Dysmenorrhoea

What is dysmenorrhoea?

Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhoea is described as menstrual pain that is severe enough to limit a woman’s normal activities and is requiring medical attention. Most women experience dysmenorrhoea some time during their lives. During menstrual periods, the pain a woman is suffering can be so severe that she is unable to carry on with her normal activities. She may also experience other symptoms such as nausea, vomiting, heart palpitation, sweating and headache. Usually, the pain starts at the beginning of the period lasting for a few hours, but in some women it may continue for several days.

 

Different types of dysmenorrhoea
Two types of dysmenorrhoea are distinguished, namely:

     
  • primary dysmenorrhoea, and  
  • secondary dysmenorrhoea.

Primary dysmenorrhoea
Primary dysmenorrhoea is pain during menstruation for which no organic cause can be found. It is characterised by sharp pains or cramps which present as spasmodic or colicky sensation, sometimes described as labour-like pain.

Prevalence
Most women suffer from primary dysmenorrhoea. It occurs mainly in young women in their early teens (who have just started to menstruate) to late twenties. It is also more common in women who have never had children. Pregnancy and childbirth, with the associated increase and stretching of uterine muscles fibres, often cause an end to primary dysmenorrhoea in many women.

Cause
The real causative mechanism for primary dysmenorrhoea is not known, but it appears that a major role is played by a group of hormones called prostaglandins, which are present in various body tissues including the uterus. Prostaglandins influence the tension and constriction of muscles of the uterus and of blood vessels which not only cause menstrual cramps but may also be responsible for general symptoms like headache, nausea and vomiting. The constricting and tightening of the muscles are responsible for the sharp pains that are sometimes felt in the inner thighs and lower abdomen. As there is less blood circulation and oxygenation to the uterus, waste products such as carbon dioxide and lactic acid may accumulate, which in turn intensifies the pain and discomfort.

Prostaglandins are made inside the tissue from precursors such as fatty acids which increase after ovulation. Research has shown that women who do not ovulate, do not experience cramps, and primary dysmenorrhoea can be treated by inhibiting ovulation with oral contraceptives. This has led to the conclusion that an imbalance of oestrogens and progesterone, the main hormones of the menstrual cycle, may play a role.

Secondary Dysmenorrhoea
Secondary dysmenorrhoea is characterised by pain, usually felt more to one side, which occurs at the time of menstruation, the pain being secondary due to an organic cause.

Rarely, a personality factor with a conditioned behaviour or psychosexual disorder may be present. This is sometimes referred to as psychogenic dysmenorrhoea, which is attributed to an unpleasant sexual experience or a lack of information about menstruation and sexuality, combined with negative attitudes towards sex.
Prevalence
Secondary dysmenorrhoea most frequently occurs in women in their late thirties or forties. For these women, menstruation may unexpectedly become painful after years of pain-free menstrual periods. Secondary dysmenorrhoea, however, is less prevalent than primary dysmenorrhoea.

Cause
The doctor will establish the organic disorder, which may occur at any age, by taking a detailed history and performing a medical examination. An organic cause should also be considered if a woman does not respond to standard treatment for suspected primary dysmenorrhoea. The organic cause may be an underlying disease or structural abnormality inside or outside the uterus, such as:

     
  • Endometriosis  
  • Pelvic inflammatory disease  
  • Fibroid tumours of the uterus  
  • Endometrial polyps  
  • Structural abnormalities of the genital tract  
  • Pelvic congestion syndrome  
  • Cervical stenosis
Endometriosis

Endometriosis is the main cause of secondary dysmenorrhoea and may be present with a false diagnosis of primary dysmenorrhoea. The main symptom is pain which may start several days before and then becoming worse during menstruation. Furthermore, the patient can suffer from pain during sexual intercourse and may present with infertility.

The term “endometriosis” refers to the endometrium (the inner lining of the uterus), and the disease is characterised by implants of endometrium (so-called ectopic or out-of-place endometrium) growing outside the uterine cavity. Ectopic endometrium can develop at any area in the pelvic cavity, including the fallopian tubes, the ovaries and even the intestines. If endometrial tissue appears within the muscle wall of the uterus, the condition is referred to as adenomyosis. At the onset of menstruation, all endometrial tissue irrespective of location, starts to bleed. While blood from the uterine cavity lining can leave the body through the cervix and vagina, bleeding from endometrial implants at all ectopic (out-of-place) sites becomes trapped leading to the formation of blood-containing cysts. With each menstruation these cysts expand and cause pain.

During absence of menstruation, no expansion occurs, and this is the reason why pregnancy helps for endometriosis. However, women who suffer from endometriosis are more likely to become infertile due to the scarring and other structural damage which the disease causes in the reproductive tract. In advanced cases of endometriosis, a hysterectomy with removal of the implant areas even including the ovaries may become necessary.

Pelvic inflammatory disease (PID)
This serious infection may involve the uterus and fallopian tubes, initially without and later with the ovaries and other pelvic structures. Symptoms include fever, chills, back pain, an abnormal vaginal discharge, pain during or after intercourse and spotting. PID requires quick diagnosis and medical treatment to prevent scarring of the reproductive organs with subsequent infertility. If PID recurs and becomes chronic, it can cause the formation of adhesions of the pelvic organs with associated menstrual pain.

Fibroid tumours of the uterus (also called myomas or leiomyomas)
Such tumours develop as excessive growth of the uterine muscle tissue and are most prevalent in women in their reproductive years. They are benign and their growth is oestrogen-dependent. This means that they can become larger during pregnancy with the increased production of oestrogens, and also that they shrink after menopause when oestrogen levels decrease. The tumours may increase the size of the uterus to that of a pregnant woman. Fibroids can cause menstrual cramps and can be responsible for additional pain when they press against the bladder and bowel (causing frequent urination and bowel symptoms), or when they become so large that they outgrow their own blood supply. Apart from menstrual cramps and pelvic pain, fibroid tumours can cause excessive menstrual bleeding (sometimes necessitating a hysterectomy).

Endometrial polyps
Polyps which develop from the endometrium, may fill the uterine cavity in the same way like a submucosal fibroid which has grown beneath the endometrial lining (or: mucosa). The uterine muscles contract around these tumours trying to expel them, hereby causing labour-like contraction pains. The doctor will identify polyps and submucosal fibroids by ultrasonography or by looking inside the uterine cavity with an endoscope (hysteroscopy).

Structural abnormalities of the genital tract
This refers to the very rare condition of a congenital defect, for example, when the uterus is malformed and has a horn. This horn may be lined with endometrium but may not have a connection with the uterine cavity. During periods, the menstrual blood is trapped inside the horn with a similar effect like endometriosis.

Pelvic congestion syndrome
This refers to engorgement of blood vessels within the pelvic cavity. When examined by the doctor with laparoscopy (inspection of the organs inside the abdomen through an endoscope), varicose veins are visible at the pelvic side walls and in the ligaments attached to the uterus.

Cervical stenosis
If the cervical canal, which links the uterine cavity to the vagina, is severely narrowed, menstrual flow is inhibited causing a build-up of shed endometrium and blood inside the uterus with subsequent cramps. The stenosis (narrowing) may be congenital or due to infection or trauma of the cervix following previous operations. The condition may improve after pregnancy and vaginal delivery.

When to see a doctor

Whether you suffer from primary or secondary dysmenorrhoea, always call your health professional when:

     
  • Menstrual pain is so severe that it disrupts your life  
  • Menstrual periods always hurt  
  • Over-the-counter medications do not provide relief  
  • Unexplained symptoms accompany painful periods  
  • If your period is a week or two later than expected and you are bleeding heavily (you may have a miscarriage)  
  • If your period is a few weeks later than expected and you have severe pain on one side (it may indicate an ectopic pregnancy)
Diagnosis

When seeking medical attention, patients who report cyclic pain during menstruation may have other diseases such as appendicitis, ectopic pregnancy and ovarian cysts, which all have to be differentiated from conditions which cause dysmenorrhoea. Another possible misdiagnosis can occur when patients are thought to have primary dysmenorrhoea while they are actually suffering from secondary dysmenorrhoea due to endometriosis.

Primary or secondary dysmenorrhoea can only be diagnosed after:

     
  • A thorough medical history has been taken. The health professional will enquire about the patient’s menstrual history, such as:
           
    • The quantity of menstruation (was the amount of bleeding with the last menstrual period normal or excessive?)      
    • Time pattern of menstrual periods (does the patient have periods at regular intervals?)      
    • Self-treatment (how effective were home remedies?)      
    • Other symptoms

     

  • A thorough physical examination, which includes a gynaecological examination. If the patient is a virgin, digital palpation through the vagina will be replaced by rectal examination.

Other diagnostic tests that may be performed include:

     
  • Abdominal or transvaginal ultrasound scan of the pelvic organs  
  • Hysteroscopy with or without dilatation of the cervix (looking into the uterus with a thin fibre-optic endoscope which can be attached to a video-camera)  
  • Laparoscopy (looking into the abdomen with a similar endoscope)  
  • Blood tests and cultures (to rule out sexually transmitted diseases such as gonorrhoea, syphilis or chlamydia infections)
How is it treated?

Home remedies
Treatment for primary dysmenorrhoea focuses on pain relief. Women who suffer from primary dysmenorrhoea are usually advised to relieve menstrual cramps with the following home remedies:

     
  • A diet with increased intake of magnesium, calcium, vitamin B-1 and omega-3 fatty acid containing food such as fish and fish-oil  
  • Heat (with a warm bath/shower or a hot water bottle, applied to the lower abdomen)  
  • Relaxation techniques supported by deep breathing and light abdominal massage with stroking fingers  
  • Exercise, such as waist-bending, pelvic rock exercises and walking  
  • Drinking warm beverages may be helpful

Medication
Whether or not to use a medication and what type of treatment should be administered is best decided by a doctor who will diagnose and differentiate between primary and secondary dysmenorrhoea. For primary dysmenorrhoea, the following drugs have been used successfully, some of which are available as over-the-counter medicines:

     
  • Several non-steroidal anti-inflammatory drugs (NSAIDs) are beneficial in the management of menstrual cramps. Their mode of action is inhibiting the production and release of prostaglandins. There are different types of NSAIDs available such as: mefenamic acid (Ponstanreg;), naproxen (Naprosynreg;), and ibuprofen (Nurofenreg; Ibumedreg;). The response to these drugs can vary and some women may only find relief by switching from one type of brand to another one after one or two menstrual cycles. These medicines are taken from the beginning of the period through the first two to three days. Taking them with food can minimise side-effects such as nausea and diarrhoea. Usually, NSAIDs become effective within 30-60 minutes and it is not necessary to start two to three days before the period as it was sometimes customary in the past. Since there are certain contraindications for NSAIDs (e.g. stomach ulcer and others), advice on these drugs for treating dysmenorrhoea needs to be obtained from a health professional.  
  • Aspirin, also used for alleviating primary dysmenorrhoea, is not recommended since it is not strong enough in the usual dosage to reach sufficient anti-prostaglandin activity.  
  • Oral contraceptives (OCs) are up to 90% effective for treating primary dysmenorrhoea. Their mode of action is the inhibition of ovulation and the reduction of menstrual flow. For women who suffer from primary dysmenorrhoea and who require contraception, using OCs is the first-line treatment.

For secondary dysmenorrhoea, medication is aimed at the underlying disease:

     
  • For pelvic inflammatory disease, antibiotics will be prescribed. The choice of antibiotics is influenced by the detection of specific micro-organisms at the laboratory from culture specimens of the patient.  
  • For endometriosis, a number of drugs are available including NSAIDs to inhibit prostaglandin production by ectopic endometrium, and continuous treatment with different hormone regimens to induce amenorrhoea (absence of menstruation).

Surgery
This may be necessary in women who cannot obtain adequate pain relief or control and is especially indicated in secondary dysmenorrhoea to remove endometriotic cysts, polyps, adhesions and fibroids. A hysterectomy may be indicated in cases of advanced endometriosis or large fibroids.

Interruption of the sensory nerves supplying the uterus can be performed by means of a presacral neurectomy or laparoscopic uterosacral nerve ablation (LUNA), meaning the cutting of the nerves which run in the uterosacral ligaments (in the ligaments from the uterus to the sacrum bone of the pelvis). These operations are very rarely performed and only in patients with severe dysmenorrhoea who do not respond satisfactorily to other medical and/or surgical treatment.

Johns Hopkins patient information

Last revised: December 4, 2012
by Amalia K. Gagarina, M.S., R.D.

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