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Home , Dysmenorrhea, Endometrioma, Hydrosalpinx, Vaginal discharge

7 Painful Menstrual Period:

Regine Unkels

INTRODUCTION issues such as sexually transmitted infections (STIs) and contraception and help the girl to establish a Dysmenorrhea is a very common gynecological life-long link to reproductive health services. A problem. As is very subjective and as such pre-condition for this is that the first visit works out difficult to assess, studies show a broad range of well for the girl and is not, as often, traumatizing. prevalences from 17 to 81%1. Pain perception is You will find more on this very important issue in also influenced by cultural background. This ex- Chapter 1 on gynecological examinations and plains different prevalences found in different parts Chapter 32 on adolescent gynecology. of the world. Most studies deal with dysmenorrhea in industrialized settings and there are no data avail- Definition able from resource-limited settings. This doesn’t mean, however, that dysmenorrhea is not import- Dysmenorrhea describes recurrent cyclic pain dur- ant in those settings. As the causes for dysmenor- ing menstrual periods. The pain is usually cramp- rhea are the same all over the world you can assume like, colicky, located in the suprapubic region with that as many women are affected by it in resource- radiation to the lower back and the legs and stays poor settings as in industrialized regions. The usually 24–48 h. Often women describe accompany- studies mentioned above found that 15% of the ing symptoms such as , , and participants mentioned the pain to be severe and tiredness. There are two forms of dysmenorrhea. interfering with their normal activities. In one This differentiation is important as you will see: study, 35% of female high school students reported Primary dysmenorrhea starts by definition around the missing school2. If you consider that daily activities and describes pain during the menstrual in low-resource settings are physically much harder period without any underlying cause. So most than in industrialized countries, and that the cir- patients you’ll see for primary dysmenorrhea will cumstances for girls going to school are much more be of younger age. The onset of pain is usually a difficult in many parts of the world, you can imag- few hours before blood flow starts and will last ine how effective treatment for this common con- for the first one to two days of the period. Often dition can significantly influence socioeconomic primary dysmenorrhea becomes less with age or performance and social well-being. after childbirth. In addition, dysmenorrhea has a psychological aspect, as women and especially adolescents suffer- Secondary dysmenorrhea relates to pain during men- ing from it are often concerned that something strual periods with an underlying pathology (see might be wrong with their reproductive organs, below). As a matter of fact, symptoms will only hampering their fertility in later years. This can start after the underlying cause has developed. cause a lot of fear and should also be addressed. Patients with secondary dysmenorrhea will be In adolescent girls dysmenorrhea might cause mostly more mature women. Often, pain starts the first contact with a reproductive health service. many hours or even days before the onset of blood This can be an opportunity for counseling on other flow and can last the whole period.

79 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS

CAUSES OF DYSMENORRHEA , cancer) and expulsion efforts of blood clots from the uterine cavity leading to dysrhythmic Primary dysmenorrhea contractions. In some, traction (adhesions, PID), or This is caused by an excessive production of pros- the production of or - taglandins in the body just before like factors (acute STI, ) might play a starts. This is due to the fall in which role. induces sloughing of the endometrial lining to pre- These conditions are dealt with in their respec- pare for menstruation and, through this, increased tive chapters and Chapter 6 on chronic . prostaglandin production. Prostaglandin is a hor- mone which you might know from obstetrics as misoprostol. The additional symptoms of dysmen- HISTORY TAKING orrhea such as nausea and diarrhea are the same as the side-effects of misoprostol! • Actual complaints: type of pain, radiation, onset in Prostaglandin is a sort of by-product of men- relation to and period. Other strual changes of the and it is not symptoms: watch out for the above-mentioned known why some women produce more prosta- accompanying symptoms such as diarrhea and glandin than others, but this seems to be only poss- nausea. Endometriosis can grow in the bladder ible when menstrual cycles are ovulatory (with an and bowel and cause hematuria and bloody ). The fact that often the very first cycles stool. Ask about pain during intercourse (dys- in a girl are anovulatory explains why primary pareunia) hinting at endometriosis, adenomyo- dysmenorrhea often only starts a few cycles after sis, fibroids or PID. Also ask about dyschezia menarche. Excess of prostaglandins leads to hyper- (pain during defecation) which is a sign for frequent, dysrhythmic uterine contractions and re- bowel endometriosis. duced uterine blood flow, which leads to pain. • Duration of complaints (primary/secondary, how Very seldom, primary dysmenorrhea is caused by many months/years). Watch out: every newly congenital or acquired malformations of the female appearing dysmenorrhea can be a mistaken ec- reproductive tract, such as imperforated hymen, topic ! and obstruction after female genital mutilation. • Duration of periods and regularity of the cycle: adeno- It is good to know that primary dysmenorrhea myosis and fibroids often go along with menor- can be very painful but that it is always harmless rhagia (increased blood loss and prolonged and does not interfere with reproductive function. menstruation). Spotting and irregular bleeding can be a sign for STI. Bleeding after or during Secondary dysmenorrhea intercourse can hint at STI but also at cervical cancer. Possible causes of secondary dysmenorrhea are: • Parity, pelvic operations: subfertility can be a sign • Endometriosis (endometrial cells growing out- for endometriosis, PID and fibroids; recurrent side the , leading to cysts and adhesions) abortion can hint at the existence of uterine (see Chapter 6). fibroids. Pelvic operations can cause adhesions • Adenomyosis (endometrial cells growing within or lead to infections which in turn can cause the uterine wall in the muscle layer called PID. D&Cs carried out under unsterile condi- ). tions are a very important risk factor in this con- • Uterine fibroids (benign tumors of the uterine text but are often missed during history taking. wall) (see Chapter 19). • Use of contraceptives can ease pain in primary dys- • Acute STIs and chronic pelvic inflammatory menorrhea and endometriosis. disease (PID) (see Chapter 17). • Desire for pregnancy in order to determine the use • Pelvic adhesions (postoperative or post- of oral contraceptives for therapy. infectious) (see Chapter 6). • Fever, discharge and abdominal pain can be a signs • Reproductive cancers (late sign) (see Chapters 26, of STI, but can also be a late sign of cervical 28–30). cancer. In most of these conditions, menstrual pain is re- • Stress or a family history of dysmenorrhea: primary lated to pressure of the impaired tissue (fibroids, dysmenorrhea can be psychosomatic. The way

80 Painful Menstrual Period: Dysmenorrhea

older female relatives deal with their menstrual Speculum examination period can influence the perception of girls During a speculum examination you can find signs about womanhood and menstruation and the of cervical cancer (bleeding, ulcers, erosions, way they deal with painful periods. Stress in masses) or for STI (abnormal , a school or around issues of and reddish cervical surface, discharge from the cervical growing up can lead to a change in pain percep- os) and for vaginal endometriosis (dark-red or tion and primary dysmenorrhea as well. purple blisters or spots). The can be distorted Please bear in mind that a menstrual period is to one side by fibroids, tubo-ovarian masses or the inevitable sign that a pregnancy did not endo metriosis, or shortened by cervical or intra- work out. So, for women with difficulties in cavitary fibroid growth. conceiving or in cases where their in-law family or society puts pressure on them to conceive, every period is ‘painful’ in a psychological way. Wet mount The wet mount can show signs of vaginal or cervi- cal infections including STI (pus cells, clue cells, PHYSICAL EXAMINATION Trichomonas). Most of the time you can make the diagnosis with- out many investigations in your facility. Primary Vaginal examination dysmenorrhea is a diagnosis of exclusion, but your During bimanual palpation you can find signs of history with onset of symptoms and menarche can adenomyosis (enlarged, soft, often tender uterus) or already help you to establish the diagnosis. In pri- fibroids (enlarged, firm uterus, bulky uterus with mary dysmenorrhea your examination outside humps, mobile or immobile) and ovarian masses menstruation will be normal as there is no under- such as benign or malignant ovarian tumors and lying cause for it. Most women come when they tubo-ovarian as a sign of PID (masses are having pain, so it might be wise to re-examine right, left or behind the uterus, mobile or im- them once their period is over to see the difference. mobile). Cervical tenderness can be a sign of acute Be aware of possible congenital malformations like or chronic infection (STI, PID) but also for endo- a rudimentary uterine horn that can cause the pain. metriosis and . A painful palpation Keep in mind: a woman can start with primary of the posterior fornix can be a sign of endometrio- dysmenorrhea and with time experience additional sis of Douglas’ space or infiltration of the tissue secondary symptoms due to new underlying causes. between and bowel. So ask every woman if the pain changed with time, especially concerning onset and duration. You Rectal examination must do a full gynecological examination on all patients with dysmenorrhea to establish or rule A rectal examination can reveal blood or anal pain out underlying causes. Special considerations for which can be signs of endometriosis and sometimes examination of young girls or virgins are given in endometriosis in recto-vaginal septum can be pal- Chapter 1 on gynecological examination and pated by recto-vaginal examination. in Chapter 24 on adolescent gynecology. You can find a description on each examination method or Further investigations investigation in Chapter 1. Vaginal/abdominal Abdominal palpation If your clinical diagnosis is secondary dysmenor- rhea look for the following pathology: By doing an abdominal examination you can assess abdominal masses (fibroids, cancer) or points of Uterine fibroids Their echogenicity in ultrasound is a pain-related resistance (PID, adhesions). You bit less than normal myometrium. They usually should look for scars and assess their healing. An have well-defined borders to the myometrium and ugly broad scar might be a sign of secondary heal- a capsule. Don’t forget to do abdominal ultrasound ing with the likelihood of infection or adhesions. as well as sometimes you will miss them in vaginal

81 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS ultrasound if they are big and outside the true of those drugs above another NSAID, but all are . more effective than placebo, paracetamol or butyl scopolamine (Buscopan®). This is due to Adenomyosis Adenomyosis is difficult to see with their mode of action: NSAIDs stop prosta- ultrasound and the diagnosis is often one of exclu- glandin production, something which paraceta- sion. The posterior wall of the uterus might be mol or Buscopan cannot do. thicker than the anterior wall and you may find • NSAIDs only lower production of prosta- areas of hyperechogenicity in it. The uterus is of- glandins. They do not reduce the effect of pros- ten enlarged. Patients with adenomyosis often taglandin on the uterus. Once prostaglandins are suffer from menstrual disorders together with in the circulation they will cause pain and dysmenorrhea. NSAIDs will not work as effectively. Endometrioma often appear as tumors Usually women with primary dysmenorrhea know in the . If they are big enough you may see when pain starts and how long it usually stays and them on ultrasound. They are usually cystic with there are only few cycles where they won’t experi- decreased or absent echogenicity and can resemble ence pain. Thus, for a successful treatment and ovarian cysts or . good compliance there are three important Tubo-ovarian , hydrosalpinx, pelvic abscess Pelvic messages you have to give your patient: infections can lead to abscesses in various sides. See • Always have your NSAIDs in stock and in reach Chapter 17 on STI for description of ultrasound when you are near your period. findings. • Always take your NSAIDs as early as you feel the pain coming. Don’t wait until the pain is Urine pregnancy test/urinalysis very strong because this is too late. Every patient with new pelvic pain should have a • Always take your NSAIDs as long as the pain urine pregnancy test (UPT) to exclude ectopic usually stays. pregnancy even if she claims she has had her period. It is important to prescribe drugs for 3 months and Do urine analysis to exclude chronic urinary tract then see the patient again to assess together with infection and schistosomiasis in endemic areas. her whether she saw some relief. If not, change to another NSAID or add an oral contraceptive if no Erythrocyte sedimentation rate/white blood cell count pregnancy is planned. These can help confirm or exclude an infectious cause of pelvic pain such as tubo-ovarian masses or Non-steroidal anti-inflammatory drugs for PID. dysmenorrhea

• tablets 25 mg t.d.s. for 48–72 h each MANAGEMENT menstruation. The therapy for primary dysmenorrhea is very • tablets 400 mg t.d.s for 48–72 h each simple and cheap: menstruation. • tablets 50 mg t.d.s. for 48–72 h each • For women with the desire for contraception a menstruation. normal contraceptive pill (OCP) with < 35 mg estrogen and progesterone has shown some The treatment of secondary dysmenorrhea differs effect in many trials although the evidence is not according to the underlying causes. The pain will firm due to the study designs3. You can also pre- stop or decrease once the underlying cause is scribe the OCP non-cyclic: the woman will not treated. You will find the respective therapies for get a period and will not have dysmenorrhea. each cause in their chapters and in Chapter 6 on • For all other patients with primary dysmenor- chronic pelvic pain. In cases where no underlying rhea any non-steroidal anti-inflammatory drug pathology is found in a woman in later reproduc- (NSAID: aspirin, diclofenac, ibuprofen, indo- tive life, treat with NSAIDs as for primary dysmen- metacin) is very effective (level I evidence). orrhea. If there is no actual desire for pregnancy There is no study showing the superiority of one you can give COC continuous (see Chapter 6)

82 Painful Menstrual Period: Dysmenorrhea which will reduce the number of painful periods. psycho somatics, as a lot of gynecological problems In adult women, long-term contraception with have psychosomatic components and your service progestins like depot injectables or implants lead to will greatly profit from a cooperation between in 50% of women after the first year of these departments. use which also reduces the number of painful men- struations. An alternative that becomes increasingly REFERENCES available in resource-poor settings as well is the 1. Latthe P, Latthe M, Say L, et al. WHO systematic review called Mirena®. of prevalence of chronic pelvic pain: a neglected repro- More than 80% of women will be amenorrheic ductive health morbidity. BMC Public Health 2006;6:177 after a year and before the prevalence of dysmenor- 2. Banikarim C, Chacko MR, Kelder SH. Prevalence and rhea is reduced. The progestin-based long-term impact of dysmenorrhea on Hispanic female adoles- cents. Arch Pediat Adolesc Med 2000;154:1226–9 contraceptives can be used in primary dysmenor- 3. Wong CL, Farquhar C, Roberts H, Proctor M. Oral rhea as well, but a regular contraceptive pill is pre- contraceptive pill for primary dysmenorrhea. Cochrane ferred in adolescents. Database Syst Rev 2009;4:CD002120 Don’t forget that dysmenorrhea can have psycho somatic causes as well and assess the patient Further reading for this or refer to a competent provider in your Marjoribanks J, Proctor M, Farquhar C, Derks RS. Non- facility. It is worthwhile talking to the psychiatric steroidal anti-inflammatory drugs for dysmenorrhea. nurse of your hospital and sensitizing her for Cochrane Database Syst Rev 2010;l;CD001751

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