly eicosanoids released from the endometrium during menstruation Ie excess prostaglandins at the time of endometrial sloughing Pain is a consequence of factors as – Uterus contracts frequently and dysrhythmically ( myometrial hypercontractility ) with increased basal tone and increased active pressure ,development of ischaemia and hypoxia , increased peripheral nerve hypersensitivity ,decreased blood flow.

 

Risk factors – Several risk factors have been identified – but the association can be inconsistent

 earlier age of menarche nulliparity longer and heavier menstrual flow family h/o dysmenorrhoea depression and stress / disruption of social networks high socioeconomic status attempts to loose weight smoking

Secondary dysmenorrhoea – risk factors based on underlying pathology
 Women using oral contraceptive generally report less severe dysmenorrhoea.

 

History – Menstrual history – cover
- age at menarche
- duration of bleeding
- interval between periods
- assessment of menstrual flow Onset of pain Location Characteristic Aggravating and relieving factors Family history Sexual history Associated symptoms Impact on daiy living for e.g
- absenteeism from school/work
( dysmenorrhoe is the most common reason for short term absence from school in adolescent girls )
- social withdrawal
- impact on academic performance , relationship , productivity.

 

Onset typically about 6-12 months after menarche- after ovulatory cycles have been established Periodic and predictable Pain is usually sharp , intermittent spasm like and concentrated on the suprapubic area – the pain may radiate to the back or the legs Pain starts within hours of the start of the menstruation and peaks as the flow becomes heaviest during the 1st day or two Duration of pain may be 8-72 hrs It may be associated with other symptoms as low back pain , headache , diarrhoea , fatigue , nausea or vomiting , sweating & sleep disturbances- ( These symptoms probably happen due to influx of PGs and its derivatives into the systemic circulation ) Improves with age Pain is not progressive and does not persist after menses.

 

As primary dysmenorrhoea is not associated with any underlying pathology – abdominal and pelvic examination would be normal Examine abdomen ( all ) Pelvic examination is not essential for adolescent who never had vaginal intercourse In case the teenager c/o cyclical pain without flow consider outflow obstruction as imperforate hymen or tranverse vaginal septum Swabs for infections would be normal.

 

NASIDs- All NSAIDs effective other than aspirin No agent has shown superiority over another Reduce prostaglandin via inhibition of cyclooxygenase-mediated production Backed by evidence from several trials Advice to start 1-2 days before symptom or bleeding onset , scheduled ( not PRN ) and to continue daily until cycle day 2 or 3.

 

Hormonal contraception- All forms of combined contraceptive pills- give relief including COCP , vaginal rings , transdermal patches and LARCs Progestin only methods , levonorgestrel-releasing IUD or implantable rods – are also efficacious Oral contraceptives work by inhibiting ovulation which reduces the volume of endometrium during menstruation –> reduced prostaglandin -relieves menstrual cramps Good quality RCTs on effectiveness of oral contraceptive are lacking but there is some evidence in general population that COCP can effectively treat dysmenorrhoea.

 

Alternative therapy- Complimentary and alternative therapies are frequently used by patients Limited data and poorly studied High frequency transcutaneous electrical nerve stimulation ( TENS ) Topical heat Dietary modifications Herbal supplements.

 

Referral- Poor symptom control or progressive worsening of symptoms following a 3-6 months trial of first line agents Doubt about diagnosis Pelvic ultrasound is considered first line investigation and you may wish to request that while awating specialist opinion.

 

Secondary dysmenorrhoea – Patients usually i their 30s or 40s Pain starts before the onset of bleeding and continues throughout or it may not be related to menstruation alone ( for e.g it may occur throughout the luteal phase of the menstrual cycle and worsen as the menses progress rather than being confined to the first 24-48 hrs – BMJ Best Practice ) Can be of new onset or a change in nature of symptoms over time Can be associated with other symptoms as
- dyspareunia
- painful defaecation
- menstrual cycle disturbance
( symptoms of underlying pathology )

 

Examination would essentially be abnormal with significant clinical findings which may include Localized pain Uterine enlargement or asymmetry in those with adenomyosis Reduced uterine mobility Pelvic mass Lateral deviation of the cervix Nodularity in the rectovaginal segment Uterine or cervical tenderness Mucopurulent discharge in PID.

 

Common causes of secondary dysmenorrhoea include Endometriosis ( commonest cause with main features of dysmenorrhoea , chronic pelvic pain and infertility ) Adenomyosis ( presence of endometrial glands and stroma within the myometrium , presentation can be with dysmenorrhoea and abnormal uterine bleeding ) Chronic pelvic inflammatory disease Intrauterine polyps Pelvic adhesions Submucous fibroids Intrauterine devices

Patient information links

Useful summary from BUPA https://www.bupa.co.uk/health-information/womens-health/dysmenorrhoea

NHS explainer with  video on menstrual cycle https://www.nhs.uk/conditions/period-pain/

American Collge of Obstetricians and Gynaecology ( ACOG ) with a FAQ like presentation https://www.acog.org/womens-health/faqs/dysmenorrhea-painful-periods

Betterhealth channel on dysmenorrhoea https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menstruation-pain-dysmenorrhoea

Link from Children’s Hospital Colorado https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/dysmenorrhea/

Printable leaflet from Women’s Health Concern https://www.womens-health-concern.org/help-and-advice/factsheets/period-pain/

References

  1. Sharghi, Maedeh et al. “An update and systematic review on the treatment of primary dysmenorrhea.” JBRA assisted reproduction vol. 23,1 51-57. 31 Jan. 2019, doi:10.5935/1518-0557.20180083
  2. Modern management of dysmenorrhoea
    BENJAMIN THOMAS AND ADAM MAGOS Trends in Urology Gynaecology & Sexual Health September/October 2009 Modern management of dysmenorrhoea – Thomas – 2009 – Trends in Urology, Gynaecology & Sexual Health – Wiley Online Library
  3. Treatment options for primary
    and secondary dysmenorrhoea
    DIMITRIOS MAVRELOS AND ERTAN SARIDOGAN Prescriber November 2017 Treatment options for primary and secondary dysmenorrhoea – Mavrelos – 2017 – Prescriber – Wiley Online Library
  4. Hong Ju, Mark Jones, Gita Mishra, The Prevalence and Risk Factors of Dysmenorrhea, Epidemiologic Reviews, Volume 36, Issue 1, 2014, Pages 104–113, https://doi.org/10.1093/epirev/mxt009
  5. Azagew, A.W., Kassie, D.G. & Walle, T.A. Prevalence of primary dysmenorrhea, its intensity, impact and associated factors among female students’ at Gondar town preparatory school, Northwest Ethiopia. BMC Women’s Health 20, 5 (2020). https://doi.org/10.1186/s12905-019-0873-4
  6. Proctor, Michelle, and Cynthia Farquhar. “Diagnosis and management of dysmenorrhoea.” BMJ (Clinical research ed.) vol. 332,7550 (2006): 1134-8. doi:10.1136/bmj.332.7550.1134
  7. Harada, Tasuku. “Dysmenorrhea and endometriosis in young women.” Yonago acta medica vol. 56,4 (2013): 81-4.
  8. CKS NHS Dysmenorrhoea management Management | Dysmenorrhoea | CKS | NICE
  9. Hailemeskel, Solomon et al. “Primary dysmenorrhea magnitude, associated risk factors, and its effect on academic performance: evidence from female university students in Ethiopia.” International journal of women’s health vol. 8 489-496. 19 Sep. 2016, doi:10.2147/IJWH.S112768
  10. Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-13. doi: 10.1093/epirev/mxt009. Epub 2013 Nov 26. PMID: 24284871.
  11. Dawood, M Yusoff MD Primary Dysmenorrhea, Obstetrics & Gynecology: August 2006 – Volume 108 – Issue 2 – p 428-441 doi: 10.1097/01.AOG.0000230214.26638.0c ( Abstract )
  12. Kho KA, Shields JK. Diagnosis and Management of Primary Dysmenorrhea. JAMA. 2020;323(3):268–269. doi:10.1001/jama.2019.16921
  13. BMJ Best Practice – Assessment of dysmenorrhoea Assessment of dysmenorrhoea – Differential diagnosis of symptoms | BMJ Best Practice
  14. Bernardi, Mariagiulia et al. “Dysmenorrhea and related disorders.” F1000Research vol. 6 1645. 5 Sep. 2017, doi:10.12688/f1000research.11682.1

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