Discover causes, symptoms, and management of dysmenorrhea. Find relief and take control of your menstrual health with Meri Sehat.

Dysmenorrhea

Humza Khizer

Overview

Defined as painful menstruation, dysmenorrhea affects 16-91% of women of reproductive age across the world<a href="#accordion">[1]</a>. It is characterized by cramping lower abdominal pain that occurs either before or during menstruation. The pain may radiate to the back and thighs; other symptoms such as nausea, vomiting, diarrhea, and fatigue are also frequently reported.

In Pakistan, researchers have found an alarmingly high prevalence of dysmenorrhea among university students, ranging from 56 to 92%<a href="#accordion">[2]</a><a href="#accordion">[3]</a>.&nbsp;These women also reported difficulty concentrating on studies, a decrease in social activity, and sleep disturbances due to the pain<a href="#accordion">[3]</a>. Thus, affecting their quality of life.&nbsp;

Dysmenorrhea is the most common menstrual disorder among adolescent girls<a href="#accordion">[4]</a>. It most commonly occurs in the absence of an underlying disorder (primary dysmenorrhea); however, some cases can result from pelvic pathology (secondary dysmenorrhea). Although not life-threatening, a huge majority of women are unable to carry out everyday tasks due to this debilitating condition, resulting in frequent leaves from work and school. In the USA, dysmenorrhea causes a loss of approximately 140 million working hours per year<a href="#accordion">[5]</a>.

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Signs And Symptoms

Symptoms of dysmenorrhea include:

<ul>
	<li>Pain in the lower abdomen, often radiates to the back or thighs</li>
	<li>Pain is often described as throbbing, dull, and continuous</li>
	<li>Typically, the pain lasts 2-3 days&nbsp;</li>
	<li>Headaches</li>
	<li>Dizziness or fainting</li>
	<li>Nausea and vomiting</li>
	<li>Diarrhea or <a href="https://www.merisehat.pk/disease/constipation" target="_blank">constipation</a></li>
	<li>Fatigue</li>
</ul>

&nbsp;

Causes

It&#39;s not always easy to identify the exact cause of dysmenorrhea. Moreover, the causes can vary depending on the type of dysmenorrhea the person has.&nbsp;

 
Primary Dysmenorrhea - This occurs in the absence of any underlying medical condition. Researchers believe that the presence of the hormone prostaglandin likely triggers the pain. Prostaglandin F2&alpha; in particular causes the uterine muscle to contract, resulting in constriction of nearby blood vessels and a temporary block of oxygen supply to the muscle. As a result, one experiences menstrual cramps. Women with dysmenorrhea have shown higher levels of prostaglandins, resulting in excessive and more intense muscle contractions<a href="#accordion">[6]</a>. The pain mostly begins at an early age, shortly after a person&#39;s first period. However, the pain tends to lessen in intensity with age.

&nbsp;

Secondary Dysmenorrhea - Painful menstrual cramps due to a pelvic pathology fall under secondary dysmenorrhea. It usually begins later in life, 30s-40s, and gets worse over time. The following conditions can cause secondary dysmenorrhea: 
&nbsp;

<ul>
	<li>Uterine Fibroids - Also called leiomyomas, fibroids are noncancerous growth of muscle and tissue that form from the uterine walls. Small fibroids are generally asymptomatic, but larger ones can often cause dysmenorrhea and heavy periods.</li>
	<li><a href="https://www.merisehat.pk/disease/endometriosis-89" target="_blank">Endometriosis</a><a href="https://www.merisehat.pk/disease/endometriosis-89" target="_blank"> </a>- This condition occurs from the growth of endometrial tissue in locations other than the uterus such as on the fallopian tubes, ovaries, or bladder. The hormonal change during menstruation causes this tissue to also bleed, resulting in pain. Moreover, the formation of pelvic adhesions can further cause pain&nbsp;</li>
	<li>Pelvic Inflammatory Disease (PID) - Sexually transmitted bacteria cause inflammation and infection of the upper female reproductive organs (uterus, fallopian tubes, ovaries). Thus, resulting in lower abdominal pain, vaginal discharge, and painful sexual intercourse.</li>
	<li>Adenomyosis - Adenomyosis is characterized by a thickening and enlargement of the uterus due to the growth of the endometrium into the muscle of the uterus (myometrium). As the uterus increases in size, it leads to abnormal uterine bleeding and painful periods.</li>
	<li>Uterine Polyps - Polyps result from an overgrowth of the endometrium and can turn precancerous in rare cases. They can often result in menstrual cramps and heavy periods.</li>
	<li>Ovarian Cysts - These are fluid-filled sacs that form in the ovaries, mostly due to hormonal changes during puberty or menopause. A majority of cysts go unnoticed while some may cause irregularities with the menstrual cycle. Ruptured or hemorrhagic cysts are most commonly associated with dysmenorrhea.</li>
	<li>Cervical Stenosis - Cervical stenosis is a rare narrowing of the cervix that can result from cysts, uterine surgeries, and even cervical cancer. The narrowing of the cervix results in slower menstrual flow and an increase in intra-uterine pressure; thus, causing dysmenorrhea.</li>
	<li>Congenital Malformations - Certain congenital malformations such as subseptate or bicornuate uterus can also cause painful menstruation.&nbsp;</li>
	<li>Intrauterine Contraceptive Device (IUCD) - Many women report heavier and painful periods after insertion of an intrauterine contraceptive device.</li>
	<li>Premenstrual Syndrome (PMS) - Hormonal changes cause women to experience monthly changes in mood, behavior, and health, 1-2 weeks before the onset of menstruation. However, symptoms usually disappear 1-2 days after start of menstruation.</li>
</ul>

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Diagnosis

A complete detailed history is vital to diagnosing dysmenorrhea. Along with history, a pelvic exam also helps doctors evaluate for infections, structural abnormalities, and other causes of dysmenorrhea. However, additional tests may also be conducted. These include:

<ul>
	<li>Ultrasound - An ultrasound gives an image of your uterus, ovaries, fallopian tubes, and cervix.&nbsp;</li>
	<li>CT Or MRI - These two imaging tests allow for a more detailed view of the organs and tissues inside the body.&nbsp;</li>
	<li>Laparoscopy - A laparoscopy is typically conducted when doctors are suspecting endometriosis, ectopic pregnancy, fibroids, or ovarian cysts as a cause for secondary dysmenorrhea. A small abdominal incision is made to insert a laparoscope and view inside the pelvic and abdominal area.&nbsp;</li>
	<li>Hysteroscopy - A hysteroscope is inserted through the vagina and allows viewing of the cervix and uterus.&nbsp;</li>
</ul>

&nbsp;

Treatment

Treatment of dysmenorrhea depends on a person&#39;s age, severity of pain, cause of pain, and a person&#39;s overall health. It largely focuses on pain management and/or treatment of underlying medical conditions.&nbsp;

<ul>
	<li>Pain Relievers - Over-the-counter pain medications are usually prescribed to treat dysmenorrhea. These include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or ibuprofen.&nbsp;</li>
	<li>Hormonal Birth Control - Oral birth control pills can help prevent ovulation and thus decrease menstrual cramps. Other forms of hormonal birth control such as IUDs, injections, and implants may also be administered.</li>
	<li>Surgery - If all other medical treatments have failed to make a change in the patient&#39;s symptoms, the doctor might opt for this option. The surgery is typically aimed at removing any endometrial tissue, uterine fibroids, or ovarian cysts. In severe cases, a hysterectomy (surgical removal of the uterus) might also be conducted. However, this is mostly reserved for women not planning on having children or nearing menopause.</li>
	<li>Lifestyle Changes - These include exercising, dietary supplements, and stress-managing techniques.</li>
</ul>

&nbsp;

Certain factors put women at a higher risk of dysmenorrhea. These include:

<ul>
	<li>Early age of menstruation (menarche), before the age of 11</li>
	<li>Younger than 30 years of age</li>
	<li>Positive family history</li>
	<li>Stress</li>
	<li>Smoking and alcohol use during periods</li>
	<li><a href="https://www.merisehat.pk/disease/obesity" target="_blank">Obesity</a></li>
	<li>Heavy, or longer menstruation</li>
	<li>Nulliparity</li>
</ul>

&nbsp;

Key Points

<ul>
	<li>Dysmenorrhea, also called painful menstruation, can result from an increase in prostaglandins (primary dysmenorrhea) or the presence of underlying pelvic pathology (secondary dysmenorrhea).</li>
	<li>Primary dysmenorrhea typically begins shortly after a girl&#39;s first period and gets better with age. Whereas secondary dysmenorrhea may result from fibroids, endometriosis, pelvic inflammatory disease, ovarian cysts, or other underlying medical conditions.</li>
	<li>Common symptoms of dysmenorrhea include crampy lower abdominal pain that radiates to the back or thighs, headaches, nausea, vomiting, and fatigue.</li>
	<li>Dysmenorrhea is diagnosed through a complete history, pelvic exam, ultrasound, and in some cases laparoscopy or hysteroscopy.&nbsp;</li>
	<li>Treatments usually include pain medications such as NSAIDS and acetaminophen, hormone treatment, birth control pills, surgery in extreme cases, and lifestyle modifications.</li>
</ul>

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[1] Ju, H., Jones, M. & Mishra, G., 2014. The prevalence and risk factors of dysmenorrhea. Epidemiologic Reviews, 36(1), pp. 104-113.

[2] Azagew, A. W., Kassie, D. G. & Walle, T. A., 2020. Prevalence of primary dysmenorrhea, its intensity, impact and associated factors among female students’ at Gondar town preparatory school, Northwest Ethiopia. BMC Women's Health.

[3] Ostrzenski, A., 2002. Gynecology: Integrating Conventional, Complementary, and Natural Alternative Therapy. s.l.:Lippincott Williams & Wilkins.

[4] Ullah, A. et al., 2021. Prevalence of Dysmenorrhea and Determinants of Pain Intensity Among University-Age Women. Pain Medicine, 22(12), pp. 2851-2862.

[5] Yasir, S., Kant, B. & Dar, M. F., 2014. FREQUENCY OF DYSMENORRHOEA, ITS IMPACT AND MANAGEMENT STRATEGIES ADOPTED BY MEDICAL STUDENTS. Journal of Ayub Medical College Abbotabad, 26(3).