Copyright 2000. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program. All Rights Reserved.

RECOMMENDATIONS FOR THE TREATMENT OF DYSMENORRHEA

INTRODUCTION:

• Definition:

  Dysmenorrhea: Greek for painful menstruation, and often described as cramping, lower abdominal pain with or without backache that occurs just prior to and/or during menses.

  1. Primary Dysmenorrhea: Menstrual pain without pelvic pathology occurring with ovulatory menstrual cycles
  2. Secondary Dysmenorrhea: Menstrual pain associated with pelvic pathology

• Incidence:

  Dysmenorrhea is the most common gynecologic problem in menstruating women.

  1. Primary Dysmenorrhea:
  • 50% of menstruating women experience dysmenorrhea
  • 10% of menstruating women are incapacitated for 1-3 days/month, leading to absence from school or work.
  • Some evidence shows that there is an increased incidence or occurrence of more severe episodes of dysmenorrhea in women who are obese, smoke, are nulliparous or delay childbearing, or are sexually inactive.
  • Onset occurs when ovulatory cycles begin, usually 6-12 months after menarche, peaks during the late teens and early 20’s, then declines gradually with age.
  2. Secondary Dysmenorrhea:
  • Exact incidence is unknown due to its many causes.
  • Increased incidence as women grow older, with onset usually after age 25-30.

PATHOPHYSIOLOGY:

1. Primary Dysmenorrhea
• Associated with ovulatory cycles.
• Associated with increased production and release of uterine prostaglandins, especially prostaglandin F (PGF 2).
• Women with dysmenorrhea can produce 10 times as much prostaglandin F as asymptomatic women.
• Majority of prostaglandins are released during the first 48 hours of menstruation, thus explaining the timing and limitation of symptoms.
• Prostaglandins stimulate an increase in myometrial muscle tone and contractions, and vasopression of uterine blood vessels which results in ischemic pain and other associated symptoms.
2. Secondary Dysmenorrhea

Associated with pelvic pathology and may be classified as follows:

1. External to the uterus: endometriosis, tumors, adhesions, and non-gynecologic causes.
2. Within the wall of the uterus: adenomyosis, leiomyomas.
3. Within the cavity of the uterus: polyps, infection.

SUBJECTIVE ASSESSMENT:

1. HISTORY:
   Obtain a complete detailed menstrual and gynecologic history. This should include the following:
• Age of menarche
• Frequency and duration of menses, nature of flow
• Assessment of pain including location, when pain occurs in the menstrual cycle, radiation of pain, pain independent of menses in addition to occurring with menses, dyspareunia, relieving or aggravating factors, and what is used for self management
• Sexually transmitted diseases (STDs), Papanicolaou smear history, sexual risk (including number of partners, condom use, substance use)
• Contraception including the use of intrauterine device (IUD), birth control pills
• Any associated symptoms such as nausea, vomiting, and diarrhea
• Pregnancy history
2. SYMPTOMS:
1. Primary Dysmenorrhea
• "Crampy", "spasmodic" discomfort located to lower abdomen and suprapubic area.
• Discomfort radiates to groin, upper thighs, and lower back.
• Discomfort frequently begins several hours prior to the onset of menses, lasting 24-72 hours.
• Other associated symptoms may include: nausea, vomiting, diarrhea, and headache as a result of prostaglandins and prostaglandin metabolites entering into the systemic circulation.
2. Secondary Dysmenorrhea
• Description of symptoms varies dependant on the underlying cause (gastrointestinal symptoms, urinary tract infection symptoms, dyspareunia, and pelvic pain unrelated to menses).
• Discomfort may occur at any time in the menstrual cycle, and the onset of discomfort increase with age (pain begins after the age of 25).
3. PAST MEDICAL HISTORY:
• As noted above, a detailed menstrual and gynecologic history is to be obtained.
• Note hospitalizations, surgeries, and/or procedures.
• Note any chronic medical conditions, note liver disease, renal disease.
4. MEDICATION HISTORY:
• Current prescription medications
• Any and all over the counter medications including alternative medicines or herbal treatments
• Any contraceptive agents
5. FAMILY HISTORY:
• Note any positive family history of dysmenorrhea or other gynecologic pathology
6. PSYCHOSOCIAL HISTORY:
• Evaluate coping skills
• Evaluate historically the mechanisms utilized for coping with pain
• Evaluate availability of support systems
7. DIETARY HISTORY:
• Obtain complete dietary history, especially that of the obese patient
• Evaluate for excess caffeine use
• Evaluate for diet high in refined sugar and salt

OBJECTIVE ASSESSMENT:

1. PHYSICAL EXAM:
• General appearance
• Vital signs, including weight and height
• Neck: assess for enlarged thyroid or masses
• Heart and lungs
• Abdomen: evaluate for bowel sounds, tenderness, masses, rigidity, guarding, rebound tenderness, and/or other abnormalities
• Pelvic exam: speculum visualization of cervix to inspect for mucopurulent discharge, evaluate cervix for friability by gently scraping
• Bimanual exam: assess for adnexal tenderness, cervical motion tenderness, uterine tenderness, and uterine enlargement, adnexal abnormality
• Rectal exam to rule out mass and assess for point tenderness
• In primary dysmenorrhea, the physical exam is normal. Pregnancy and pelvic infection must be ruled out if client is being evaluated for the first time.
• In secondary dysmenorrhea, pelvic pathology may or may not be present on the exam and additional testing must be done to confirm a diagnosis.
2. DIAGNOSTIC PROCEDURES:
1. Primary Dysmenorrhea:
• Pregnancy test to rule out pregnancy
• Pap smear, vaginal wet mount, and cervical cultures to rule out pelvic infection
2. Secondary Dysmenorrhea: rule out secondary dysmenorrhea based on tests and H and P results
• Complete blood count (CBC) and/or erythrocyte sedimentation rate (ESR) to rule out infection or inflammation
• Rapid plasma reagin (RPR) test to rule out syphilis
• Cervical culture to rule out conorrhea and chlamydia
• Vaginal wet mount to rule out bacterial vaginosis, trichomoniasis, and candidiasis
• Pap smear to rule out cervical cancer
• Pregnancy test
• Urinalysis
• Thyroid function studies/TSH
3. Additional Tests:
• Vaginal and pelvic ultrasonography
• Laparoscopic exam
• Hysteroscopy
• Hysterosalpingogram

DIAGNOSIS:

1. Primary Dysmenorrhea
• The most important differential diagnosis to consider is secondary dysmenorrhea
• With a typical history and a lack of abnormal findings on physical exam no further diagnostic evaluation is recommended
2. Secondary Dysmenorrhea
• The diagnosis of secondary dysmenorrhea is based on abnormal findings from the history and physical:
• Differential diagnosis must include:
  • Endometriosis
  • Complications of pregnancy
  • Pelvic infection or inflammatory process
  • Congenital malformations of the ovaries, uterus, or cervix
  • Other causes: appendicitis, gastrointestinal pathology, renal pathology

PHARMACOLOGIC THERAPY:

• Pharmacologic options:
  • Nonsteroidal anti-inflammatory drugs (NSAIDS) suppress prostaglandin synthesis, thereby reducing pain symptoms. If periods are regular, NSAID treatment will be more effective if initiated one day before menstruation begins. Drugs most commonly used are Ibuprofen and Naproxen. Recently rofecoxib (Vioxx[R]) has been approved by the U.S. Food and Drug Administration (FDA) with an indication to treat dysmenorrhea. Dosage for women 18 years old and over: initially 50mg once daily for a maximum of five days. It is contraindicated in persons with aspirin allergy and third trimester pregnancy. Not recommended for persons with advanced renal disease, moderate to severe hepatic insufficiency, and nursing mothers. Discontinue if liver disease develops. Precautions include fluid retention, heart failure, hypertension, alcoholism, dehydration, and asthma. Monitor for GI bleed/ulcer (risk increased if patient is otherwise at high-risk, extended drug treatment, high doses, history of GI bleed or ulcer).
  • Oral contraceptives: low dose combination birth control pills reduce dysmenorrhea by inhibiting ovulation. They are first-line treatment if contraception is desired and there are no absolute contraindications (thrombophlebitis or thromboembolic disorder, family history of hereditary thrombophilia in a first degree relative, cerebrovascular disease, coronary artery or ischemic heart disease, known or suspected breast cancer, known or suspected estrogen-dependent neoplasia, known or suspected pregnancy, benign or malignant liver tumor, current impaired liver function, or undiagnosed abnormal vaginal bleeding).

NONPHARMACOLOGIC THERAPY:

• EXERCISE
  • Exercise will increase the release of natural endorphins, suppress prostaglandin from being released, will raise the estrone-estradiol ratio which acts to decrease endometrial proliferation, and will shunt blood away from the uterus. Pelvic congestion and pain will be decreased by exercise.

• ACUPUNCTURE AND ACUPRESSURE
  • Acupuncture and acupressure stimulate the body’s integrative regulatory systems and activate a variety of endocrine and neurologic mechanisms, which in turn stimulate a variety of physiologic functions toward homeostasis. In a study by Stux and Pomeranz (Beal, 1999) on biological mediaries of acupuncture analgesia, the researchers summarize a model that includes three sites of endogenous opiate activity: the spine, the midbrain, and the pituitary. In addition to "the involvement of the endogenous opiates, acupuncture analgesia has been found to the facilitated by serotonin, reserpine, and acetylcholine, and its effects reduced by atropine, naloxone, and some antagonists and blockers of neurotransmitters."

• TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)
  • Transcutaneous electrical nerve stimulation (TENS) can serve as an adjuvant therapy to conventional pharmacological agents in severe cases of dysmenorrhea or can serve as the main treatment for women who cannot or do not wish to use the conservative pharmacological approach.
  • In one study, TENS induced pain relief (within 30 to 60 minutes) without significant changes in uterine activity. It was concluded that TENS treatments resulted in decreased uterine ischemia and/or decreased activity in the pain transmission system at the spinal or supraspinal levels.

• SMOKING CESSATION
  • Smoking has been associated with increased duration of bleeding, increased daily amount of bleeding (subjectively scored), and increased duration of dysmenorrhea, especially in the heaviest smokers.
  • Smoking was not associated with cycle length, but evidence was found for increased variability of cycle length among heavier smoking.

• DIET
  • In women with moderate to severe dysmenorrhea, a low-fat vegetarian diet was found to be associated with a significant increase in mean serum sex hormone-binding globulin concentration and reductions in mean body weight and BMI as well as significant reductions in menstrual pain duration, pain intensity, and duration of premenstrual symptoms related to concentration, behavioral change, and water retention.
  • Low-fat diets reduce serum estrogen concentrations in pre- and post-menopausal women. Estrogen conjugates are excreted in bile and are subject to enterohepatic circulation, which can be interrupted by dietary fiber, encouraging fecal elimination. Increased serum sex-hormone binding globulin or decreased serum estrogen concentrations might reduce estrogenic stimulation of the endometrium, limiting proliferation of tissues that produce prostaglandins.

FOLLOW-UP

Follow up in six months to evaluate treatment efficacy or sooner if symptoms worsen

REFERRAL

For secondary dysmenorrhea, treatment of the underlying cause is indicated; if no obvious cause is uncovered, refer to expert for management.

REFERENCES

1. Adult Health Advisor (1999). Menstrual Cramps (Dysmenorrhea). InteliHealth-Home to John Hopkins Health Information: InteliHealth.(On-line), Available: www.intelihealth.com.
2. Barnard N, Scialli A, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol 2000;95:245-50.
3. Beal MW. Acupuncture and acupressure: applications to women’s reproductive health care. J Nurse-Midwifery 1999;44:217-30.
4. Coco AS. Primary dysmenorrhea. Am Fam Physician 1999;60:489-96.
5. Carr PL, Freund KM, Somani S. The medical care of women. Philadelphia (PA): W.B. Saunders Co., 1995.
6. Gould D. Uterine problems: The menstrual cycle. Nursing Standard 1998;12(50):38-45.
7. Hatcher RA, Trussell J, Stewart F, Cates GK, Guest F, Kowal D. Contraceptive technology (17^th ed.). New York: Ardent Media, Inc., 1998.
8. Horsby PP, Wilcox AJ, Weinberg CR. Cigarette smoking and disturbance of menstrual function. Epidemiology 1998;9:193-8.
9. Kaplan B, Peled Y, Pardo J, Rabinerson D, Hirsh M, Ovadia J, Neri A. Transcutaneous electrical nerve stimulation (TENS) as a relief for dysmenorrhea. Clin Exper Obstet Gynecol 1994;21(2):87-90.
10. Milsom I, Hedner N, Mannheimer C. A comparative study of the effect on high-intensity transcutaneous nerve stimulation and oral naproxen on intrauterine pressure and menstrual pain in patients with primary dysmenorrhea. Am J Obstet Gynecol 1994;170(1 Pt 1):123-9.
11. Robinson JC, Plichta S, Weisman CS, Nathanson CA, Ensminger M. Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic. Am J Obstet Gynecol 1992;166:578-83.
12. Second Cox-2 inhibitor. Am J Nurs 1999;99(10):24DDD.
13. Sherif K. Benefits and risks of oral contraceptives. Am J Obstet Gynecol 1999;180(6 Pt 2):S343-8.
14. Sulak PJ. Oral contraceptives: therapeutic uses and quality-of-life benefits and case presentations. Contraception 1999;59(1 Suppl):35S-38S.
15. Uphold CR, Graham MV. Clinical guidelines in family practice (3^rd ed.). Florida: Barmarrae Books, 1998.
16. Youngkin, E.Q., & Davis, M.S. (1998). Women’s health: A primary care clinical guide (2^nd ed.). Stamford, Connecticut: Appleton and Lange.
17. Zhang WY, Li Wan Po A. Efficacy of minor analgesics in primary dysmenorrhea: a systematic review. Br J Obstet Gynaecol 1998 105;780-9.

Copyright 2000. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program. All Rights Reserved.

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program, 1700 Red River, Austin TX 78701.