DYSMENORRHOEA

Dysmenorrhea

is defined as severe, cramping pain in the lower abdomen that occurs just before or during menses.

(primary or secondary)

Primary dysmenorrhoea occurs in the absence of significant pelvic pathoIogy. usually develops within the first 2 years of the menarche

Characteristics of primary dysmenorrhoea

The pain is often intense, cramping, crippling and severely incapacitating so that it causes a major disruption of social activities.

It is usually associated with the onset of menstrual blood loss but may begin on the day preceding menstruation.

The pain only occurs in ovulatory cycles, is lower abdominal in nature but sometime radiates down the anterior aspect of the thighs.

The pain often disappears or improves after the birth of the first child.

Dysmenorrhoea is often associated with vomiting and diarrhoea Pelvic examination reveals no abnormality of the pelvic organs.

Pathophysiology of primary dysmenorrhoea

Primary dysmenorrhoea is a feature of ovulatory cycles and usually appears within 6 to 12 months of the menarche.

The etiology of primary dysmenorrhea has been attributed to uterine contractions or ischemia, psychological factors, and cervical factors.

Psychological factors may alter the perception of pain but are not unique to the problem of dysmenorrhea.

There is no convincing evidence of cervical stenosis in patients

with dysmenorrhea, so there is no basis for incriminating cervical stenosis or psychological factors as major contributors to the

problem of primary dysmenorrhea.

Pathophysiology of primary dysmenorrhoea

Women with dysmenorrhea have increased uterine activity, which may manifest as increased resting tone, increased contractility, increased frequency of contractions, or incoordinate action.

Prostaglandins are released as a consequence of endometrial cell lysis with instability of Iysosomes and release of enzymes. which break down cell membranes

The evidence that prostaglandins are involved in primary dysmenorrhoea is convincing. Menstrual fluid from women with dysmenorrhea has higher than normal levels of prostaglandins (especially PGF2a and PGE2), and these levels can be reduced to below normal with nonsteroidal anti-inflammatory drugs (NSAIDs). which are effective treatments.

Clinical Symptoms

Primary dysmenorrhoea usually begins 6 to 12 months after menarche, almost invariably coinciding with the onset of ovulatory cycles. Patients complain of spasmodic or cramping lower abdominal pain that may radiate suprapubically or to the inner aspect of the thighs. They may have backache of varying severity. They may also have other accompanying symptoms, such as headache, nausea,vomiting, diarrhea, or fatigue. Symptoms typically last 48 hours or less, but sometimes may last up to 72 hours.

Secondary dysmenorrhoea Secondary dysmenorrhoea is caused by organic pelvic

pathology and it usually has its onset many years after the menarche.

Any woman who develops secondary dysmenorrhoea should be considered to have organic pathology in the pelvis until proved otherwise.

Pelvic examination is particularly important in this situation and, if the findings are negative, laparoscopy is indicated.

Common associated pathologies include endometriosis, adenomyosis, pelvic infections and intra-uterine lesions such as

submucous,fibroid.

Pathophysiology of secondary dysmenorrhoea

The mechanism of pain in secondary dysmenorrhoea is due to pelvic congestion which is more marked in the premenstrual period.

Pain increases in its severity as menstruation approaches and is relieved by the onset of menstrual flow, due to the diminution of pelvic congestion.

Clinical Symptoms

Secondary dysmenorrhoea usually starts few days (about 3 to 5 days) before menstruation.

Pain is continuous dull aching lower abdominal pain accompanied by backache occurring in parous women after many years of relatively painless menstruation.

Secondary dysmenorrhoea may be associated with other symptoms as dyspareunia, infertility and abnormal bleeding.

Management

Primary dysmenorrhoea: General and psychological treatment: Discussion and reassurance are an essential part of

management. Primary dysmenorrhoea tends to present some months after the menarche and is associated with ovulatory cycles, early cycles frequently being anovulatory. The intensity of pain may be aggravated by apprehension and fear, and reassurance that the pain does not indicate any serious disorder may lessen the symptoms. It is also common for the pain to either disappear or substantially lessen after the birth of the first child.

Drug therapy: Dysmenorrhoea can be effectively treated by drugs

that inhibit prostaglandin synthesis and hence uterine contractility.

These drugs include aspirin, mefenamic acid, naproxen or ibuprofen. As dysmenorrhoea is often associated with vomiting, headache and dizziness, it may be advisable to start therapy either on the day before the period is expected, or as soon as the menstrual flow commences

Mefenamic acid is given in a dose of 250 mg 6-hourly. This drug also reduces menstrual flow in some women with menorrhagia.

If these drugs are inadequate, suppression of ovulation with the contraceptive pill is highly effective in reducing the severity of dysmenorrhoea. Where it is ineffective, then careful consideration should be given to the possibility of underlying pathology.

If all conservative medical therapy fails, then relief may sometimes be achieved by mechanical dilatation of the cervix or by the surgical removal of the pain fibers to the uterus in an operation known as presacral neurectomy, but these methods of treatment should be approached with considerable caution.

Physical therapy Encourage regular and aerobic exercises in fresh air

to raise their general health . Relaxation techniques, as well as meditation and

hypnosis may be helpful for raising their pain threshold.

Avoid constipation. Massage . Hot packs on the lower abdomen for 10-15 minutes. Accupressure on the lumosacral area and 3 cm

superior to the medial malleolus.

TENS Low level laser therapy

Secondary dysmenorrhoea:

In cases of secondary dysmenorrhoea, the treatment is dependent on the nature of the underlying pathology. If the pathology is not amenable to medical therapy, the symptoms may only relieved by hysterectomy. However, the role of physical therapy in such cases will consist of pre and post operative physical treatment.