Dysmenorrhea: Causes, Symptoms and Treatment

Overview

Dysmenorrhea is also known as a painful menstrual period or menstrual cramps. Dysmenorrhea can be classified into two categories- primary dysmenorrhea and secondary dysmenorrhea. Most people complain of menstrual cramps just before and during their menstrual cycle.

Classification of dysmenorrhea

Dysmenorrhea can be broadly classified into two categories. They are listed below:

• Primary dysmenorrhea:

It is also called spasmodic dysmenorrhea. Primary dysmenorrhea is caused due to prostaglandin F2α which is a potent myometrial stimulant and vasoconstrictor in the secretory endometrium. The female tends to have severe pain a few days before or during the menstrual cycle.

• Secondary dysmenorrhea:

It is also called congestive dysmenorrhea. It usually occurs during their 30’s or 40’s. It is caused due to disorders in the reproductive system which include pelvic inflammatory disease, endometriosis, uterine fibroids, adenomyosis, etc.

Causes of dysmenorrhea

Menstrual pain is usually caused due to increase in abnormal uterine contractions due to anatomical, psychological, and biochemical imbalances. The anatomical abnormalities include abnormal uterine positions and abnormality in the length and shape of the cervix. Biochemical imbalances include high levels of prostaglandins which are associated with severe menstrual cramps. A few more causes are:

• Uterine fibroids
• Endometriosis
• Pelvic inflammatory disease
• Adenomyosis
• Cervical stenosis 

Risk factors associated with dysmenorrhea

The risk factors associated with dysmenorrhea are listed below:

The risk factors for primary dysmenorrhea are:

• Nulliparity
• Obesity
• Smoking
• Women who are having heavy or prolonged menstrual flow
• Early age of menarche (< 12 years)
• Hereditary (early family history)

The risk factors for secondary dysmenorrhea are:

• Endometriosis
• Uterine fibroids
• Pelvic inflammatory disease
• Tubo-ovarian abscess
• Ovarian torsion 
• Uterine abnormalities
• Cervical stenosis

Symptoms of dysmenorrhea

Symptoms associated with dysmenorrhea are listed below:

• Throbbing or cramping pain in the lower abdomen
• Nausea
• Vomiting
• Diarrhea
• Lower back pain, around the hip area, and inner thigh
• Pain radiating down to legs
• Weakness
• Fatigue, dizziness
• Headache
• Dull or continuous pain abdomen

Diagnosis of dysmenorrhea

The diagnosis of dysmenorrhea can be done by following these steps. They are:

• Physical examination- During the physical examination, the doctor will examine the abdominal area carefully. A pelvic examination is done to exclude uterine irregularities and to look for any abnormal nodules, or cul-de-sac tenderness.
• External genital examination- the doctor does the external genital examination to look for genital rashes, swelling, or any abnormal discoloration.
• Vaginal vault examination- it is done to look for vaginal discharge or any foreign particles
• Bimanual examination- during this procedure, the doctor places the left hand on the abdomen, and right hand, the doctor uses the gloved fore and middle finger into the genital area to assess the cervical motion tenderness, uterine or adnexal tenderness, or any masses in the pelvic area.
• Laboratory tests- they include a complete blood count to look for any evidence of infection, ESR count, enzyme immune assay (EIA), and DNA probing test to exclude PID (pelvic inflammatory test), STIs (sexually transmitted infections), urine test, stool guaiac to rule out GI bleeding.
• Investigational scans- include ultrasonography (to examine the uterus, cervix, fallopian tubes, and ovaries), CT scan of the abdomen and pelvis, and MRI scans.
• Hysterosalpingography and saline-infused sonohysterography- are done to exclude congenital abnormalities of the uterus, endometrial polyps, and leiomyomas.
• Investigational laparoscopy- it is the single most useful diagnostic procedure done to look for any abnormalities in the pelvic and reproductive organs which includes uterine fibroids, endometriosis, ectopic pregnancy, and ovarian cysts.
• Hysteroscopy and D&C- these procedures are usually suggested only in cases where they find any abnormalities in the imaging scans.
• Biopsy- endometrial biopsy is indicated in the case of endometritis 

Treatment of dysmenorrhea

The treatment of dysmenorrhea can be done by these steps. They include:

1) Medications- they include

1. Pain killers- NSAIDs (they are the first-line medication for treating dysmenorrhea) that include acetaminophen, ibuprofen, naproxen, and aspirin.
2. Hormonal birth control- oral birth control pills contain hormones that will prevent ovulation and reduce the severity of menstrual pain. Other hormonal birth controls include combination oral contraceptives, depot medroxyprogesterone acetate, levonorgestrel intrauterine device, etc help in providing effective pain relief and are associated with reduced menstrual flow.
3. Progesterone only pill
4. Dietary and other therapies- which include a low-fat diet, adding magnesium and potassium, vitamin E in the diet, and various other dietary supplements will help in treating dysmenorrhea. Other therapies include acupuncture, acupressure, auriculotherapy, and aromatherapy 

2) Surgery- surgery is suggested in case of endometriosis, uterine fibroids, or other diseases which is not responded to conservative management. Hysterectomy (removal of the uterus) is advised in such cases 

3) Physical activity- exercises which include yoga, walking, etc. help in reducing menstrual pain, and symptoms.

4) Transcutaneous electrical nerve stimulation- transcutaneous electrical nerve stimulation (TENS) is a treatment that involves the use of electrode patches that are applied near the pain area on the skin 

5) Herbal medicine.

Prevention of dysmenorrhea

Although dysmenorrhea cannot be prevented completely, there are a few measures that will help minimize the risk of reducing dysmenorrhea. A few of them are listed below:

• Lifestyle modification
• Exercising regularly
• Avoid smoking
• Reduce stress
• Use heat- using a hot water bag, hot showers, heating pads, and heat patches will help in reducing menstrual pain
• Dietary supplements 

References

1. Dysmenorrhea"medscape"
2. Menstrual Cramps "mayoclinic"
3. Dysmenorrhea "hopkinsmedicine"