DYSMENORRHEA

Erum Ahmed- OMS-III, Hau Tran- OMS III, Theodore B. Flaum- D.O., FACOFP, Sheldon C. Yao, DO, FAAO

INTRODUCTION

Dysmenorrhea, or painful cramping related to menstruation, is a common problem experienced by women in their reproductive years (approximately 50% of all menstruating women), especially at age 20-24. When severe, it interferes with the performance of daily activities, often leading to absenteeism from school, work, and other responsibilities. 10% of severe cases require bed rest. Pain during menstruation has been accepted as a “normal” part of the menstrual cycle which greatly decreases the number of affected females seeking medical help even though they would greatly benefit from it. The significance of dysmenorrhea in females is also often overlooked by healthcare professionals.

Known risk factors for dysmenorrhea include high BMI, smoking, earlier age at menarche, longer and heavier menstrual flow, alcohol consumption, family history and nulliparity.

Primary dysmenorrhea is diagnosed when no obvious underlying cause is found. Secondary dysmenorrhea is associated with an identified pathological cause, most commonly endometriosis which is important to identify due to infertility risks.

Primary dysmenorrhea is more common than secondary dysmenorrhea and usually starts during adolescence. Primary dysmenorrhea often becomes less severe with age and after pregnancy.

PATHOGENESIS

Primary dysmenorrhea is caused by intense uterine contractions that result in uterine ischemia. Prostaglandins release from the endometrium at the beginning of menses and are a major cause of these contractions resulting in pain detected by nociceptive nerve fibers. Due to the cyclical nature of pain occurrence, nociceptive feedback loops are continuously maintained in high sensitivity and serve as an ongoing source of stress for patients.

PATIENT PRESENTATIONS:

Primary dysmenorrhea is characterized by recurrent, intermittent or constant crampy, midline lower abdominal pain extending to lower back or legs that occurs during or prior to menses in the absence of pelvic pathology that could account for the pain. Secondary dysmenorrhea is the occurrence of painful menses due to another gynecological disease. Often, the pain starts shortly before or during the menstrual period, peaks after 24 hours, and subsides within two days. Other common symptoms include headache, nausea, constipation or diarrhea, irritability, nervousness, depression, breast tenderness, abdominal bloating, fatigue and an urge to urinate frequently. When the pain is severe, vomiting may occur.

The diagnosis of primary dysmenorrhea is based upon the presence of characteristic clinical features in the absence of demonstrable disease that could account for the pain.

Secondary dysmenorrhea is excluded primarily by history and physical examination. The most common causes of secondary dysmenorrhea are pelvic inflammatory disease and endometriosis. Laboratory tests and imaging studies are not mandatory to exclude disorders associated with secondary dysmenorrhea, but should be performed, as indicated, if pelvic disease is suspected.

DIFFERENTIAL DIAGNOSIS:

1. Polycystic ovary syndrome (PCOS) 2. Endometriosis 3. Adenomyosis 4. Pelvic Inflammatory disease 5. Fibroids 6. Uterine polyps 7. Uterine carcinoma 8. Ovarian cancer 9. Pregnancy 10. Ectopic pregnancy

TREATMENT:

Standard medical treatment for primary dysmenorrhea usually involves nonsteroidal anti- inflammatory drugs, such as ibuprofen, naproxen, and mefenamic acid. Others may include hormonal contraception, Tocolytics (Nitric oxide, nitroglycerin, and calcium channel blockers) and heated patch application to lower abdomen. The treatment of secondary dysmenorrhea depends on the cause. Surgery may be utilized to widen the cervical canal, or in extreme cases, to sever the nerves to the uterus.

Yoga and sexual activity may be helpful. Anecdotal experience suggests menses-related discomfort is relieved by orgasm in some women.

Acupuncture: In a systematic review including three trials that compared acupuncture to sham acupuncture, all three trials observed a reduction in pain in both groups, but only one trial noted greater pain reduction in the real versus the sham acupuncture group. There need to be more data from controlled trials demonstrating safety and efficacy before these modalities can be recommended.

Behavioral interventions — Behavioral interventions include attempts at modification of the way the patient thinks about her pain (eg, desensitization based procedures, hypnotherapy, imagery, coping strategies) and attempts at modification of her response to pain (eg, biofeedback, electromyographic training, Lamaze exercises, relaxation training). There is no high quality evidence to support or refute use of these modalities; a systematic review of randomized trials concluded some women may be helped by them Diet and vitamins: low fat-vegetarian diet, dietary dairy intake, vitamin E (500 units per day or 200 units twice per day, beginning two days before menses and continuing through the first three days of bleeding), vitamin B1 (100 mg daily), vitamin B6 (200 mg daily), and fish oil supplement (1080 mg eicosapentaenoic acid, 720 mg docosahexaenoic acid, and 1.5 mg vitamin E).

Exercise prescription Self-stretching and strengthening exercises to reduce lordosis and development of postural strain

Neuromuscular Manual Therapy (NMT) A controlled, randomized, single-blind clinical trial with 60 participants compared NMT with pharmacology therapy using the menstrual distress questionnaire, a validated survey to measure dysmenorrhea symptoms. The NMT group was treated with 8 neuromuscular manual lumbar and abdominal therapy sessions twice per week for 4 weeks. Treatments targeted osteomuscular structures of the lumbar and pelvic areas. Techniques included superficial massage followed by direct strokes using stripping, frictional and pincer pressure. The pharmacology group was given Ibuprofen and Naproxen as needed for pain. Results show that both interventions reduced pain perceptions. NMT was found to have greater improvements in pain duration with prolonged effects as compared to pharmacological therapies. One small trial reported Japanese herbal combinations were more effective for reducing pain than placebo. In a systematic review of 39 randomized trials of Chinese herbal medicine for treatment of primary dysmenorrhea, this approach appeared to be promising compared to other therapies, but no firm conclusions could be made due to poor methodologic quality of the available trials.

OMM INTEGRATION

Osteopathic Structural Examination

Somatic dysfunction related to diagnosis:

-Parasympathetic output affecting the OA and sacrum -Increased sympathetic output from T10-L2. Somatic Dysfunction in T10, T11, T12 (62.5%) -Increased lordosis affecting type II dysfunctions in the lumbar spine, sacrum, and pelvis, such as Somatic dysfunction at L5 (75%), Sacral Torsion (100%) -C3 and T3 dysfunctions due to stress carried in muscle tension in the thoracic and cervical regions -Anterior Chapmans Points for uterus at medial edge of the obturator foramen and ovaries inferior to the pubic tubercle -Posterior Chapmans Points for uterus between the posterior superior iliac spine and the transverse process of L5 and ovaries at the T10 transverse processes

Trigger points for Dysmenorrhea: center Rectus Abdominis below belly button

OMT for Dysmenorrhea:

Goals for osteopathic manipulative management: includes - Alleviate/reduce pain - Treat somatic dysfunctions - Modify autonomic input - Decrease congestion - Restore normal motion to visceral structures

Time to treat: Minimum of 24 hours before menstruation begins. Once pain is already established, it is less effective. If pain is present for >12 hours, manipulative treatment was largely ineffective.

Sacral inhibition: normalizes hyperparasympathetic activity in pelvic structures

Procedure: with patient in prone position, apply deep direct pressure at the sacrum for 2 minutes

Sacral Rocking: relaxes muscles of lumbosacral junction

Procedure: with patient in prone position, apply gentle pressure at the sacrum with rocking motion augmenting flexion and extension phases associated with respiration or with cranial rhythmic impulse.

Treating Chapman's Points along the Iliotibial and in the anterior and posterior uterine and ovarian locations

Treat Somatic Dysfunction at T10 to L2 (Sympathetics)

Paraspinal Release: normalizes hypersympathetic tone in pelvic structures

Procedure: with patient in supine position, contact tight paravertebral muscles pushing anteriorly to meet the resistance of the tissues until muscle releases and loosens up.

Treat Somatic Dysfunction at Innominate & Sacrum (S2-4 Parasymp) A systematic review of four trials of high velocity, low amplitude spinal manipulation reported the technique was no more effective than sham manipulation for the treatment of primary dysmenorrhea, although it was possibly more effective than no treatment.

Lymphatic approach :

Treat Thoracic Inlet Dysfunction Abdominal Diaphragm Pelvic Floor Pumps Thoracic Pump Abdominal Pump Dalrymple Pedal Pump Marion Clarke Drainage

REFERENCES:

1. Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol 2001; 97:343. 2. Akin M, Price W, Rodriguez G Jr, et al. Continuous, low-level, topical heat wrap therapy as compared to acetaminophen for primary dysmenorrhea. J Reprod Med 2004; 49:739. 3. Proctor ML, Murphy PA, Pattison HM, et al. Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2007; :CD002248. 4. Cho SH, Hwang EW. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG 2010; 117:509. 5. Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2006; :CD002119. 6. http://www.uptodate.com.arktos.nyit.edu/contents/primary-dysmenorrhea-in-adult-women- clinical-features-and- diagnosis?source=machineLearning&search=dysmenorrhea&selectedTitle=3~150§ionRank =1&anchor=H52181096#H52181096 7. Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015 Nov-Dec;21(6):762-78. doi: 8. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014 Mar 1;89(5):341-6. Review. PubMed PMID: 24695505 9. Barassi, G., Bellomo, R. G., Porreca, A., Felice, P. A., Prosperi, L., & Saggini, R. (2018). Somato-Visceral Effects in the Treatment of Dysmenorrhea: Neuromuscular Manual Therapy and Standard Pharmacological Treatment. The Journal of Alternative and Complementary Medicine, 24(3), 291-299. doi:10.1089/acm.2017.0182