DYSMENORRHEA: an important health issue in women

DYSMENORRHEA: an important health issue in women

Dysmenorrhea literally means painful menstruation. But a more realistic and practical definition includes cases of painful menstruation of sufficient magnitude so as to incapacitate day-to-day activities.

The burden of dysmenorrhea is greater than any other gynecological complaint: it is the leading cause of gynecological morbidity in women of reproductive age regardless of age, nationality, and economic status. The effects extend beyond individual women to society, resulting annually in an important loss of productivity. Thus, the World Health Organization estimated that dysmenorrhea is the most important cause of chronic pelvic pain.

Types:

(A)  PRIMARY DYSMENORRHEA (Spasmodic) : Is one where there is no identifiable pelvic pathology.

      Incidence:   Is about 15–20 percent. 

     Causes:  The mechanism of initiation is difficult to establish. Mostly confined to adolescents and is related to         dysrhythmic uterine contractions and uterine hypoxia.

 

1.Psychosomatic factors  (tension and anxiety)

2.Uterine myometrial hyperactivity - There is marked hyperperistalsis of the JZ (subendometrial layer of myometrium) in women with endometriosis and adenomyosis along with significant changes. These include irregular thickening and hyperplasia of smooth muscle (Junctional zone hyperplasia)and less vascularity(may cause ischemia)

3.Imbalance in the autonomic nervous control of uterine muscle with overactivity of the sympathetic nerves resulting in hypertonicity of the circular fibers of the isthmus and internal os.

4.Prostaglandins (PGF2 α, PGE2 ) -increased production or increased sensitivity of the myometrium to prostaglandins, leading to increased myometrial contraction with or without dysrhythmia. Endothelinscan act in synergism with prostaglandins.

5.Vasopressin - Vasopressin increases prostaglandin synthesis and also increases myometrial activity directly. It causes uterine hyperactivity and dysrhythmic contractions → ischemia and hypoxia → pain.

6.Platelet activating factor (PAF) and Leukotrienes are vasoconstrictors and stimulate myometrial contractions.

 

Clinical features: The pain begins a few hours before or just with the onset of menstruation. The severity may extend to 24 hours but seldom persists beyond 48 hours. Thepain is spasmodic and confined to lower abdomen; may radiate to the back and medial aspect of thighs. Systemic discomforts like nausea, vomiting, fatigue, diarrhoea, headache and tachycardia may be associated.

Treatment: General measures include improvement of general health and simple psychotherapy. Usual activities including sports are to be continued. Mild analgesics and antispasmodics may be prescribed.

Severe cases: The drugs used are —

  1. Prostaglandin synthetase inhibitors reduce the prostaglandin synthesis and also have a direct analgesic effect.
  2. Fenamate group — mefanamic acid 250–500 mg 8 hourly or flufenamic acid 100–200 mg 8 hourly.
  3. Propionic acid derivatives — ibuprofen 400 mg 8 hourly or naproxen 250 mg 6 hourly.
  4. Indomethacin 25 mg 8 hourly.
  5. Transdermal use of smooth muscle relaxant glyceryl trinitrate can also be used.
  6. Oral contraceptive pills: Should be used for 3–6 cycles. If the above protocol fails, laparoscopy is indicated to find out any pelvic pathology to account for pain, the important one being endometriosis.
  7. Surgery: Transcutaneous electrical nerve stimulation (TENS), Laparoscopic uterine nerve ablation (LUNA) may be used.Laparoscopic presacral neurectomy is done to cut down the sensory pathways (via T11–T12) from the uterus thoughit is not helpful for adnexal pain (T9 –T10)
  8. Dilatation of cervical canal: It relieves pain bydamaging the sensory nerve endings

 

(B)  SECONDARY DYSMENORRHEA (Congestive)- is normally considered to be menstruation  associated pain       occurring in the presence of pelvic pathology.

Causes: The pain may be related to increasing tension in the pelvic tissues due to pre-menstrual pelvic congestion or increased vascularity in the pelvic organs:

  1. Cervical stenosis
  2. chronic pelvic infection
  3. pelvic endometriosis
  4. pelvic adhesions
  5. adenomyosis
  6. uterine fibroid
  7. endometrial polyp
  8. IUCD in utero
  9. pelvic congestion
  10. Obstruction due to mullerian malformations

 

Clinical features: The pain is dull, situated in the back and in front without any radiation. It usually appears 3–5 days prior to the period and relieves with the start of bleeding. The onset and duration of pain depends on the pathology. The patients may have some discomfort even in between periods along with symptoms of associated pelvic pathology. Abdominal and vaginal examinations usually reveal the offending lesion. At times, the lesion is revealed by laparoscopy, hysteroscopy or laparotomy

Treatment: The treatment aims at the causative pathology rather than the symptom. The type of treatment depends on the severity, age and parity of the patient

 

MITTELSCHMERZ’S SYNDROME (Ovular Pain) :

It appears in the mid-menstrual period. The pain is usually situated in the hypogastrium or in either iliac fossa. Nausea or vomiting is conspicuously absent.

It rarely lasts more than 12 hours. It may be associated with slight vaginal bleeding or excessive mucoid vaginal discharge.

The exact cause is not known.

The probable factors are:

  1. Increased tension of the Graafian follicle just prior to rupture,
  2. Peritoneal irritation by the follicular fluid following ovulation
  3. Contraction of the tubes and uterus.

    Treatment is effective with assurance and analgesics and with contraceptive pills.