DYSMENORRHEA
Primary
dysmenorrhea is painful menstruation, with no identifiable pelvic pathology. It
occurs at the time of menarche or shortly there-after. It is characterized by
crampy pain that begins before or shortly after the onset of menstrual flow and
continues for 48 to 72 hours. Pelvic examination findings are normal.
Dysmenorrhea is thought to result from excessive production of prostaglandins,
which causes painful contraction of the uterus and arteriolar vasospasm.
Psycho-logical factors, such as anxiety and tension, may also contribute to
dysmenorrhea. As women grow older, dysmenorrhea often decreases and frequently
completely resolves after childbirth.
In
secondary dysmenorrhea, pelvic pathology such as endo-metriosis, tumor, or
pelvic inflammatory disease (PID) exists. Pa-tients with secondary dysmenorrhea
frequently have pain that occurs several days before menses, with ovulation,
and occasion-ally with intercourse.
A
complete pelvic examination is performed to rule out possible abnormalities,
such as strictures of the cervix or vagina, an im-perforate hymen, or other
conditions, such as endometriosis, PID, adenomyosis, and fibroid uterus. A
laparoscopy is usually required to identify organic causes.
In
primary dysmenorrhea, the reason for the discomfort is ex-plained, and the
patient is assured that menstruation is a normal function of the reproductive
system. If the patient is young and accompanied by her mother, the mother may
also need reassur-ance. Many young women expect to have painful periods if
their mothers did. The discomfort of cramps can be treated once anx-iety and
concern over its cause are dispelled by adequate expla-nation. Symptoms usually
subside with appropriate medication. Aspirin, a mild prostaglandin inhibitor,
may be taken at recom-mended doses every 4 hours. Other useful prostaglandin
antago-nists include NSAIDs such as ibuprofen (Motrin), naproxen (Aleve,
Anaprox, Naprosyn), and mefenamic acid (Ponstel). Rofecoxib (Vioxx), a COX-2
inhibitor, may also be used. If one medication does not provide relief, another
may be recommended. Usually these medications are well tolerated, but some
women experience gastrointestinal side effects. Contraindications include allergy,
peptic ulcer history, sensitivity to aspirin-like medica-tions, asthma, and
pregnancy. Low-dose oral contraceptives pro-vide relief in more than 90% of
patients and are indicated in women with dysmenorrhea who are sexually active
but do not desire a pregnancy.
Continuous
low-level local heat has recently been found to be effective in treating
primary dysmenorrhea and may be as effec-tive as medication (Akin, Weingand,
Hengehold et al., 2001). The mechanism is not clear, but heat may counteract
the activity of hormones that cause the uterus to contract. Heat is a
vasodila-tor that increases blood flow and may counteract constriction and
muscle contraction. Heat therapy and medication have been found to work well in
combination.
The
patient is encouraged to continue her usual activities and to increase physical
exercise if possible, as this seems to relieve dis-comfort for some women.
Taking analgesic agents before cramps start, in anticipation of discomfort, is
advised.
Management
of secondary dysmenorrhea is directed at diag-nosis and treatment of the
underlying cause (eg, endometriosis or PID). The same analgesic agents used for
primary dysmenorrhea may be part of the management of secondary dysmenorrhea
due to endometriosis.
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