Painful Menstruation or Dysmenorrhea

Definition: Painful menstruation of sufficient magnitude so as to incapacitate day to day activities.

TYPES

Primary or Spasmodic Dysmenorrhea:

Menstrual pain associated with ovulatory cycles in the absence of pathologic findings

Patient profile: Onset is within 2 years of menarche; may become more severe with time; frequency of cases increase upto age 20 and then decreases with age

History/PE:

• Pain: begins a few hours before or just with onset of menstruation, may last for 1 or more days, spasmodic, lower abdomen, radiates to back and medial aspect of thigh
• Usually relieved following pregnancy
• Associated symptoms: Nausea/vomiting, diarrhea, fatigue, headache, flushing
• Pelvic examination: No pathologic findings

Causes of pain:

• Prostaglandin mediated: uterine vasoconstriction, anoxia and sustained contractions
• Psychogenic factors: stress, anxiety, low pain threshold of a person
• Uterine defects: stenosis, septate or bicornuate uterus, uterine hypoplasia, dyrhythmic contraction and autonomic dysfunction

Treatment:

A) Drugs (For 3-6 cycles):

NSAIDs (Prostaglandin Synthetase inhibitors + Analgesic):

1. Mefenamic Acid 250-500 mg TDS or Flufenamic acid 100-200 mg TDS
2. Ibuprofen 400 mg TDS or Naproxen 250 mg QID
3. Indomethacin 25 mg TDS

Oral Contraceptive Pills (OCP – suppresses ovulation):

1. Indications: Patients wanting contraception, heavy periods and unresponsive to PGI therapy.
2. Started on Day 5 of cycle for 20 days

B) Surgery:

1. Laparoscopy or USG: to exclude pelvic pathology (endometriosis)
2. Dilatation Of Cervical canal (loss of tone and injury to nerve ending)
3. If recurs: Laparoscopic Presacral neurectomy

Membranous dysmenorrhea: rare variety of primary dysmenorrheal caused due to deficiency of tryptic ferment

• Not relieved even following pregnancy

Secondary or Congestive Dysmenorrhea:

Mesntrual pain occurring in the presence of pelvic pathology

Caused of pain: pelvic congestion or increased vascularity in pelvic organs

Associated pelvic pathologies: Chronic PID, Pelvic endometriosis, Adenomyosis, Uterine fibroid, Endometrial polyp, IUCD

Patient profile: Onset after menarche; 30-40s

History/PE:

• Pain: 3-5 days prior to period, dull, back and front, no radiation, relieves by bleeding
• No systemic discomfort
• Symptoms of associate pelvic pathology
• Pelvic examination: Reveal offending lesion

Treatment: Of underlying cause

Causes of Unilateral Dysmenorrhea:

1. Ovarian Dysmenorrhea: continuous, dull pain in T10-L1 innervated area due to ovarian nerve degeneration (relieved by infundibulopelvic ligament division)
2. Right ovarian vein syndrome: Pelvic congestion → Engorgement of right ovarian vein → Pressure on ureter → Stasis → Infection → Pyelonephritis → Pain
3. Bicornuate uterus
4. Unilateral pelvic endometriosis
5. Fibroid polyp near one cornu
6. Colonic/Cecal spasm

MITTELSCHMERZ’S SYNDROME (OVULAR PAIN)

• Unilateral midmenstrual period pain (usually – doesn’t change from side to side according to which ovary is ovulating)
• May be associated with slight vaginal bleeding or excessive mucoid vaginal discharge
• Cause: Peritoneal irritation by follicular fluid following ovulation, Contraction of tubes and uterus, Increased tension in graafian follicle just prior to rupture
• Treatment: Assurance, Analgesics, OCPs

Note: Avoid using drugs without prescription

Sources:

• Textbook of Gynecology by D.C. Dutta
• First Aid for USMLE Step 2 CK