Dysmenorrhea—Myths and Facts1

Dysmenorrhea—myths and facts1

Gita P. Gidwani, M.D. Dysmenorrhea has plagued young women since ancient times. The author discusses its treatment in other ages and cultures, as well as recent research that has led to a better understanding and alleviation of this condition. The necessity of a thorough work-up to exclude mechanical obstruction of the genital tract is empha- sized, along with the clinical criteria for the work-up. Recently recognized conditions, e.g., endometriosis, are discussed and newer treatments, such as prostaglandin inhibitors and oral contraceptives, are reviewed. Index term: Dysmenorrhea Cleve Clin Q 50:367-370, Fall 1983

The term dysmenorrhea, derived from the Greek, means difficult menstrual flow.1 Primary dysmenorrhea is painful menstruation in the absence of gross pathological conditions of the pelvic organs, whereas secondary dysmenorrhea denotes painful menstrual periods in the presence of gross pathological conditions of the pelvic organs, e.g., endometriosis, salpingitis, congenital anomalies of the Miillerian system, or pathology caused by an intrauterine device. A recent report from Gothenburg, Sweden, on a random sample of 19-year-old women showed that 72% reported dysmenorrhea.2 In 15%, dysmenorrhea limited daily activity and was unrelieved by analgesics. Fifty-one percent of the women suffering from dysmenorrhea had been absent from work or school as a result. Despite these large num- 1 Department of Gynecology, The Cleveland Clinic bers, only one fifth (21%) consulted a physician. Why did Foundation. Submitted for publication May 1983; accepted June 1983. these women not report dysmenorrhea to a physician? 367

Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. '368 Cleveland Clinic Quarterly Vol. 50, No. 2

Perhaps most women accept dysmenorrhea as introduction of intrauterine balloons and cathe- normal or do not believe treatment is available. ters have been done. In 1976, the microtrans- Only in the past decade have the relationship ducer catheter was used to measure contractions, 7 of prostaglandins to dysmenorrhea and the avail- o patient symptoms, and uterine blood flow. Ak- ability of nonsteroidal anti-inflammatory agents erlund et al5 showed that the dull continuous renewed interest in this condition. This recently component of menstrual pain correlated with defined etiology of dysmenorrhea has elicited an recordings of high basal tone and short relaxation infinite number of proposed remedies.3 intervals between contractions. Sharp pains oc- Historical review curred when contractions of high amplitude were 3 associated with decreased blood flow. These trac- As discussed by Wright, Hippocrates recom- ings helped assess drug effects so that evaluation mended fumigation of external genitalia by va- of different therapies became possible. pors of sweet wine, fennel seed and root, and Meanwhile, other investigators were determin- rose oil. Chinese medicine recommended moxi- ing causes of uterine contractility. Pickles et al6 bustion, which involves a cone of wormwood on used menstrual extracts to stimulate smooth mus- a slice of ginger placed on the abdomen, set cle in vitro. He identified a lipid-soluble acid in aflame, and allowed to burn down to the skin. these menstrual extracts that later was found in Oscar Polano, in 1907, claimed relief of dysme- endometrial material obtained by curettage. norrhea by applying suction cups to the breasts, Chromatography revealed that this acid included and, in 1865, Dr. Battey, in Georgia, performed two active substances, which, by 1963, had been bilateral oophorectomy of normal ovaries to cure identified as prostaglandin E2 (PGE2) and pros- dysmenorrhea. Ovarian radiation and insertion 7 6 taglandin F2a (PGF2a). Pickles et al then quan- of stem pessaries are other obsolete measures. tified these substances in menstrual extracts and Traditionally attitudes toward menstruation found that menstrual fluid from dysmenorrheic usually have been negative. Cultural taboos and women has about ten times as much PGF2a as religious beliefs, which persist to the present in the secretory endometrium, suggesting that some cultures, involve isolation and ritual clean- PGF2a is formed shortly before or during men- sing- struation. In addition, the secretory endome- The Victorians treated menstruation as an ill- trium seemed to have a higher PGF/PGE ratio ness. Supposedly, dysmenorrhea could be pre- than proliferative phase samples. vented or relieved by seclusion and rest with a Research into prostaglandins and their deriva- minimum of needle work and piano playing and tion from arachidonic acid and the hypothesis absolutely no singing. Working class women used that nonsteroidal anti-inflammatory agents menses as a refuge from daily drudgery. (NSAI) are specific inhibitors of PG synthesis all The changing status of women in the early part contributed to the suggestion by Pickles6 in 1972 of this century and the reaction against their that NSAIs might be of value in treating dysmen- being labelled the "weaker sex" popularized the horrhea. It has only been since 1974 that psychogenic origin of dysmenorrhea. Paulson Schwartz et al8 and Massey et al,9 working inde- and Wood,4 in 1966, showed that all of the pendently, chose a NSAI to treat uterine pain psychiatrists and half of the gynecologists ques- because these drugs inhibit prostaglandin synthe- tioned about their attitude toward dysmenorrhea sis. supported the psychogenic theory of its origin. Both prostaglandins are produced by endo- The advent of oral contraception in the 1960s metrial cell destruction through the release of helped to alter this psychogenic theory as women intracellular lysosomes. This endometrial cell taking oral contraceptives experienced relief of breakdown releases phospholipids that are con- dysmenorrhea. verted to arachidonic acid, the immediate pre- All contemporary lines of investigation assume cursor of the prostaglandins. Although prosta- that the symptoms of dysmenorrhea, namely, glandins are produced in the endometrium, the nausea, vomiting, pain, headaches, and dizziness prostaglandin receptor sites are in the myo- are real and organic. They attempt to explain metrium.10 Pain in dysmenorrhea results from that the consistent finding of hypercontractility creased basal tone of the uterus; namely, tonus is caused by ischemia of the myometrium. greater than 50 mm Hg, which is recorded dur- Studies of tracings of uterine contractions in ing cramps. Most investigators agree that uterine both normal and dysmenorrheic women by the pain is secondary to myometrial ischemia pro-

Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. Fall 1983 Dysmenorrhea 369 duced by high intensity contractions superim- trointestinal ulcers and in asthmatic patients. Ap- posed on a high basal uterine tonus. proximately 20% of asthmatic patients are sensi- tive to aspirin and will have increased broncho- Clinical features of primary dysmenorrhea constriction. Most will experience the same sen- Primary dysmenorrhea usually occurs in ovu- sitivity to prostaglandin inhibitors. latory cycles and appears shortly after menarche 3. Oral contraceptives in a sexually active ad- (about 6-12 months), when ovulatory cycles are olescent effectively control dysmenorrhea. They established. It is characterized by sharp colicky prevent thickening of the endometrium, thus pain in the suprapubic region radiating to the eliminating the formation of prostaglandins. An back and along the thighs. It begins several hours oral contraceptive with 30-50 mg of estrogen is before or immediately after the onset of men- usually effective with minimal side effects. If the struation and may be accompanied by nausea, patient has symptoms in the presence of oral vomiting, diarrhea, palpitations, flushing, dizzi- contraceptives, a small dose of NSAI may help. ness, lower backache, and headaches. Syncope 4. Other measures, e.g., antispasmodics and and collapse have been reported by patients, and beta-blockers with vasodilating properties, have symptoms usually last from a few hours to one not been helpful. Dilation and curettage have no day but may last for two to three days. therapeutic effect unless the patient has endo- The differential diagnosis of primary dys- metriosis or cervical stenosis. Term pregnancy is menorrhea includes all causes of secondary dys- curative for dysmenorrhea, probably because the menorrhea, but the character and duration of ensuing hypertrophy of blood vessels reduces the pain, onset immediately after menarche, and a relative vascular insufficiency. However, this can- negative pelvic and rectal examination help con- not be recommended for therapy. firm the diagnosis. Laparoscopy and examination under anesthesia must be done to rule out en- Secondary dysmenorrhea dometriosis in patients who have a family history Although primary dysmenorrhea is the most of endometriosis or who do not respond to the common cause of menstrual pain, endometriosis, following therapy. pelvic inflammatory disease, and Miillerian abnormalities can cause cyclical and acyclical pain Therapy of primary dysmenorrhea in adolescents. 1. Analgesics and simple explanation may al- Endometriosis, once considered a disease of leviate anxiety and help the patient cope with women in the third decade of life, has been mild symptoms. Narcotics should not be pre- found, with the advent of the laparoscope, in scribed because of the high risk of abuse. adolescents. In one study of patients with pelvic 2. Prostaglandin inhibitors, which inhibit ac- pain, 47% of the adolescents were found to have cumulation of prostaglandin, e.g., ibuprofen endometriosis." Similarly, in a series of 43 con- (Motrin) in doses of 400-800 mg, mefenamic secutive laparoscopics in teenagers, Chatman re- acid (Ponstel) 250-500 mg, or naproxen sodium ported an incidence of 65% of endometriosis.12 (Anaprox) in doses of 250-500 mg, are used An adolescent with dysmenorrhea who has sig- commonly with relief of symptoms in 75%-80% nificant positive pelvic findings or does not re- of patients3 (Table). Prostaglandin inhibitors spond adequately to antiprostaglandins and/or should be used cautiously in patients with gas- oral contraceptives should undergo laparoscopy. A coagulation of endometrial implants could be performed at that time with a dilatation and Table. Available prostaglandin inhibitors curettage. Endometriosis is more common in ad-

Aspirin olescents with affected mothers or sisters. Phenylbutazone (Butazolidin) Pelvic inflammatory disease can cause dysmenor- Oxyphenbutazone (Tandearil) rhea. The patient may have positive cultures Indomethacin (Indocin) from the endocervix and an elevated white blood Ibuprofen (Motrin) Mefenamic acid (Ponstel) cell count and sedimentation rate. Laparoscopy Naproxen (Naprosyn) may assist diagnosis. Naproxen sodium (Anaprox) Miillerian abnormalities, especially noncanaliza- Tolmetin sodium (Tolectin) tion of a double system, can cause dysmenorrhea. Fenoprofen (Nalfon) Rectal examination and ultrasound recordings Sulindac (Clinoril) are often helpful. Abnormalities, particularly ab-

Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission. '370 Cleveland Clinic Quarterly Vol. 50, No. 2

sence of a kidney, should alert the examiner to from secondary dysmenorrhea, reassurance, and the presence of Miillerian abnormalities. adequate therapy. The myth that "a woman must suffer" should Workup be expunged, and the fact that an adolescent must not be handicapped by dysmenorrhea Work-up of the patient with dysmenorrhea in- should be publicized. cludes a careful history of the nature and severity of the pain, menstrual history, familial history of References endometriosis and dysmenorrhea, sexual history 1. ACOG technical bulletin: Dysmenorrhea. 26 March 1983. with history of contraceptive use, including the 2. Andersch B, Milsom I. An epidemiologic study of young intrauterine device. It is best to take the history women with dysmenorrhea. Am J. Obstet Gynecol 1982; from the adolescent both with and without the 144:655-660. parent and to assure confidentiality. The physi- 3. Wright CK, in discussion, Dingfelder JR. Primary dysmenor- cian should explain the anatomy of the pelvic rhea treatment with prostaglandin inhibitors: a review. Am J organs and the necessity of performing tests to Obstet Gynecol 1981; 140:874-879. 4. Paulson MJ, Wood KR. 1. Perceptions of the emotional cor- rule out abnormality. Most teenagers respond relates of dysmenorrhea. Am J Obstet Gynecol 1966; well if explanation and examination are done in 95:991-996. a confident and unhurried manner. Also, use of 5. Akerlund M, Andersson KE, Ingemarsson I. Effects of ter- a small virginal speculum helps alleviate anxiety. butaline on myometrial activity, uterine blood flow, and lower If no abnormality is detected on pelvic and rectal abdominal pain in women with primary dysmenorrhoea. Br J Obstet Gynecol 1976;83:673-678. examination, an antiprostaglandin or an oral con- 6. Pickles VR, Hall WJ, Best FA, et al. Prostaglandins in endo- traceptive in a sexually active teenager is pre- metrium and menstrual fluid from normal and dysmenor- scribed. The patient is seen again in about three rhoeic subjects. J Obstet Gynaec Brit Comm 1965; 72:185- months. If pain continues in spite of therapy, or 192. if the findings on pelvic examination are abnor- 7. Eglinton G, Raphael RA, Smith GN, Hall WJ, Pickles VR. mal, ultrasound recordings, cultures from the Isolation and identification of two smooth muscle stimulants from menstrual fluid. Nature 1963; 200:960, 993-995. genitals for pathogens, and erythrocyte sedimen- 8. Schwartz A, Zor U, I.indner HR, Naor S. Primary dysmenor- tation rate should be obtained. The final diag- rhea. Alleviation by an inhibitor of prostaglandin synthesis nosis is usually made by examination under anes- and action. Obstet Gynecol 1974; 44:709-712. thesia; hysterosalpingography, and diagnostic la- 9. Massey SE, Varady JC, Henzl MR. Pain relief with naproxen paroscopy may be performed. A psychological following insertion of an intrauterine device. J Reprod Med 1974; 13:226. consultation is rarely necessary after a thorough 10. Abraham GE. Primary dysmenorrhea. Clin Obstet Gynecol work-up fails to reveal pathology. Biofeedback, 1978;21:139-145. relaxation techniques, and self-hypnosis have 11. deCholnoky C, Leventhal JM, Emans SJ. Goldstein DE. New helped these patients. insights into the old problem of chronic pelvic pain. J Pediatr Surg 1979; 14:675-680. The overall approach to dysmenorrhea should 12. Chatman DL, Ward AB. Endometriosis in adolescents. J Re- include proper diagnosis to distinguish primary prod Med 1982; 27:156-160.

Downloaded from www.ccjm.org on October 1, 2021. For personal use only. All other uses require permission.