Dysmenorrhea

Dysmenorrhea refers to painful menstruation that can significantly affect daily activities and quality of life. It is one of the most common gynecological complaints among women of reproductive age. Understanding its types, causes, and management is essential for effective treatment.

Introduction

Dysmenorrhea is characterized by crampy lower abdominal pain occurring before or during menstruation. It can be classified into primary and secondary forms, each with distinct etiologies and clinical features. The prevalence varies worldwide, with a significant proportion of women experiencing symptoms severe enough to interfere with daily functioning.

Classification

Primary Dysmenorrhea

• Occurs in the absence of any underlying pelvic pathology.
• Typically begins within 6–12 months after menarche.
• Pathophysiology involves excessive production of uterine prostaglandins causing increased uterine contractions.

Secondary Dysmenorrhea

• Occurs due to identifiable gynecological conditions such as endometriosis, uterine fibroids, adenomyosis, or pelvic inflammatory disease.
• Often develops later in reproductive life.
• Pain may be more prolonged and associated with other symptoms depending on the underlying cause.

Etiology and Pathophysiology

Primary Dysmenorrhea

• Excessive production of prostaglandins (especially PGF2α) in the endometrium during menstruation.
• Prostaglandins induce strong uterine contractions, leading to ischemia and pain.
• Other mediators such as vasopressin contribute to increased myometrial tone and heightened pain perception.

Secondary Dysmenorrhea

• Structural or pathological conditions cause menstrual pain through mechanical distortion or inflammation.
• Endometriosis: Ectopic endometrial tissue leads to inflammation and cyclic pain.
• Uterine fibroids: Localized uterine contractions and pressure effects produce pain.
• Adenomyosis: Invasion of endometrial tissue into myometrium increases uterine contractility and pain.
• Pelvic inflammatory disease: Chronic inflammation and adhesions exacerbate menstrual discomfort.

Risk Factors

• Age: Younger women and adolescents are more commonly affected.
• Early menarche: Associated with higher incidence of primary dysmenorrhea.
• Menstrual factors: Longer duration, heavier flow, and shorter cycle length increase risk.
• Lifestyle factors: Smoking, higher body mass index, and low physical activity are contributing factors.
• Family history: Genetic predisposition may influence susceptibility.

Clinical Features

Symptoms

• Crampy lower abdominal or pelvic pain, often radiating to the back and thighs.
• Associated gastrointestinal symptoms such as nausea, vomiting, diarrhea, or bloating.
• Urinary symptoms including frequency or discomfort in some cases.
• Systemic symptoms like fatigue, headache, dizziness, or irritability.

Timing and Duration

• Pain usually begins 1–2 days before or at the onset of menstruation.
• Peak intensity is typically within the first 24 hours of menses.
• Symptoms generally resolve within 2–3 days but may persist longer in secondary dysmenorrhea.

Diagnosis

Clinical Assessment

• Detailed menstrual history including onset, duration, severity, and associated symptoms.
• Pain assessment using scales such as the Visual Analogue Scale (VAS) or numerical rating systems.
• Identification of risk factors and family history to differentiate primary from secondary causes.

Physical Examination

• Abdominal examination to rule out other causes of pelvic pain.
• Pelvic examination to detect uterine tenderness, masses, or signs of infection.

Investigations

• Imaging: Ultrasound or MRI may be used to detect structural causes like fibroids or endometriosis.
• Laboratory tests: Hormonal assays or inflammatory markers if secondary causes are suspected.

Management

Non-Pharmacological Approaches

• Lifestyle modifications such as regular physical exercise and maintaining a healthy body weight.
• Heat therapy, including heating pads applied to the lower abdomen.
• Dietary adjustments, including reducing caffeine and salt intake.
• Stress reduction techniques such as yoga, meditation, or relaxation exercises.

Pharmacological Therapy

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): First-line treatment to reduce prostaglandin-mediated pain.
• Hormonal Therapy: Oral contraceptives or progestins to regulate menstrual cycles and reduce dysmenorrhea.
• Adjunctive medications may include antispasmodics or analgesics for breakthrough pain.

Surgical Management

• Reserved for secondary dysmenorrhea caused by structural pathologies.
• Laparoscopic excision of endometriotic lesions or adhesions.
• Myomectomy for symptomatic fibroids or hysterectomy in severe, refractory cases.

Complications and Impact

• Significant limitation of daily activities, including work, school, and social engagements.
• Psychological effects such as anxiety, depression, and emotional distress.
• Increased absenteeism from school or work, affecting productivity and quality of life.
• Potential for chronic pain if left untreated, especially in secondary dysmenorrhea.

Prevention and Counseling

• Early recognition and treatment of dysmenorrhea to prevent progression and chronic pain.
• Education on lifestyle measures such as regular exercise, balanced diet, and stress management.
• Counseling regarding menstrual hygiene and understanding the normal menstrual cycle.
• Guidance on use of medications like NSAIDs or hormonal therapy for symptom control.
• Referral to a gynecologist for evaluation of secondary causes if symptoms are severe or persistent.

References

1. Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006;19(6):363-371.
2. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-1138.
3. Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015;(7):CD001751.
4. French L. Dysmenorrhea. Am Fam Physician. 2005;71(2):285-291.
5. Chiou CF, Su HY, Lin CC. Endometriosis-associated dysmenorrhea. Taiwan J Obstet Gynecol. 2013;52(1):9-12.
6. Burnett M, Lemyre M. No. 345 – Primary dysmenorrhea consensus guideline. J Obstet Gynaecol Can. 2017;39(7):585-595.
7. Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-113.
8. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014;89(5):341-346.
9. Armour M, Parry K, Steel K, et al. Dysmenorrhea and related disorders. Int J Women’s Health. 2019;11:169-179.
10. Rana A, Kaur S. Dysmenorrhea: Pathophysiology and management strategies. J Clin Diagn Res. 2016;10(9):QE01-QE05.