DYSMENORRHOEA

Dysmenorrhea
is defined as severe, cramping pain in the
lower abdomen that occurs just before or
during menses.
(primary or secondary)
Primary dysmenorrhoea occurs in the
absence of significant pelvic pathoIogy. usually
develops within the first 2 years of the
menarche

Characteristics of primary dysmenorrhoea

The pain is often intense, cramping, crippling and severely

incapacitating so that it causes a major disruption of social
activities.
It is usually associated with the onset of menstrual blood loss
but may begin on the day preceding menstruation.
The pain only occurs in ovulatory cycles, is lower abdominal in
nature but sometime radiates down the anterior aspect of the
thighs.
The pain often disappears or improves after the birth of the first
child.
Dysmenorrhoea is often associated with vomiting and diarrhoea
Pelvic examination reveals no abnormality of the pelvic organs.

Pathophysiology of primary dysmenorrhoea

Primary dysmenorrhoea is a feature of ovulatory cycles and

usually appears within 6 to 12 months of the menarche.
The etiology of primary dysmenorrhea has been attributed to
uterine contractions or ischemia, psychological factors, and
cervical factors.
Psychological factors may alter the perception of pain but are
not unique to the problem of dysmenorrhea.
There is no convincing evidence of cervical stenosis in patients
with dysmenorrhea, so there is no basis for incriminating cervical
stenosis or psychological factors as major contributors to the
problem of primary dysmenorrhea.

Pathophysiology of primary dysmenorrhoea

Women with dysmenorrhea have increased uterine activity,

which may manifest as increased resting tone, increased
contractility, increased frequency of contractions, or incoordinate
action.
Prostaglandins are released as a consequence of endometrial
cell lysis with instability of Iysosomes and release of enzymes.
which break down cell membranes
The evidence that prostaglandins are involved in primary
dysmenorrhoea is convincing. Menstrual fluid from women with
dysmenorrhea has higher than normal levels of prostaglandins
(especially PGF2a and PGE2), and these levels can be reduced
to below normal with nonsteroidal anti-inflammatory drugs
(NSAIDs). which are effective treatments.

Clinical Symptoms
Primary dysmenorrhoea usually begins 6 to 12
months after menarche, almost invariably coinciding
with the onset of ovulatory cycles. Patients complain
of spasmodic or cramping lower abdominal pain that
may radiate suprapubically or to the inner aspect of
the thighs. They may have backache of varying
severity. They may also have other accompanying
symptoms, such as headache, nausea,vomiting,
diarrhea, or fatigue. Symptoms typically last 48
hours or less, but sometimes may last up to 72
hours.

Secondary dysmenorrhoea

Secondary dysmenorrhoea is caused by organic pelvic

pathology and it usually has its onset many years after the
menarche.
Any woman who develops secondary dysmenorrhoea should be
considered to have organic pathology in the pelvis until proved
otherwise.
Pelvic examination is particularly important in this situation and, if
the findings are negative, laparoscopy is indicated.
Common associated pathologies include endometriosis,
adenomyosis, pelvic infections and intra-uterine lesions such as
submucous,fibroid.

Pathophysiology of secondary
dysmenorrhoea
The mechanism of pain in secondary
dysmenorrhoea is due to pelvic congestion
which is more marked in the premenstrual
period.
Pain increases in its severity as menstruation
approaches and is relieved by the onset of
menstrual flow, due to the diminution of pelvic
congestion.

Clinical Symptoms
Secondary

dysmenorrhoea usually starts few

days (about 3 to 5 days) before menstruation.

Pain is continuous dull aching lower

abdominal pain accompanied by backache
occurring in parous women after many years
of relatively painless menstruation.

Secondary dysmenorrhoea may be

associated with other symptoms as
dyspareunia,
infertility
and
abnormal
bleeding.

Management
Primary
General

dysmenorrhoea:

and psychological treatment:

Discussion and reassurance are an essential part of

management. Primary dysmenorrhoea tends to present
some months after the menarche and is associated with
ovulatory cycles, early cycles frequently being
anovulatory. The intensity of pain may be aggravated by
apprehension and fear, and reassurance that the pain does
not indicate any serious disorder may lessen the
symptoms. It is also common for the pain to either
disappear or substantially lessen after the birth of the first
child.

Drug therapy:

Dysmenorrhoea can be effectively treated by drugs

that inhibit prostaglandin synthesis and hence uterine
contractility.
These drugs include aspirin, mefenamic acid, naproxen
or ibuprofen. As dysmenorrhoea is often associated with
vomiting, headache and dizziness, it may be advisable to
start therapy either on the day before the period is
expected, or as soon as the menstrual flow commences
Mefenamic acid is given in a dose of 250 mg 6-hourly.
This drug also reduces menstrual flow in some women
with menorrhagia.

If these drugs are inadequate, suppression of

ovulation with the contraceptive pill is highly
effective in reducing the severity of dysmenorrhoea.
Where it is ineffective, then careful consideration
should be given to the possibility of underlying
pathology.
If all conservative medical therapy fails, then relief
may sometimes be achieved by mechanical
dilatation of the cervix or by the surgical removal of
the pain fibers to the uterus in an operation known
as presacral neurectomy, but these methods of
treatment should be approached with considerable
caution.

Physical therapy

Encourage regular and aerobic exercises in fresh air

to raise their general health .
Relaxation techniques, as well as meditation and
hypnosis may be helpful for raising their pain
threshold.
Avoid constipation.
Massage .
Hot packs on the lower abdomen for 10-15 minutes.
Accupressure on the lumosacral area and 3 cm
superior to the medial malleolus.

 TENS
Low

level laser therapy

Secondary dysmenorrhoea:
In cases of secondary dysmenorrhoea, the
treatment is dependent on the nature of the
underlying pathology. If the pathology is not
amenable to medical therapy, the symptoms
may only relieved by hysterectomy. However,
the role of physical therapy in such cases will
consist of pre and post operative physical
treatment.