Dysmenorrhea

Overview

Dysmenorrhea is a frequent secondary symptom of a variety of gynecological illnesses, but it is also present in the majority of women as a main form of sickness. The pain associated with dysmenorrhea is produced by prostaglandin hypersecretion and increased uterine contractility. Primary dysmenorrhea is relatively common in young women and has a reasonable prognosis, despite being linked with a bad quality of life.

Secondary dysmenorrhea is connected with endometriosis and adenomyosis and may be the primary symptom. The diagnosis is suspected based on the clinical history and physical examination and can be verified by ultrasonography, which is particularly valuable in ruling out some secondary causes of dysmenorrhea, such as endometriosis and adenomyosis.

Nonsteroidal anti-inflammatory medicines (NSAIDs) can be used alone or in combination with oral contraceptives or progestins.

Dysmenorrhea definition

Dysmenorrhea is described as the presence of painful uterine cramps during menstruation and is one of the most prevalent causes of pelvic discomfort and menstrual problem. Pain is defined as "an unpleasant sensory and emotional experience linked with existing or potential tissue damage, or explained in terms of such damage" by the International Association for the Study of Pain. Chronic pelvic pain, in particular, is centered in the pelvic area and lasts for 6 months or more.

The burden of dysmenorrhea exceeds that of any other gynecological complaint: dysmenorrhea is the primary cause of gynecological morbidity in women of reproductive age, regardless of age, country, or socioeconomic level. The consequences extend beyond individual women to society, resulting in a significant loss of production each year. According to the World Health Organization, dysmenorrhea is the leading cause of persistent pelvic discomfort.

Although dysmenorrhea is rarely fatal, it may be physically and psychologically draining for many women. Some people choose to self-medicate at home and never seek medical help for their discomfort. Dysmenorrhea is the leading cause of job absenteeism and the most prevalent reason for teenage school absence. Chronic pelvic discomfort, which includes dysmenorrhea, costs women up to $20,898 a year in direct and indirect expenditures.

The history is important in determining the diagnosis of dysmenorrhea and should include an evaluation of the onset, duration, type, and degree of discomfort. A detailed menstruation history is also required. A thorough physical examination should be carried out. A thorough abdominal check is recommended for younger teenagers who have never been sexually active. A pelvic examination is essential in older teenagers or those who are sexually active.

Behavioral and psychological variables have also been linked to primary dysmenorrhea. Although these factors have not been proven to be causal, they should be explored if medical treatment fails. The extent to which hormones and mediators, basal body temperature, sleep patterns, and the central nervous system (CNS) interact in primary dysmenorrhea is not fully known.

There are no tests that can be used to diagnose primary dysmenorrhea. Laboratory testing, abdominal or transvaginal ultrasonography, hysterosalpingography, hysteroscopy, or laparoscopy may be recommended to determine the etiology of secondary dysmenorrhea.

Epidemiology

Dysmenorrhea is a frequent gynecological condition that affects all women, regardless of age or ethnicity. It is one of the most commonly diagnosed etiologies of female pelvic discomfort. In women of reproductive age, the prevalence of dysmenorrhea ranges from 16% to 91%, with severe discomfort occurring in 2% to 29% of cases. Adolescents have an 80 percent prevalence of dysmenorrhea. Approximately 40% of them experienced severe dysmenorrhea.

Dymenorrhea symptoms include gastrointestinal symptoms such as nausea, bloating, diarrhea, constipation, or both, as well as vomiting and indigestion. Irritability, headache, and low back discomfort are also common in women with primary dysmenorrhea. Dymenorrhea is also related with fatigue and dizziness. Dysmenorrhea is connected with a considerable reduction in quality of life in 16% to 29% of women. Furthermore, dysmenorrhea-related absenteeism accounts for 12% of monthly school and job activities.

Etiology 

Since the 1960s, several ideas have been proposed to explain the origin of dysmenorrhea. This covers etiologies that are psychological, physiological, or anatomical in nature. The anatomical theory encompassed aberrant uterine positions as well as changes in the shape or length of the cervix. There is a link between cervical length and the amount and degree of dysmenorrhea. However, some homogeneous investigations have shown that the biochemical theory is more powerful than others.

Associated risk factors are

• Age 
• Smoking 
• Attempts to lose weight
• Higher body mass index
• Depression/anxiety
• Earlier age at menarche
• Nulliparity
• longer and heavier menstrual flow
• Family history of dysmenorrhea
• Disruption of social networks

Primary dysmenorrhea:

The primary contribution to the cause of dysmenorrhea is prostaglandin F (PGF). PGF is released by endometrial cells at the moment of endometrial shedding at the start of menstruation. Prostaglandin (PG) produces uterine contractions, and the severity of the cramps is proportional to the amount of PGs produced following the sloughing process initiated by the decreasing hormonal surge.

Secondary dysmenorrhea:

Secondary dysmenorrhea is a clinical condition in which menstruation discomfort is caused by an underlying illness, ailment, or anatomical anomaly within or outside the uterus. Endometriosis, fibroids (endometriomas), adenomyosis, endometrial polyps, pelvic inflammatory disease, and perhaps the use of an intrauterine contraceptive device are all major causes of secondary dysmenorrhea.

Pathophysiology

The pathogenesis of primary dysmenorrhea is unknown. Nonetheless, the recognized reason is owing to uterine inner lining prostaglandin hypersecretion. Prostaglandin F2alpha (PGF-2a) and Prostaglandin PGF 2 enhance uterine tone and generate high-amplitude uterine contractions. Primary dysmenorrhea has also been connected to vasopressin. Vasopressin enhances uterine contractility and, due to its vasoconstriction actions, can produce ischemic discomfort.

The uterine contractility is more noticeable during the first two days of the menstrual month. Progesterone levels fall before menstruation, resulting in increased synthesis of PGs, which causes dysmenorrhea. The most prevalent causes of secondary dysmenorrhea in premenopausal women are endometriosis and adenomyosis.

Dysmenorrhea symptoms

A thorough history, as well as an acceptable physical examination, are required to establish the diagnosis. A history of the location, onset, features, and duration of the pain, as well as concomitant symptoms such as tiredness, headache, diarrhea, nausea, and vomiting, may be useful in establishing a diagnosis.

The physical examination is typically normal in cases with primary dysmenorrhea. A pelvic examination is not required for adolescents and women who have primary dysmenorrhea symptoms. A pelvic examination is recommended for adolescents and women who have previously been sexually active, when a secondary cause is suspected, or when there is a lack of response to treatment. The following are some of the most prevalent symptoms of secondary dysmenorrhea:

• Young age (around menarche) primary dysmenorrhea vs. older age > 25 years old (secondary dysmenorrhea)
• Fluid in the vaginal vault of foul odor or whitish grayish in color. (Pelvic Inflammatory Disease)
• Associated dysuria, dyspareunia, dyschezia, infertility, nodularity, adnexal masses, tenderness (endometriosis, non-gynecological etiology) 
• Abnormal bleeding with the enlarged symmetrical uterus (Adenomyosis)
• Abnormal bleeding with the enlarged asymmetrical uterus (Fibroids)
• Obstructive anatomical abnormalities and history of other congenital anomalies
• Pelvic masses (fibroids, neoplasms, ovarian cysts)

Before beginning empiric therapy for symptoms of primary dysmenorrhea in teenagers, a pelvic examination is not usually required. If symptoms do not improve, or if additional problematic symptoms or signs appear, or if secondary dysmenorrhea is suspected, a comprehensive physical examination should be undertaken. A pelvic examination is essential for ruling out uterine abnormalities, cul-de-sac pain, and suggestive nodularities, and it comprises the following:

• Inspection of the external genitalia
• Inspection of the vaginal vault
• Inspection of the cervix
• Bimanual examination

Diagnosis

Primary dysmenorrhea is diagnosed, depending upon the history and physical examination.

1. If the history of start and duration of lower abdomen discomfort implies secondary dysmenorrhoea or if the dysmenorrhoea is not responding to medicinal therapy, a pelvic examination is recommended.
2. The use of ultrasonography in the diagnosis of primary dysmenorrhea is insignificant. However, ultrasonography can help distinguish between secondary dysmenorrhea and other reasons such as endometriosis and adenomyosis. Secondary dysmenorrhoea can afflict any woman after menarche, and it can appear as a new symptom in women in their 30s or 40s. It is accompanied with varying degrees of discomfort as well as other symptoms such as dyspareunia, menorrhagia, intermenstrual, and postcoital hemorrhage.
3. Pregnancy tests based on urine human chorionic gonadotropin (B-HCG) are beneficial when there is a history of probable pregnancy.
4. Patients who are at risk of sexually transmitted infections (STIs) or who have a history of pelvic inflammatory disease (PID) will require endocervical or vaginal swabs.
5. Cervical cytology samples may be necessary to rule out probable cancer if clinical examination and history indicate it.
6. If torsion of the adnexa, adenomyosis, or deep pelvic endometriosis is suspected, or if transvaginal ultrasound results are unclear, magnetic resonance imaging (MRI) or Doppler ultrasonography may be necessary.
7. When all non-invasive examinations have been exhausted and the cause remains unexplained, laparoscopy may be considered.

Dysmenorrhea treatment

Pharmacological Treatment

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for dysmenorrhea. In compared to placebo or other therapies, NSAIDs are particularly successful in the treatment of dysmenorrhea. NSAIDs help cure dysmenorrhea by inhibiting the cyclooxygenase enzyme, which prevents the formation of prostaglandins.

There are no NSAIDs that are safer or more effective than others. However, there is evidence that around 20% of individuals with dysmenorrhea do not respond to NSAID therapy. Fenamates (mefenamic acid) may be somewhat more effective than phenyl propionic acid derivatives (ibuprofen, naproxen) because fenamates have a dual function of suppressing PG activity and limiting PG synthesis.

In terms of safety and efficacy, ibuprofen and fenamates be favored. When compared to paracetamol, NSAIDs are still more effective. Paracetamol, on the other hand, is a viable option when NSAIDs are contraindicated. Pain was decreased when paracetamol was combined with caffeine and/or Pamabrom (a short-acting diuretic).

COX-2 selective NSAIDs can be employed, although they are not more effective or tolerated than NSAIDs due to their cardiovascular adverse effects. COX-2 selective NSAIDs and the mechanism by which they decrease PGs have been associated to delayed ovulation.

Oral contraceptive pills (OCPs)

Oral contraceptive pills (OCPs) have been shown to be more effective than placebo in alleviating dysmenorrheic discomfort in teens. Due to small sample numbers and inadequate comparison data, several additional research argued against the efficacy of OCPs as a therapy for dysmenorrhea. OCPs work by inhibiting the development of the endometrial lining. It inhibits the synthesis of prostaglandins. Women using OCPs have low amounts of PGs in their menstrual fluid. Contraceptive pill users tended to have reduced incidence of dysmenorrhea and used fewer analgesics.

Progestin-only pills (POPs) are more appropriate for individuals with secondary dysmenorrhea caused by endometriosis, although their efficacy as a therapy for initial dysmenorrhea is unknown. POPs primarily function by promoting endometrial lining atrophy and preventing ovulation.

Non-pharmacological Treatment

Maintaining an active lifestyle and a vitamin and mineral-rich diet are typically suggested for improved health outcomes. Such a diet and lifestyle are especially beneficial in reducing the severity of dysmenorrhea.

Though various forms of exercise are normally suggested owing to a variety of health advantages and minimal or no risk, it also aids in reducing the severity of dysmenorrhea. There is no strong data concerning specific exercise activity or duration, although moderate exercise is suggested, particularly in obese women.

Heat is more effective than NSAIDs and appears to be a favored simple therapeutic choice for many individuals due to its lack of side effects. High-quality research is still required.

Dymenorrhea is treated with food supplements, complementary or alternative medicine, such as plant-based therapy, Chinese medicine, and supplements. They are also not controlled by the FDA. There is inadequate evidence to recommend any of the other herbal and dietary therapy. A few studies that lack active comparisons and solid methodological approaches support the efficacy of acupuncture.

Differential Diagnosis of dysmenorrhea

Differential diagnosis of dysmenorrhea is broad, and it can be listed as gynecological conditions and non-gynecological conditions: 

Gynecological conditions:

• Endometriosis
• Imperforate hymen, transverse vaginal septum, vaginal agenesis, OHVIRA syndrome (uterus didelphys with blocked hemivagina and ipsilateral renal agenesis), cervical stenosis are all examples of reproductive tract obstruction.
• Adnexal cysts, functional and nonfunctional: Para tubal and para ovarian cysts, endometrioma, benign ovarian cysts such as benign cystic teratoma and benign serous or mucinous cystadenoma, and rare occurrences of ovarian borderline or malignant tumors are examples of nonfunctional adnexal cysts.
• Adnexal torsion
• Adenomyosis
• Pelvic inflammatory disease / sexual transmitted infections
• Endometrial polyps
• Asherman syndrome
• Ectopic pregnancy
• Chronic pelvic pain
• Membranous dysmenorrhea

Non-Gynecological conditions: (gastrointestinal, urological, and musculoskeletal)

• Irritable bowel syndrome
• Urinary tract Infections
• Interstitial cystitis
• Musculoskeletal causes: abdominal wall muscles, the abdominal wall fascia, the pelvic and hip muscles, the sacroiliac joints, and the lumbosacral muscles

Pelvic inflammatory disease

PID is a uterine and fallopian tube infection with or without ovarian or parametrial involvement. It is an ascending infection that occurs during or soon after menstruation; if left untreated, it can cause dysmenorrhea. The most prevalent infections that cause PID are Chlamydia trachomatis and Neisseria gonorrhoeae, however other organisms such as Gardnerella vaginalis, anaerobes, and gram-negative rods can also cause it.

Previously, albeit mostly clinical, the diagnosis of PID was based on the presence of three major criteria (abdominal pain, adnexal discomfort, and cervical motion tenderness) and one minor criterion (fever, vaginal discharge, leukocytosis, positive cervical cultures, gram-negative stain, intracellular diplococci, or white blood cells on vaginal smear).

The presence of adnexal soreness indicates a 95.5 percent sensitivity for histologic endometritis. This trial's findings suggest empiric therapy of all women at risk for PID who have adnexal soreness and no other clear explanation. All women at risk for PID who have adnexal, uterine, or pelvic soreness on bimanual examination and have no alternative explanation for these findings should be treated empirically for PID.

Patients require sufficient antimicrobial coverage in addition to appropriate analgesia. Ceftriaxone 250 mg IM with doxycycline 100 mg daily for 14 days is the most often utilized combination. If outpatient therapy fails, the patient has intractable nausea or vomiting, has a complicating tubo-ovarian abscess, or is immunocompromised, he or she should be hospitalized. Tubo-ovarian abscess and Fitz-Hugh Curtis syndrome (perihepatitis) can occur if pus from the fallopian tubes spills into the peritoneum.

Endometriosis

Endometriosis is defined as the presence of endometrium-like tissue outside of the uterus, most typically in the ovaries. Women frequently present with dyspareunia as well as pelvic and back discomfort. Although endometriosis is an exclusion diagnosis, individuals may have a history of cyclic dysmenorrhea with menstruation. It is crucial to remember, however, that endometriosis can coexist with other disease processes that cause dysmenorrhea, making diagnosis even more challenging.

Chronic pelvic discomfort that is recalcitrant to antibiotics or analgesics may also be present in the history. Furthermore, a good obstetric history may reveal a history of recurrent miscarriages or problems conceiving. The traditional exam finding is a fixed uterus with "ash" patches (purple-blue discolorations) on the cervix; however, this finding is not always present, and the examination may be unremarkable.

CT may offer some promise as a diagnostic technique in the future, but for the time being, endometriosis can only be detected definitely by laparoscopy or laparotomy. Some think that a definite diagnosis isn't even required. Endometriosis is frequently considered to be the source of pain when it is not. Even if endometriosis is the source of the dysmenorrhea, surgery may not be required if the discomfort is managed with hormone treatment or analgesics.

Adenomyosis

Adenomyosis is described as uterine adrenal gland invasion of the myometrium. It is an uncommon illness with symptoms that mirror uterine leiomyomas and endometrial cancer; as a result, diagnosis is challenging.

Transvaginal ultrasonography or magnetic resonance imaging are commonly used to provide a definitive diagnosis (MRI). The main discovery in the latter is a thicker junctional zone (JZ line), which is the barrier between myometrium and endometrium. According to one study, adenomyosis should be considered in the differential diagnosis when a patient is being treated for probable endometriosis and is experiencing chronic persistent discomfort.

Prognosis

Dysmenorrhea has been linked to a significant influence on a woman's daily life. The rates of absence from school or job reflect this influence. Dysmenorrhea may also impede a woman's ability to participate in sports or social activities. In addition, there are emotional pressures connected with dysmenorrhea.

Dysmenorrhea is a public health issue with a financial consequence. It is expected to be over 140 million working hours per year in the United States alone. The prognosis for primary dysmenorrhea is typically excellent when the indicated treatment options are used. NSAIDs are typically effective for mild to moderate dysmenorrhea.

Severe dysmenorrhea still responds to NSAIDs, although greater dosages or combination/adjuvant treatment may be required. Secondary causes of dysmenorrhea should be examined in cases with chronic dysmenorrhea. The kind, location, and severity of the etiology will determine the prognosis of secondary dysmenorrhea.

Complications

The degree of the discomfort impacting the women's well-being and everyday activities can be used to characterize primary dysmenorrhea consequences. There are no known consequences since primary dysmenorrhea is not associated with any pathology or illness. Secondary dysmenorrhea complications, on the other hand, vary depending on the cause. Infertility, pelvic organ prolapse, excessive bleeding, and anemia are all possible complications.

Conclusion 

Dysmenorrhea is a Greek phrase that translates to "painful monthly bleeding." Primary and secondary dysmenorrhea are the two types of dysmenorrhea. Primary dysmenorrhea is defined as lower abdomen discomfort that occurs during the menstrual cycle and is not caused by another disease or condition.

Secondary dysmenorrhea, on the other hand, is generally accompanied with additional disease inside or outside the uterus. Dysmenorrhea is a prevalent ailment among reproductive-age women. Dysmenorrhea has major emotional, psychological, and functional health consequences.

Increased physical exercise on a regular basis is useful in minimizing dysmenorrhea problems. Exercise provides non-specific analgesia by increasing pelvic blood flow and boosting the release of beta-endorphins. The major objective of treatment is to alleviate discomfort and enhance patients' quality of life who suffer from dysmenorrhea.

As a result, analgesics should be administered as needed to allow women to go about their daily lives. Endometrial ablation may be an option for people who have dysmenorrhea as well as severe menstrual bleeding. When dysmenorrheic symptoms are unmanageable and troublesome, patients should be advised to follow up with their providers.