Dysmenorrhea - Management of Normal and Altered Female Physiologic Processes

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.

Assessment and Diagnostic Findings

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.

Management

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.