Dysmenorrhea

What is Dysmenorrhea?

Dysmenorrhea, a Greek term meaning “painful monthly bleeding,” exists in two forms: primary and secondary. With primary dysmenorrhea, recurrent lower stomach pain occurs during the menstrual cycle, but it’s not tied to any other diseases or health conditions. This diagnosis is made only after ruling out other possibilities. On the other hand, secondary dysmenorrhea is tied to a specific health issue that can be identified by medical tests or exams. It’s worth noting that dysmenorrhea is a common occurrence for women during their reproductive years, and it can lead to significant emotional, psychological, and physical health problems.

Primary dysmenorrhea typically starts within 2 years after a girl’s first period or once her menstrual cycles become regular. It is more common in teenagers and young adults. The pain starts a few hours after the beginning of the period and typically goes away within 72 hours. The pain is often felt in the middle of the lower stomach and can spread to the lower back or upper legs. The pain might come in waves and can be similar each menstrual cycle. Other associated symptoms can include nausea, vomiting, headaches, dizziness, fatigue, and difficulty sleeping.

What Causes Dysmenorrhea?

Since the 1960s, experts have suggested different reasons why some people might experience dysmenorrhea, or painful periods. These include psychological factors, biochemical elements, and physical abnormalities. Physical theories include unusual positions of the uterus or irregular shape or length of the cervix. Some research even suggests that there’s a link between the length of the cervix and the severity of the menstrual pain.

However, the analysis shows that the biochemical factor has the most solid backing, making it the most probable cause.

Dysmenorrhea has several risk factors including:

Age, mostly between 13 to 30 years
Smoking
Trying to lose weight
Body mass index that is either too high or too low
Depression or anxiety
Longer menstrual cycles
Early onset of periods
Not having had a pregnancy that resulted in childbirth
A history of sexual assault
Prior cesarean section with incomplete healing of the uterine scar
Having longer, heavier menstrual periods
A family history of dysmenorrhea
Disruption in social networks

For primary dysmenorrhea, substances called prostaglandins are believed to be the main cause. It is observed that women with painful periods have higher levels of prostaglandins in their menstrual fluid and the tissue that lines the uterus. These prostaglandins are released at the start of menstruation and cause the uterus to contract which leads to pain. The severity of pain is generally related to the amount of prostaglandins released. These contractions can also lead to reduced oxygen supply to the tissues, resulting in discomfort and other symptoms like nausea and diarrhea.

Secondary dysmenorrhea, on the other hand, is a menstrual pain caused by existing health conditions or physical abnormalities related to the uterus. This can start at any time after the first menstrual period and can be a new issue for women in their 30s or 40s. Conditions associated with secondary dysmenorrhea include endometriosis, fibroids, polyps lining the uterus, cystitis, pelvic inflammatory disease, and the use of intrauterine contraception. Around 29% of women with painful periods may have endometriosis. When you consider individuals who don’t get relief from non-prescription painkillers, this number goes up to 35%. Another condition called adenomyosis is also commonly associated with secondary dysmenorrhea. Almost 4% of young women have abnormalities in their reproductive tracts, which could be causing painful periods.

Risk Factors and Frequency for Dysmenorrhea

Dysmenorrhea, or painful periods, is a common issue among menstruating individuals, regardless of age or race, and it’s a frequent reason for pelvic pain. The percentage of people of reproductive age who experience dysmenorrhea can range from 16% to 91%. Among them, 2% to 29% suffer from intense pain. Studies have found that 80% of teenagers experience dysmenorrhea, and of those, about 40% suffer from severe pain.

There are several symptoms associated with dysmenorrhea, including:

Gastrointestinal problems like nausea, bloating, diarrhea, constipation, vomiting, and indigestion.
Irritability, headaches, and back pain are common.
Fatigue and dizziness.

About 16% to 29% of women find that their quality of life is significantly affected by dysmenorrhea. In addition, dysmenorrhea causes about 12% of women to miss school or work every month.

Signs and Symptoms of Dysmenorrhea

Dysmenorrhea, or painful periods, can be diagnosed using a thorough medical history and physical examination. By asking about when the pain starts, where it is, how it feels, how long it lasts, and if it’s accompanied by other symptoms like tiredness, headaches, diarrhea, nausea, and vomiting, a medical professional can potentially identify dysmenorrhea.

In cases of primary dysmenorrhea, which is period pain without an underlying condition, physical examinations generally don’t show any abnormalities. The uterus is usually a normal size and doesn’t cause pain when touched. There generally isn’t any unusual discharge, growths on the ovaries, or lumps in the tissues supporting the uterus.

Secondary dysmenorrhea, on the other hand, is period pain caused by an underlying condition. This can sometimes be identified through signs such as:

Being older (primary dysmenorrhea is more common in younger individuals)
Having abnormal vaginal discharge, which could suggest pelvic inflammatory disease
A fragile cervix, suggesting a sexually transmitted infection
Painful urination, painful sexual intercourse, involuntary contraction of vaginal muscles, difficult bowel movements, an increased difficulty in conceiving, or noticeable lumps, growths on the ovaries, or tenderness detected during pelvic examination
Heavy menstrual bleeding alongside a slightly big and symmetrical uterus, indicating the possibility of adenomyosis (a condition where the uterus’s inner lining breaks through the muscle wall)
Abnormal bleeding and an enlarged asymmetrical uterus, raising the possibility of leiomyomas (fibroids)
Obstructions or a history of birth defects, which could suggest a Müllerian anomaly (abnormal development of the uterus of fallopian tubes)
Growth in or around the pelvis, such as cancer, ovarian cysts, or endometrioma (a type of ovarian cyst)

Testing for Dysmenorrhea

Primary dysmenorrhea, or period pains, can usually be diagnosed simply based on somebody’s medical history. The pain typically starts just before or right when menstrual bleeding begins, following a pattern that begins with ovulation, or the release of an egg from the ovaries. This usually starts around two years after a person’s first period. The pain is at its worst 23 to 48 hours after bleeding starts, and typically doesn’t continue for more than three days.

A pelvic exam can also be helpful in understanding period pains. This type of examination can exclude the possibility of secondary dysmenorrhea, which is when the pain is due to a physical condition, like a disease. If the pain can’t be managed with medication or if it started recently, a pelvic exam may be done. However, this is not necessary for young females who have not been sexually active and whose symptoms align with typical primary dysmenorrhea.

Ultrasound technology, while not particularly useful for diagnosing primary dysmenorrhea, can be beneficial for distinguishing causes of secondary dysmenorrhea like endometriosis, fibroids, abnormalities in the female reproductive system, and adenomyosis, where the inner lining of the uterus breaks through the muscle wall. Ultrasound is the first go-to method to investigate the cause of secondary dysmenorrhea as well.

For those who may be at risk of sexually transmitted infections, or if pelvic inflammatory disease is suspected, a swab from the cervix or vagina may be needed.

In some cases, it might be necessary to take a sample for testing from the cervix to confirm or rule out suspected cancer.

Magnetic resonance imaging (MRI) or Doppler ultrasonography can help if there’s a suspicion of a twisted ovary, adenomyosis, deep pelvic endometriosis, or if the ultrasound results are unclear. MRIs are particularly useful for spotting abnormalities in the uterus, but it’s not the most cost-effective method for initial screening.

If a woman who wants to become pregnant is experiencing secondary dysmenorrhea that may be caused by endometriosis, keyhole surgery might be considered as an option.

Treatment Options for Dysmenorrhea

The treatment for dysmenorrhea, or painful periods, aims to provide adequate pain relief to ensure patients can carry out their daily activities. Both primary and secondary dysmenorrhea start with similar treatment methods. These include patient education, reassurance, supportive therapy, and medical treatment. If symptoms do not improve with these initial treatments, a more in-depth evaluation is necessary. There are two main treatment types: medication-based and non-medication-based. It’s important to note that opioids and tramadol should not be used regularly for dysmenorrhea.

Non-medication-based treatments include applying heat to the lower abdomen and regular exercise. Many patients prefer these methods, as they have no side effects. While regular exercise is recommended to treat dysmenorrhea, there isn’t concrete evidence about the type, time, or frequency of exercise. Maintaining an active lifestyle and a nutrient-rich diet can lead to better health outcomes and potentially lessen the intensity of dysmenorrhea. While there are various food supplements, complementary medicines, and alternative medicines available to treat dysmenorrhea, they are not regulated by the FDA and lack sufficient supporting evidence. Non-medication treatments also include spinal manipulation, acupuncture, transcutaneous electrical nerve stimulation, and behavioral counseling, however, their effectiveness varies.

When it comes to medication-based treatments, Nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first choice. They block the production of certain enzymes, which can ease the discomfort of dysmenorrhea. However, around 20% of patients don’t have a positive response to NSAIDs, leaving them searching for other options. Alternatives to NSAIDs include hormonal contraception, progestin-only contraception, gonadotropin-releasing hormone agonists and antagonists, aromatase inhibitors, vasodilators, calcium channel blockers, vasopressin/oxytocin receptor agonists, antispasmodics, and magnesium.

Surgery isn’t typically an option unless a patient hasn’t responded well to medication-based treatments. In such situations, procedures like laparoscopy, endometrial ablation, or hysterectomy may be considered. However, these procedures come with their own risks and should only be pursued if necessary.

The process of figuring out the exact cause of painful periods, also known as dysmenorrhea, considers numerous possibilities. These potential causes can mainly be grouped into two categories: conditions related to the female reproductive system (gynecological conditions) and those not related to it (non-gynecological conditions).

Under the gynecological conditions, potential causes could include:

Endometriosis
Blockage in the female reproductive system due to conditions like imperforate hymen, vaginal agenesis, or cervical stenosis
Different types of cysts in the ovaries
Twisting of an ovary, though this doesn’t usually cause pain that aligns with menstrual cycles
Adenomyosis, where the inner lining of the uterus breaks through the muscle wall of the uterus
Infections in the pelvic area or sexually transmitted infections
Growth of the tissue lining the uterus, known as endometrial polyps
Asherman syndrome, a condition where scar tissue forms inside the uterus
Ectopic pregnancy, where the fertilized egg grows outside the uterus
Chronic pelvic pain
Membranous dysmenorrhea, an extremely rare condition where the lining of the uterus sheds in one piece, resembling the shape of the uterus

Non-gynecological conditions that could lead to painful periods include gastrointestinal, urological, and musculoskeletal conditions such as:

Irritable bowel syndrome
Urinary tract infections
Interstitial cystitis, a chronic condition causing bladder pressure and pain
Pain in the muscles of the abdomen, pelvic or hip area, sacroiliac joints (joints in the lower back), and muscles in the lower back

What to expect with Dysmenorrhea

The initial medical treatment usually continues for two to three months before a check-up is done to see if symptoms have reduced. If symptoms lessen but still exist, another method of treatment might be added. If there is little to no improvement, the first treatment might be stopped and replaced with another one. Treatment is kept up for another three months followed by another assessment. If results aren’t satisfactory, the process to find out if there’s a secondary dysmenorrhea cause may start. A comprehensive examination for pelvic pain, involving physical therapy, can also be considered.

Dysmenorrhea can greatly affect the daily life of patients, leading to missing school or work, reduced participation in sports or social activities, and emotional stress. In fact, dysmenorrhea is linked to people missing roughly 140 million working hours each year in the US alone. This has a significant economic impact.

Thankfully, the outlook for primary dysmenorrhea is usually positive when using the right treatments. Mild to moderate dysmenorrhea tends to react well to NSAID medications. Severe dysmenorrhea can also improve with NSAID medications, though it might need higher doses or a combination of treatments. If dysmenorrhea persists, secondary causes should be investigated. The outlook for secondary dysmenorrhea depends on factors like the cause, type, location, and severity of the condition.

Possible Complications When Diagnosed with Dysmenorrhea

Primary dysmenorrhea, which is menstrual pain that isn’t caused by another disease, can complicate a person’s life due to the severity of the pain and the impact it can have on their daily activities. Nevertheless, it usually doesn’t result in additional health problems since it’s not linked to any disease.

On the other hand, secondary dysmenorrhea, which is menstrual pain caused by an underlying condition, can lead to a variety of complications. These complications depend on the underlying cause and can include:

Infertility
Pelvic organ prolapse
Heavy bleeding
Anemia

Preventing Dysmenorrhea

Eating a balanced diet and exercising regularly can help lessen the pain caused by dysmenorrhea, or severe menstrual cramps. It’s vital to teach younger patients about the role of good nutrition in managing this condition. Studies have shown that certain vitamins and a healthy diet can help reduce period pain.

Physical activity can also help reduce discomfort from dysmenorrhea. Exercising helps by enhancing blood flow in the pelvic area and triggering the release of a natural pain-reliever in the body called β-endorphins.

The main aim of treatment is to lessen the pain and improve the quality of life for those suffering from severe menstrual cramps. The right medical treatments can help patients carry out their everyday tasks without the need to miss school or work. If symptoms become too troublesome or are not well-controlled, patients should be advised to consult with their healthcare provider.

Frequently asked questions

Dysmenorrhea is a term used to describe painful monthly bleeding during the menstrual cycle. It can exist in two forms: primary and secondary. Primary dysmenorrhea is not tied to any other diseases or health conditions, while secondary dysmenorrhea is associated with a specific health issue.

The percentage of people of reproductive age who experience dysmenorrhea can range from 16% to 91%.

The signs and symptoms of Dysmenorrhea include: - Pain that starts during menstruation - Location of pain in the lower abdomen or pelvis - Description of pain as cramping or throbbing - Duration of pain lasting for hours or days - Presence of other symptoms such as tiredness, headaches, diarrhea, nausea, and vomiting - Abnormal vaginal discharge, suggesting pelvic inflammatory disease - Fragile cervix, indicating a sexually transmitted infection - Painful urination, painful sexual intercourse, involuntary contraction of vaginal muscles, difficult bowel movements, increased difficulty in conceiving, or noticeable lumps or growths on the ovaries detected during pelvic examination - Heavy menstrual bleeding alongside a slightly big and symmetrical uterus, indicating the possibility of adenomyosis - Abnormal bleeding and an enlarged asymmetrical uterus, raising the possibility of leiomyomas (fibroids) - Obstructions or a history of birth defects, suggesting a Müllerian anomaly - Presence of growths in or around the pelvis, such as cancer, ovarian cysts, or endometrioma (a type of ovarian cyst)

There are several factors that can contribute to the development of dysmenorrhea, including psychological factors, biochemical elements, physical abnormalities, and existing health conditions.

The doctor needs to rule out the following conditions when diagnosing Dysmenorrhea: - Endometriosis - Blockage in the female reproductive system due to conditions like imperforate hymen, vaginal agenesis, or cervical stenosis - Different types of cysts in the ovaries - Twisting of an ovary - Adenomyosis - Infections in the pelvic area or sexually transmitted infections - Growth of the tissue lining the uterus, known as endometrial polyps - Asherman syndrome - Ectopic pregnancy - Chronic pelvic pain - Membranous dysmenorrhea - Irritable bowel syndrome - Urinary tract infections - Interstitial cystitis - Pain in the muscles of the abdomen, pelvic or hip area, sacroiliac joints, and muscles in the lower back

The types of tests that may be needed to diagnose dysmenorrhea include: 1. Medical history: A detailed medical history can help identify the pattern and characteristics of the pain, as well as any associated symptoms. 2. Pelvic exam: A pelvic exam can help exclude secondary causes of dysmenorrhea and assess the health of the reproductive organs. It may not be necessary for young females who have not been sexually active and whose symptoms align with typical primary dysmenorrhea. 3. Ultrasound: Ultrasound can be beneficial for distinguishing causes of secondary dysmenorrhea, such as endometriosis, fibroids, abnormalities in the reproductive system, and adenomyosis. It is the first go-to method to investigate the cause of secondary dysmenorrhea. 4. Swab for sexually transmitted infections: If there is a risk of sexually transmitted infections or suspicion of pelvic inflammatory disease, a swab from the cervix or vagina may be needed. 5. Cervical sample for cancer testing: In some cases, a sample may be taken from the cervix to confirm or rule out suspected cancer. 6. Magnetic resonance imaging (MRI) or Doppler ultrasonography: These imaging techniques may be used if there is a suspicion of a twisted ovary, adenomyosis, deep pelvic endometriosis, or if the ultrasound results are unclear. It's important to note that the specific tests ordered will depend on the individual patient's symptoms, medical history, and suspected underlying causes.

Dysmenorrhea, or painful periods, can be treated through a combination of medication-based and non-medication-based methods. Non-medication-based treatments include applying heat to the lower abdomen, regular exercise, maintaining an active lifestyle, and a nutrient-rich diet. However, the type, time, and frequency of exercise are not clearly defined. It's important to note that food supplements, complementary medicines, and alternative medicines lack sufficient supporting evidence and are not regulated by the FDA. Medication-based treatments often start with Nonsteroidal anti-inflammatory drugs (NSAIDs), which block the production of certain enzymes to ease discomfort. If NSAIDs are not effective, alternatives such as hormonal contraception, progestin-only contraception, and other medications can be considered. Surgery is typically a last resort if other treatments have not been successful, and procedures like laparoscopy, endometrial ablation, or hysterectomy may be considered.

When treating dysmenorrhea, the non-medication-based treatments such as applying heat to the lower abdomen and regular exercise have no side effects. However, it's important to note that food supplements, complementary medicines, and alternative medicines available to treat dysmenorrhea are not regulated by the FDA and lack sufficient supporting evidence. The effectiveness of non-medication treatments like spinal manipulation, acupuncture, transcutaneous electrical nerve stimulation, and behavioral counseling varies. As for medication-based treatments, nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first choice and can ease the discomfort of dysmenorrhea. However, around 20% of patients don't have a positive response to NSAIDs. Other medication-based options may include hormonal contraception, progestin-only contraception, and various other medications, but their specific side effects are not mentioned in the given text.

The prognosis for dysmenorrhea is usually positive when using the right treatments. Mild to moderate dysmenorrhea tends to react well to NSAID medications. Severe dysmenorrhea can also improve with NSAID medications, though it might need higher doses or a combination of treatments. If dysmenorrhea persists, secondary causes should be investigated. The outlook for secondary dysmenorrhea depends on factors like the cause, type, location, and severity of the condition.

A gynecologist.

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