Dysmenorrhea or Dysminorrhea: Pathogenesis, Classification, Symptoms and Treatment

What is it? – Medical Definition

Dysmenorrhea is a term used to describe low anterior pelvic pain that occurs in association with menstrual periods.

How Dysmenorrhea manifests

It is uterine pain throughout the time of menstruation. Pain can occur with menstruation or precede menstruation for 1 to 3 days. The pain tends to reach its peak 24 hours after the onset of menstruation and disappears after 2 to 3 days. It is usually acute, but may be cramping, throbbing, or a constant and dull discomfort; It can radiate to the legs.

  • Headache, nausea, constipation or diarrhea, low back pain, and urinary frequency are common; vomiting occurs from time to time.
  • The symptoms of premenstrual syndrome can occur during part or all of menstruation.
  • Sometimes endometrial clots or casts are expelled.

Dysmenorrhea can be: Primary (most common) and secondary (due to abnormalities of the pelvis)

Primary dysmenorrhea

The symptoms can not be explained by structural gynecological disorders. The pain is believed to be the result of uterine contractions and ischemia,

  • Contributing factors may include the following:
  • Passage of menstrual tissue through the cervix
  • A narrow cervical orifice
  • A badly positioned uterus
  • Lack of exercise
  • Anxiety about menstruation

Primary dysmenorrhea begins within a year after menarche and occurs almost invariably in ovulatory cycles.

Pain usually begins when menstruation starts (or just before) and persists for the first 1 to 2 days; This pain, described as spasmodic, overlaps the constant lower abdominal pain, which can radiate to the back or thigh.

Patients may also have general malaise, fatigue, nausea, vomiting, diarrhea, back pain or headache.

Pathogenesis

It is thought to be due to an excess or imbalance of prostaglandins and leukotrienes in the menstrual fluid, which in turn produces vasoconstriction in the uterine vessels, causing uterine contractions that produce pain.

The release of prostaglandin may also be responsible for the symptoms of diarrhea, nausea, headache and lightheadedness that may occur in association with dysmenorrhea.

Classification

Dysmenorrhea can be considered primary or secondary.

Primary dysmenorrhoea

Primary dysmenorrhea occurs in young women without pelvic pathology.

It often begins with the onset of ovulatory cycles from six months to one year after menarche.

The pain begins with the beginning of the period and can last from 24 to 72 hours.

Secondary dysmenorrhea.

Secondary dysmenorrhea occurs in association with some form of pelvic pathology:

  • It is more likely to occur years after the onset of menstruation.
  • Pain may precede the beginning of the period for several days and may last throughout the period.
  • There may be associated dyspareunia.

Secondary dysmenorrhea can occur as a result of:

  • Endometriosis / adenomiosis.
  • Pelvic inflammatory disease.
  • Fibroids, when it is often associated with heavy menstrual bleeding.
  • Adhesions
  • Development anomalies.
  • The intrauterine contraceptive device containing copper (Cu-IUCD) can cause pelvic pain in the first months after adjustment, but does not influence the severity of long-term dysmenorrhea.

Epidemiology

Dysmenorrhea is very common, although the precise incidence is not known, as it often does not manifest itself.

Primary dysmenorrhea is the most common cause of school absence among adolescents and approximately 15% complain of severe dysmenorrhea.

A long duration of menstruation, early menarche, smoking. Alcohol and obesity are all risk factors associated with dysmenorrhea.

Women who are depressed and / or have poor social support networks are also more likely to experience pain. Labor reduces dysmenorrhea and its severity decreases with age.

Evaluation

A presumptive diagnosis of primary dysmenorrhoea can be made in the history ± abdominal examination only in young patients who are not sexually active, and vaginal examination is not normally required in this group of patients.

The investigation of dysmenorrhoea is primarily aimed at ruling out the underlying pathology and may include any or all of the following as appropriate for the patient. It is taken into account:

History

  • Age of menarche.
  • Cycle time.
  • If the cycle is regular.
  • Duration of bleeding
  • Moment of pain in relation to the period.

Location of pain Dysmenorrhea is usually suprapubic, but it can be felt on the back of the legs or the lower back.

History of smoking

  • If the patient is sexually active.
  • Obstetric history.
  • Contraceptive history.

Any trait that suggests an underlying pathology (for example, vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia).

Dyschezia and / or rectal pain or bleeding – particularly suggestive of endometriosis.

Exams

Abdominal / vaginal exams are indicated if they are sexually active:

  • Adenomyosis: The uterus may be enlarged and tender with a typical touch.
  • Endometriosis – generalized tenderness in the pelvic area. The uterus can be fixed ± retroverted due to adhesions, and the nodules can be palpable in the uterosacral ligaments.
  • Hymen partially perforated (rare)
  • Vaginal partition (rare).
  • Pain management.

Patients may be concerned about the possibility of an underlying pathology and, when appropriate, reassurance and an explanation of the mechanism of menstrual pain may be helpful.

Lifestyle changes – Longitudinal studies have analyzed risk factors for dysmenorrhea and found a clear association between smoking and dysmenorrhea.

Therefore, patients should be informed of this relationship and assisted in any attempt to quit smoking.

Complementary and alternative medicines – several dietary supplements and herbal remedies have been suggested, but there is insufficient evidence to recommend any of them.

They include calcium and magnesium, thiamine, ginger, fish oil supplements, toki-shakuyaku-san, acupuncture and acupressure. Some remedies can have adverse effects and can interact with the medication.

Pharmacology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs most commonly used for the treatment of dysmenorrhea due to their inhibition of prostaglandin synthesis.

This is a class effect and all the Aines appear equally effective. Ibuprofen is used more frequently due to its low incidence of side effects.

Although it is specifically authorized for dysmenorrhoea, there is concern that mefenamic acid is more likely to induce seizures in overdoses and has a low therapeutic window that increases the risk of accidental overdose.

Treatment for Dysmenorrhea

Symptomatic treatment begins with adequate rest and sleep and regular exercise. A low-fat diet and nutritional supplements such as omega-3 fatty acids, flaxseed, magnesium, vitamin E, zinc and vitamin B1 are suggested as potentially effective.

Women with primary dysmenorrhea feel safe about the absence of structural gynecological disorders.

Other hormone therapy, such as danazol, progestogens (eg, levonorgestrel, etonogestrel, medroxyprogesterone acetate), gonadotropin-releasing hormone agonist, or a levonorgestrel-releasing IUD, may decrease symptoms of dysmenorrhea.

Hypnosis is being evaluated as a treatment. Other proposed non-pharmacological therapies, including acupuncture, acupressure, chiropractic therapy, and transcutaneous electrical nerve stimulation, have not been well studied, but may benefit some patients.

For intractable pain of unknown origin, laparoscopic presacral neurectomy or uterosacral nerve ablation has been effective in some patients for a period of 12 months.

Hormonal treatments

If the woman with dysmenorrhea does not want to conceive, hormonal contraception can be suggested. Ovarian suppression seems to control cyclic pelvic pain, whether caused by endometriosis or not.

Adolescents and young adults who do not respond to hormonal treatment after three months should be evaluated for secondary causes of dysmenorrhea. This is likely in approximately 10% of patients.

Combined hormonal contraception is often used.

Despite the common use of oral treatment in the treatment of dysmenorrhea (and the orientation of the Faculty of Sexual and Reproductive Health indicating that it can be used for this purpose of menarche), the previous evidence has not been conclusive, due to the lack of randomized controlled trials.

However, it can also be used to increase the duration of the cycle by tricycle and, therefore, reduce the frequency of menstruation and, therefore, the symptoms.

Oral contraception with progestin alone can also be used.

In a study of 406 women with dysmenorrhea who were administered desogestrel 75 micrograms / day (Cerazette®), pain resolved or improved significantly in 93% and, despite a high incidence of adverse effects, mainly hemorrhagic irregularities, by 90%.

Depo-medroxyprogesterone acetate (Depo-Provera®) is also sometimes used, as many women become amenorrheic within a year of starting treatment.

It has been shown that the intrauterine system containing levonorgestrel (LNG-IUS, Mirena®) reduces the severity of dysmenorrhea despite not being anovulatory.

It could also be considered, even in teenagers. Neither the 52 mg of LNG-IUS (Mirena®) nor the new 13.5 mg LNG-IUS (Jaydess®) are authorized for the treatment of dysmenorrhea; Jaydess® is less likely than Mirena® to lead to amenorrhea.

Danazol is rarely used now and only under the supervision of the specialist in the treatment of severe refractory cases.

Leuprolide acetate can be used in rare cases to suppress the menstrual cycle, but it has a significant side effect profile.