Dysmenorrhea- Assessment and Management

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SCIENCE
Dysmenorrhea- Assessment and Management
Key Take-Away: 

Dysmenorrhea refers to the pain or discomfort associated with menstruation. About 50% of women experience some degree of dysmenorrhea and up to 10% have severe enough cramps to keep them from work or school for up to 3 days per month. Management of dysmenorrhoea aims to relieve pain or symptoms either by affecting the physiological mechanisms behind menstrual pain (such as prostaglandin production) or by relieving symptoms.

Dysmenorrhea, a painful menstruation, is a common gynecological condition which usually affects the women in the reproductive years. Menstrual cramps can occur a few days prior to the menstruation or even during the menstruation. Dysmenorrhea is further classified into 2 subcategories based on the history and the examination:

  • Primary dysmenorrhea which occurs in the absence of pelvic pathology
  • Secondary dysmenorrhea which occurs in the presence of pelvic pathology

In primary dysmenorrhea, pain usually occurs in the lower abdomen, cramping in nature and often radiates to back and inner thighs. This pain can last from 8 to 72 hours and often accompanies menstrual flow. Along with the pain, vomiting, nausea, diarrhea, fatigue and headache can also occur.

Secondary dysmenorrhea often occurs years after the onset of menarche and is often associated with the pelvic disorders. Pain can occur throughout the luteal phase of the menstrual cycle. Along with the pain, irregular bleeding, heavy periods, vaginal discharge and dyspareunia may also occur.

Assessment Approach:

For the assessment of dysmenorrhea, a focused history is necessary. History should include the age of menarche, characteristics of pain that which type of pain patient is experiencing, timing and duration of the pain i.e. primary dysmenorrhea occurs at or few hours prior to menstruation and subsides completely with the end of blood flow, whereas, secondary dysmenorrhea usually starts before the onset of the menses, increasingly throughout the luteal phase & continues during the menstruation. Several symptoms like fatigue, irritability, dizziness, headache, lower backache, diarrhea, nausea and vomiting. Menstrual history is also important which includes menstrual cycle length and regularity, duration and amount of menstrual flow. Other information includes post coital bleeding, inter-menstrual bleeding, vaginal discharge or deep dyspareunia.

Treatment is often introduced prior to investigations or assessment, particularly in young women who may also require the contraception.

Management of dysmenorrhea:

Management of dysmenorrhoea aims to relieve pain or symptoms either by affecting the physiological mechanisms behind menstrual pain (such as prostaglandin production) or by relieving symptoms. The management of dysmenorrhea includes first line treatment and second line treatment.

First line treatment includes use of pain killers, analgesics and other medications. Pain killers and analgesics such as paracetamol, aspirin, and NSAIDs work by reducing the activity of cyclo-oxgenase pathways, thus inhibiting prostaglandin production. Other medications include Calcium channel blockers, oral contraceptives, progesterones and antiprogestogens like medroxyprogesterone acetate, gonadotrophin releasing hormones and danazol. These medications often lead to other symptoms and side effects, so in that case, Transcutaneous electrical nerve stimulation (TENS) and levonorgestrel releasing intrauterine system are used.  TENS involves stimulation of the skin using current at various pulse rates (frequencies) and intensities to provide pain relief whereas releasing intrauterine system releases levonorgestrel (20μ/day) into the uterine cavity for at least five years, thus preventing the thickening of the lining of the uterus.

Second line treatment are used for treating secondary dysmenorrhea and further complications like endometriosis. These methods include laparoscopy, uterine nerve ablation and presacral neurectomy that interrupts most of the cervical sensory nerve fibres (thus diminishing uterine pain). Recently a new drug, Elagolix is indicated for dysmenorrhea. Elagolix, an oral, non-peptide, gonadotrophin-releasing hormone (GnRH) antagonist, produced partial to nearly full estrogen suppression. Both lower (150 mg) and higher doses of elagolix (200 mg) were effective in improving dysmenorrhea and non-menstrual pelvic pain during a 6-month period in women with endometrosis-associated pain.

References:

  • Simarjeet Kaur et al. Assessment and Comparison of Dysmenorrhea in Terms of Severity of Pain and Utilization of Non-Steroid Anti-Inflammatory Drugs among Unmarried and Married Women, International Journal of Caring Sciences September-December 2015 Volume 8 | Issue 3| Page 737
  • Nayana S. George et al. Dysmenorrhoea among adolescent girls -characteristics and symptoms experienced during menstruation, NUJHS Vol. 4, No.3, September 2014, ISSN 2249-7110
  • Michelle Proctor et al.  Diagnosis and management of dysmenorrhea, BMJ. 2006 May 13; 332(7550): 1134–1138.
  • Schiøtz HA et al ., Treatment of dysmenorrhoea with a new TENS device (OVA). J Obstet Gynaecol. 2007 Oct; 27(7): 726-8.
  • Taylor HS., Treatment of endometrosis-Associated Pain with Elagolix, an Oral GnRH Antagonist. N Engl J Med. 2017 May 19

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