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PäiviHärkki

Dysmenorrhoea

Essentials

In primary dysmenorrhoea there are no abnormalities found during a gynaecological examination and there is no need for laboratory investigations.
In secondary dysmenorrhoea, a gynaecological disease behind the condition should be sought for.

Epidemiology

Up to 95% of women have occasional dysmenorrhoea.
5-15% complain of severe dysmenorrhoea.

Symptoms

Lower abdominal pain 100%
Nausea, vomiting 90%
Tiredness 80%
Lower back pain 60%
Dizziness 60%
Diarrhoea 60%
Headache 40%

Primary dysmenorrhoea

Symptoms

Cramping lower abdominal pains emerge with the onset of menstrual bleeding and radiate to the back and thighs.
Pain lasts for about 24-48 hours.
Pain is associated with the ovulatory cycle.
The problem first emerges 6-12 months after menarche.

Aetiology

Pain is caused by prostaglandins secreted by the uterine mucosa.
The production of prostaglandins increases after ovulation.
Prostaglandins cause uterine cramps and decreased blood flow leading to ischaemic uterine pain.
Prostaglandins released into the circulation cause the systemic symptoms.

Diagnosis

Usually obvious on the basis of history.
No abnormalities found during a gynaecological examination.
No need for laboratory investigations.

Treatment

In mild cases, an explanation of the reasons behind the symptoms is sufficient.
Nonsteroidal anti-inflammatory agents are effective Nonsteroidal Anti-Inflammatory Drugs for Primary Dysmenorrhoea.
- They inhibit the action of the cyclo-oxygenase enzyme thus blocking prostaglandin synthesis.
- Medication should be taken immediately at symptom onset or rather just before symptoms.
- The duration of medication is 24-48 hours.
- Provide pain relief in 80-90% of cases.
- Reduce the contractility of the uterus.
- Reduce the amount of blood loss by 20-30%.
Combined oral contraceptives. Remember contraindications.
- Prevent ovulation and associated pain Combined Oral Contraceptive Pill for Primary Dysmenorrhoea.
- Make the endometrium thinner and reduce the production of prostaglandins.
- Reduce menstrual bleeding.
- May be prescribed even if contraception is not needed.
- May be combined with analgesics.
- May be used in longer cycles (2-3 strips without a pause).
Progestogen-only pills ("mini pills")
- Good alternative if combined oral contraceptives are not suitable
- May cause spotting or amenorrhoea.
- Partly prevent ovulation.
- Make the endometrium thinner and reduce the production of prostaglandins.
Hormone-releasing intra-uterine devices
- Make the endometrium thinner and reduce the production of prostaglandins.
- Reduce menstrual bleeding.
- Provide pain relief.
- An ordinary intra-uterine device will worsen dysmenorrhoea.
Other treatment modes
- Physical activity Exercise for Dysmenorrhoea, heat, acupuncture Acupuncture for Primary Dysmenorrhoea and TNS (transcutaneous nerve stimulation) Transcutaneous Electrical Nerve Stimulation and Acupuncture for Primary Dysmenorrhoea may ease the pain.

Secondary dysmenorrhoea

Symptoms

Previously painless menstruation becomes painful.
Pain emerges before menstruation commences.
Pain lasts for the entire duration of menstrual bleeding.
Maximum prevalence at the age of 30-40 years
Condition attributable to a gynaecological condition
Pain also partially attributable to prostaglandins

Aetiology

Adenomyosis Endometriosis, causes pain in 30% of cases
Endometriosis Endometriosis, causes pain in 50-90% of cases
Myoma Benign Gynaecological Lesions and Tumours, causes pain in 20-80% of cases
Sequela of an infection, causes pain in 10-50% of cases
Menorrhagia Abnormal Menstrual Bleeding causes pain in 20-30% of cases
Copper intra-uterine device Intrauterine Device, causes pain in 0-20% of cases

Diagnosis

Gynaecological examination, blood tests and swabs to diagnose possible infection Pelvic Inflammatory Disease (PID) and cervical (Pap) smear Pap (Cervical) Smear and Endometrial Biopsy
Transvaginal ultrasonography Gynaecological Ultrasound Examination if a gynaecological illness is suspected
Laparoscopy in severe pain

Treatment

Treatment according to the cause
If an intra-uterine device is causing dysmenorrhoea it should be removed.
Prostaglandin synthesis inhibitors, combined oral contraceptives, progestogens or a hormone-releasing IUD are worth trying.

References

Dmitrovic R, Kunselman AR, Legro RS. Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstet Gynecol 2012;119(6):1143-50. [PubMed]
Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update 2015;21(6):762-78. [PubMed]
Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: a review. Contraception 2010;81(3):185-96. [PubMed]
Ferries-Rowe E, Corey E, Archer JS. Primary Dysmenorrhea: Diagnosis and Therapy. Obstet Gynecol 2020;136(5):1047-1058. [PubMed]

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Information ⬇

Editors

Dysmenorrhoea

Essentials

Epidemiology

Symptoms

Primary dysmenorrhoea

Symptoms

Aetiology

Diagnosis

Treatment

Secondary dysmenorrhoea

Symptoms

Aetiology

Diagnosis

Treatment

References

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