MANY WOMEN'S NIGHTMARE:- HOW TO DEAL WITH THAT PAIN THAT MAKES YOU DREAD YOUR MENSTRUAL PERIOD (PRIMARY DYSMENORRHEA)

Primary dysmenorrhea refers to menstrual pain that is not associated with any pelvic disease. It is the commonest cause of painful menstrual flow and is easily diagnosed from its presentation.

Causes

Once the blood progesterone level that maintains the endometrial lining during the luteal or premenstrual phase of the menstrual cycle begins to decline, some substances e.g. prostaglandins and leukotrienesare released within the endometrium that actively results in increased tone and contractions of the uterus(womb) which are then perceived as colicky pains often referred to as menstrual cramps. It is believed that the increased uterine muscle tone and contractions, results in reduced blood flow into the endometrium causing the pain that is characteristic of primary dysmenorrhea.

Presentation

This presents commonly as cyclical lower abdominal cramps radiating to the back usually felt from or about a day prior to the onset of the menstrual flow. It is worse at the onset but gradually eases out as the menstruation progresses often abating totally prior to the cessation of the menstrual flow. The pain is predominantly felt during the first 2 days of menstruation and may be associated with or without gastrointestinal disturbances such as diarrhoea and vomiting. It is cyclical, because it is seen only in ovulatory cycles where it occurs only after ovulation.

It usually appears 6–12 months after menarche when ovulatory cycles have become established. In the first earliest cycles however, menstruation is usually painless because they are anovulatory.

It is said to affect about 72% o f 19-year old women, with nearly 40% requiring regular medication and another 8% missing school at every period according to a Swedish study. Its prevalence and severity tend to reduce with age and more specifically following child birth.

Diagnosis

This is usually made from the presentation and hardly requires any investigations. However in cases where doubts exist as to the possibility of a secondary cause i.e. a secondary dysmenorrhea, a thorough physical examination and detailed investigations are required to exclude or confirm secondary causes of dysmenorrhea. To learn more about that see Secondary dysmenorrhea.

Treatment

Based on severity, treatment ranges from mere counseling, to the use of analgesics and to the suppression of ovulation, since primary dysmenorrhea is closely associated with ovulatory cycles.

Analgesics

This involves the use of pain killers for the management of primary dysmenorrhea. In mild cases, paracetamol may suffice but in moderate to severe cases, because prostaglandin analogues are central to the origin of the pain, non steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and mefenamic acid are used to provide excellent pain relief, as they inhibit or prevent the production of these prostaglandin analogues. However, their long term usage, is associated with the occurrence of gastric ulcer and as such, it is advisable to use these drugs with food to reduce this specific risk. Also they should be used with caution only around the menstrual phase as usage around the ovulation period can inhibit or prevent ovulation, a situation that may be counterproductive in women desirous of pregnancy.

Suppression of ovulation

Oral contraceptive pills (OCPs): These are contraceptive medications taken daily to prevent ovulation usually in women desirous of contraception. They can also be used alone or in combination with analgesics in cases where analgesics alone are not effective in controlling the menstrual pain or in cases in where the adverse effect of NSAIDs prevents their usage. They are also desirous for use in women with primary dysmenorrhea desirous of contraception as other than contraception, they have the added advantage of reducing or in some cases preventing primary dysmenorrhea. Although they are routinely used in single cycles to allow for monthly flow of menses, in severe dysmenorrhea, “bicycling” and “tricycling” of the OCPs may be done, in which the OCPs are used continuously but skipped once in two months or three months, to allow for menstrual flow to occur only once in two or three months respectively.                                                                                                                                                   

Depo provera: is an intramuscular injectable contraceptive agent that prevents ovulation that may also be used.

Mirena: This is an intrauterine device embedded with progesterone that acts locally on the endometrial lining of the uterus (womb) to achieve contraception. Recently, it has along with other progesterone containing intra-uterine devices, been approved in many developed countries for the management of primary dysmenorrhea including severe cases. Though primarily meant for contraception, their local effect on the uterus and subsequent absence of menstruation in many of the women using them have made them invaluable for the treatment of dysmenorrhea in women desirous of contraception. 

Other treatment methods

Lifestyle changes: There is some evidence to suggest that a low fat, vegetarian diet and exercise by improving blood flow to the pelvis may improve the symptoms of dysmenorrhea.

Heat: Although a rather old-fashioned method for helping dysmenorrhea, many people describe considerable relief from the use of hot water bottle on the suprapubic or pelvic area.

Finally a few other drugs do alleviate symptoms of primary dysmenorrhea despite not being licensed for it and include an orally active “vasopressin receptor antagonist”, “beta-adrenergic agonists” like salbutamol and “calcium channel blockers” like nifedipine.

 Source: Ewomenclinic

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