CASE REPORT

Osteopathic Manipulative Treatment and Psychosocial Management of Dysmenorrhea

Starr Matsushita, OMS IV; Bonnie Wong, DO; Raghu Kanumalla, OMS IV, MS; Leonard Goldstein, DDS, PhD

From the A.T. Still University Dysmenorrhea, or painful menstruation, is a common cause of acute pelvic School of Osteopathic pain that affects approximately two-thirds of women who are postmenarchal Medicine in Mesa, Arizona. in the United States. Dysmenorrhea pain is frequently severe enough to Financial Disclosure: None reported. disrupt daily activities and often accompanied by other symptoms, such as diarrhea, nausea, vomiting, headache, and dizziness. Primary dysmenorrhea Support: None reported. is likely due to an excess of prostaglandins and is traditionally treated with Address correspondence to fl Bonnie Wong, DO, A.T. Still nonsteroidal anti-in ammatory drugs and hormonal therapy. Secondary dys- University School of menorrhea can have multiple origins and requires targeted therapy. Currently, Osteopathic Medicine, musculoskeletal dysfunction and psychosocial factors are not listed as 5850 E Still Cir, Mesa, AZ 85206-3618. causes of secondary dysmenorrhea. The authors present a case in which the

Email: [email protected] cause of secondary dysmenorrhea was thought to be related to both muscu- loskeletal dysfunction and emotional stress. Osteopathic manipulative treat- Submitted April 13, 2019; ment and lifestyle changes helped resolve secondary dysmenorrhea. fi nal revision received J Am Osteopath Assoc. 2020;120(7):479-482 August 12, 2019; doi:10.7556/jaoa.2020.076 accepted September 17, 2019. Keywords: dysmenorrhea, osteopathic medicine, somatic dysfunction

ysmenorrhea, or painful menstruation, is a common cause of acute pelvic pain. It affects approximately two-thirds of women who are postmenarchal in the D United States and should be differentiated from chronic pelvic pain, which is noncyclic and lasts for 6 months or more.1,2 Pain from dysmenorrhea is frequently severe enough to disrupt daily activities and is often accompanied by other symptoms, such as diarrhea, nausea, vomiting, headache, and dizziness.1,2 Dysmenorrhea is classi- fied as primary or secondary, with neither affected by childbearing.1 Primary dysmenorrhea is likely due to excess prostaglandins, particularly prostaglandin 1 F2-α, which leads to painful uterine contractions. Onset is typically during the late teens to early 20s, and incidence declines with age.1 Secondary dysmenorrhea is more common with aging, has a clinically identifiable cause, and requires targeted management.1,3 Currently, musculoskeletal and viscerosomatic contributions are not commonly listed as causes of secondary dysmenorrhea, but gynecologic (eg, endometriosis, ovarian cysts) and nongynecologic (eg, tumors, inflammation, adhesions, psychogenic disorders, irritable bowel syndrome, and irritable bowel disease) causes are listed.1 A relationship among visceral function and the musculoskeletal and autonomic nervous systems (ANS) has been suggested.4 Therefore, somatic dysfunction (SD) related to the ANS, specifically the lower thoracic and upper lumbar segments, hypogastric plexus, and the sacral plexi, can contrib- ute to dysmenorrhea symptoms. By extension, managing these SDs might improve dys- menorrhea symptoms as evidenced by randomized controlled trials showing the efficacy

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of manual therapy.5-7 Furthermore, psychological and and worsened to grade 3 in December. She then social issues should be considered with other secondary improved to grade 2 in January and was finally back to causes because of the connection of mind and body.1,8-11 her predysmenorrhea baseline by March 2018 with THere we present a case of adult-onset, nongyneco- nondebilitating, mild colicky pain that did not interfere logic secondary dysmenorrhea that resolved using a with her daily activities. holistic approach with both osteopathic manipulative The patient reported no significant physical trauma treatment (OMT) and management of psychosocial except for an adductor strain before symptom onset. The factors. We propose that these 2 elements should only abnormal historical information reported was stress be included as part of the treatment of patients with from first-year medical school coursework and living secondary dysmenorrhea. with a roommate during the 4 months prior to presentation. As a self-described introvert, she noted that her living situation added a lot of psychological stress to her life. Report of Case The review of systems was notable for a 12-pound A 32-year-old female medical student presented to our weight loss from July 2017 to February 2018 that was osteopathic medicine center in October 2017 with back accompanied by decreased appetite and inconsistent and hip pain. At the time of her presentation, the pain eating habits. She also reported headaches, lumbar back was so severe that she considered missing classes. pain, changes in mood (eg, “feeling short with people”), Three weeks later, at her second visit, she disclosed the mild breast tenderness, nausea, diffuse abdominal pain, onset of dysmenorrhea during the previous week. constipation, and diarrhea during these dysmenorrheic Although her back and hip pain resolved after 2 visits periods. She denied menorrhagia, oligomenorrhea, inter- and OMT sessions, the patient was seen during the next menstrual bleeding, mittelschmerz, bloating, vomiting, 5 months for continued dysmenorrhea described as “hor- dysuria, urinary retention, vaginal discharge or irritation, rible pain and crampingness” that lasted several hours and dyschezia. She was advised to follow up with a per day for up to 1 week in the perimenopausal period. primary care physician for further evaluation of symptoms. The patient’s gynecologic history before dysmenorrhea was normal, with menarche at age 12 years, 28-day cycles, Clinical Findings 4 to 5 days of regular flow, and nondebilitating, mild The patient had normal cardiopulmonary, neurologic, and colicky pain that did not interfere with her daily activities. abdominal examination results. The osteopathic structural She had never been sexually active. She had normal pelvic examination results showed considerable asymmetries of examination and Papanicolaou test results in September the occipitoatlantal joint, thoracic spine, lumbar spine, 2017. She regularly tracked her periods with a smartphone sacrum, and innominate bones throughout treatment. application and noted that the only significant change to A right-side superior shear of her ilium and a left-on-left her periods was the severity of pain experienced. Of note, sacral torsion during dysmenorrhea were consistently her older sister had severe grade 3 dysmenorrhea for most found. The patient had a decreased cranial rhythmic of her adult life, which was resolved with hysterectomy impulse early in the course of treatment, accompanied after unsuccessful treatment with hormonal therapy. With by hypertonicity in the suboccipital muscles. the exception of her sister’s dysmenorrhea, her medical and family histories were noncontributory. Therapeutic Intervention According to the verbal, multidimensional scoring The patient received 6 OMT sessions that took place system for the assessment of dysmenorrhea,12 she over 5 months (Figure). The patient was treated with reported being grade 0 or 1 before October 2017. She techniques that were tailored to each specificSD, progressed to grade 2 during October and November including myofascial release, strain-counterstrain, soft

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Start of medical school and abnormal living situtation

July 2017

Initial evaluation; OMT No.1 (10/10/17); Oct 2017 OMT No.2 (10/31/17)

Nov 2017 OMT No.3 (11/14/17)

Dec 2017 OMT No.4 (12/13/17)

Jan 2018

OMT No.5 (02/04/18); Feb 2018 final evaluation; and OMT No.6 (02/28/17)

Resolution of dysmenorrhea to baseline symptoms of nondebilitating, mild colicky pain that did not interfere with daily activities

Figure. Timeline of events for patient with secondary dysmenorrhea. Abbreviation: OMT, osteopathic manipulative treatment. tissue, muscle energy, suboccipital release, abdominal lifestyle changes, the patient had normal menstrual plexus release, and joint articulation. Throughout treat- periods without dysmenorrhea. By February 2018, she ment, we discussed outside stressors and counseled the had only mild cramps that lasted for 10 to 20 minutes patient on the importance of adequate caloric intake and at a time, headache, fatigue, and some moodiness that aerobic exercise. As a result, she implemented mindful- decreased on the second day. In the following month, ness meditation and yoga on a weekly basis. Her irregu- her moodiness resolved, her other symptoms were lar eating was an effect of stress and improved when back to baseline, and her verbal multidimensional she implemented the other lifestyle changes. score12 was back to her baseline of grade 1. The The patient’s pain improved, and there was a patient confirmed that her dysmenorrhea symptoms decrease in the severity of SD throughout the 6 OMT remained at baseline in a 1-year follow-up interview. sessions. Her back and hip pain resolved within the first 2 OMT sessions, but her dysmenorrhea persisted. Her last 2 OMT sessions focused on relieving pelvic Discussion and sacral restrictions using balanced ligamentous and Given the timing of onset and relative ease of resolution, balanced membranous tension of the entire pelvic we attributed this patient’s adult-onset, severe secondary bowl, including the pelvic diaphragm. We also focused dysmenorrhea to SD of the pelvis and sacrum, which on alleviating psychological stressors, which included resulted in an imbalance of the ANS. Psychosocial stres- ending her co-living situation. After OMT and making sors, via the hypothalamic-pituitary-adrenal axis, cause

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increased sympathetic tone and result in an imbalance of examine and correct sacral and pelvic SDs when applic- the ANS. This imbalance can have a negative effect on able. We also recommend managing cranial SD, par- the function of organ systems, including the uterus via ticularly in the case of headaches, menstrual-associated the sacral splanchnic nerves, which emerge from the migraines, or history of head trauma, to alleviate the sacral sympathetic trunks to join the inferior hypogastric effects of reciprocal tension membrane on the sacrum. (pelvic) plexuses.13 When the sacrum is distorted, asym- metrically torqued uterosacral ligaments also put mech- References anical stress on the uterus. 1. Smith RP, Laube DW, Herbert WNP, et al. Gynecology. In: Casanova In our patient, pelvic and sacral SD seemed to increase R, ed. Beckmann and Ling’s Obstetrics and Gynecology. 8th ed. somatovisceral reflexes in a system that was already Wolters Kluwer; 2019:279-284. hypersympathetic because of psychosocial stressors. 2. Brown K, Lee JA. Evaluation of acute pelvic pain in the adolescent female. UpToDate. https://www.uptodate.com/contents/evaluation-of- These factors led to the increased autonomic neural tone acute-pelvic-pain-in-the-adolescent-female. Accessed June 14, 2018.

of the uterus, uterine contractions, and reduced blood 3. Smith RP, Kaunitz AM. Dysmenorrhea in adult women: treatment. flow with resultant relative ischemia as uterine pressure UpToDate. https://www.uptodate.com/contents/ dysmenorrhea-in-adult-women-treatment. Accessed June 14, 2018. exceeded arterial pressure.3,4 This function is supported 4. Willard F. Autonomic nervous system. In: Chila AG, executive ed. by a historical method of correcting unresolved dysmen- Foundations of Osteopathic Medicine. 3rd ed. Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2011: 134-161. orrhea: performing presacral neurectomy to disrupt the 1 5. Barassi G, Bellomo RG, Porreca A, Di Felice PA, Prosperi L, Saggini R. connections between the neural plexi and the uterus. Somato-visceral effects in the treatment of dysmenorrhea: neuromuscular Our patient experienced considerable SD in the pelvis manual therapy and standard pharmacological treatment. JAltern Complement Med. 2018;24(3):291-299. doi:10.1089/acm.2017.0182 and sacrum, and OMT improved her symptoms. 6. Molins-Cubero S, Rodríguez-Blanco C, Oliva-Pascual-Vaca Á, In addition to OMT, the removal of psychosocial Heredia-Rizo AM, Boscá-Gandía JJ, Ricard F. Changes in pain factors that contributed to her sympathetic hyperactivity perception after pelvis manipulation in women with primary dysmenorrhea: a randomized controlled trial. Pain Med. 2014;15 helped resolve dysmenorrhea. There is a close associ- (9):1455-1463. doi:10.1111/pme.12404

ation between emotional well-being and the severity of 7. Schwerla F, Wirthwein P, Rütz M, Resch KL. Osteopathic treatment in dysmenorrhea.8-11,14 With decreased stress through patients with primary dysmenorrhoea: a randomised controlled trial. Int J Osteopath Med. 2014;17(4):222-231. doi:10.1016/j.ijosm.2014.04.003 regular aerobic exercise, meditation, and an improved 8. Ibrahim NKR, Al-Ghamdi MS, Al-Shaibani AN, et al. Dysmenorrhea living situation, the patient was able to heal. among female medical students in King Abdulaziz University: The results of this case are limited by unique muscu- prevalence, predictors and outcome. Pak J Med Sci. 2015;31 (6):1312-1317. doi:10.12669/pjms.316.8752 loskeletal and psychosocial factors. Future studies 9. Bavil DA, Dolatian M, Mahmoodi Z, Baghban AA. Comparison of could replicate OMT techniques to show that this was lifestyles of young women with and without primary dysmenorrhea. Electron Physician. 2016;8(3):2107-2114. doi:10.19082/2107 not an isolated case, continue longitudinal reassess- fi 10. Pramanik T, Shrestha R, Sherpa MT, Adhikari P. Incidence of ment, and compare the ef cacy of other treatment dysmenorrhea associated with high stress scores among the options, such as pelvic floor physical therapy, medita- undergraduate Nepalese medical students. J Inst Med. 2010;32(3):2-4. tion, yoga, or other stress relievers with OMT. 11. Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332 (7544):749-751. doi:10.1136/bmj.38748.697465.55

12. Andersch B, Milsom I. An epidemiologic study of young women with Conclusion dysmenorrhea. Am J Obstet Gynecol. 1982;144(6):655-660. doi:10.1016/0002-9378(82)90433-1 This case suggests that SD and psychological factors 13. Haroun HSW. Clinical anatomy of the splanchnic nerves. MOJ Anat should be considered during a secondary dysmenorrhea Physiol. 2018;5(2):87-90.

workup to help physicians provide appropriate and tar- 14. Herbert B. Chronic pelvic pain. Altern Ther Health Med. geted treatment options. Physicians considering OMT 2010;16(1):28-33.

for secondary dysmenorrhea management should © 2020 American Osteopathic Association

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