CHAPTER 90
Dysmenorrhea
(Menstrual Cramps)
Presentation
A young woman or female adolescent complains of crampy labor-like pains that began shortly before or at the onset of the visible bleeding of her menstrual period. The pain is focused in the lower abdomen, low back, suprapubic area, or thighs and may be associated with nausea, vomiting, increased defecation, headache, muscular cramps, or passage of clots. The pain is most severe on the first day of the menses and may last from several hours to 3 days. Often, this is a recurrent problem, dating back to the first year after menarche. Rectal, vaginal, and pelvic examinations disclose no abnormalities.
What To Do:
Ask about the duration of symptoms and onset of similar episodes; onset of dysmenorrhea after adolescence or pain that is not limited to the time of the menstrual period suggests other pelvic disease. Ask about appetite, diarrhea, dysuria, dyspareunia, abnormal vaginal discharge, and other symptoms suggestive of pelvic disease.
Perform a thorough abdominal and speculum and bimanual pelvic examination, looking for signs of infection, pregnancy, or uterine or adnexal disease. Perform cultures or other diagnostic tests to rule out sexually transmitted diseases (STDs) in sexually active patients. It is appropriate to perform only an abdominal examination and forgo the pelvic examination in young adolescents with a typical history and who truly have never been sexually active.
Confirm that the patient is not pregnant, using a urine pregnancy test (or serum beta human chorionic gonadotropin [hCG], if available).
When the history and physical examination suggest other pelvic disease, the evaluation should follow accordingly, usually with pelvic ultrasonography as the initial diagnostic test to rule out anatomic abnormalities, such as mass lesions.
For uncomplicated dysmenorrhea, nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal therapy are the mainstays of treatment. If one of these agents fails after 2 to 3 months, then consider the other.
Try NSAIDs, such as ibuprofen (Motrin), 600 mg every 6 hours or 800 mg every 8 hours, or a fenamate, such as mefenamic acid (Ponstel) 500 mg load and 250 mg every 6 hours for 3 days (expensive), or naproxen (Naprosyn), 500 mg every 12 hours. NSAIDs may be most effective when therapy is started before the onset of menstrual pain and flow. Therapy need not be continued after the end of the flow.
If hormonal contraception is desired, monophasic oral contraceptive pills (OCPs) and depo-medroxyprogesterone acetate (Depo-Provera) may be considered. Extended oral contraceptive formulations (i.e., usually taking OCPs for 12 weeks followed by 1 week off) leads to less frequent menstrual periods and is associated with less menstrual pain than the monthly regimen. Both, however, are effective. A disadvantage to the longer regimen is unscheduled spotting that occurs, causing some women to discontinue use; this, however, does decrease over time.
Use of the transdermal contraceptive patch in a randomized trial found dysmenorrhea more common in patch users than in oral users. Vaginal rings and intrauterine devices (IUDs) have shown variable results on dysmenorrhea symptoms. Implanted contraception has not been well studied for this issue. At this time, oral contraception appears to be the most efficacious agent for dysmenorrhea symptoms.
In women who do not desire hormonal contraception, use of topical heat appears to be as effective as oral analgesics. Systematic reviews found that exercise appears to reduce menstrual symptoms, and behavior modification with biofeedback, electromyographic training, Lamaze exercises, and relaxation training helped some women.
Limited data demonstrate some promise in the following:
Thiamine at a dosage of 100 mg daily
The Japanese herbal remedy toki-shakuyaku-san (TSS)
Vitamin E (500 IU per day or 200 IU twice a day) taken daily for 5 days, starting 2 days before menstruation each month (maximum effect may not be reached until 4 months of use; alternatively, start use 2 days before and continue for 3 days after onset of menses)
Fish oil supplement containing 1080 mg of eicosapentaenoic acid (EPA) and 720 mg of docosahexaenoic acid (DHA) taken daily. All these supplements are relatively simple and inexpensive alternatives that can be used alone or in combination.
Acupuncture and acupressure have been shown to be effective in treating dysmenorrhea.
If pain is not controlled with any of these approaches, pelvic ultrasonography should be performed, and gynecologic referral should be arranged for the workup of endometriosis or other secondary causes of dysmenorrhea.
What Not To Do:
Do not recommend spinal manipulation for pain relief. There is reasonable evidence that it is ineffective.
Do not use NSAIDs if the patient wants to get pregnant; NSAIDs have been linked to reduced ovulation. If the patient is trying to get pregnant, use of these agents should be avoided when possible.
Do not continue the use of NSAIDs and oral contraceptives without further gynecologic evaluation, if the patient’s symptoms persist for more than three cycles.
Discussion
Menstrual cramps affect more than half of all menstruating women, with 10% to 15% suffering enough pain to miss work, school, or home activities. It is most common during the late teens and 20s. Overproduction of prostaglandins E and F and leukotrienes in menstrual blood appears to stimulate uterine contractions and thus results in many of the symptoms of dysmenorrhea, including cramps, nausea, vomiting, bloating, and headaches. Vasopressin also may play a role by increasing uterine contractility and causing ischemic pain as a result of vasoconstriction. Risk factors for dysmenorrhea include nulliparity, heavy menstrual flow, smoking, and depression.
Most dysmenorrhea in adolescents is primary (or functional), associated with normal ovulatory cycle, with no pelvic disease, and has a clear physiologic cause.
Empirical therapy can be initiated based on a typical history of painful menses and a negative physical examination. Nonsteroidal anti-inflammatory drugs are the initial therapy of choice in patients with presumptive primary dysmenorrhea. There is no clear-cut advantage of one NSAID versus another in the treatment of dysmenorrhea. Therefore agent selection should be guided by cost, convenience, and patient preference, with ibuprofen or naproxen being good choices for most patients. Treatment with NSAIDs is most effective when initiated 1 to 2 days before the onset of menses. An adolescent who cannot predict the start of her period should be instructed to start NSAID treatment as soon as menstrual bleeding starts, or as soon as she has any menstruation-associated symptoms.
In the nonmenstruating adolescent with cyclic pain, a complete exam should be performed to evaluate for an anatomic abnormality, such as transverse vaginal septum, imperforate hymen, or noncommunicating uterine horn.
Dysmenorrhea that does not respond either to NSAIDs, administered for at least three menstrual periods, or to a combination estrogen and progestogen pill or other alternative therapies, administered for at least three ensuing menstrual cycles, should raise suspicion of secondary dysmenorrhea, and diagnostic laparoscopy should be suggested.
Primary dysmenorrhea often improves after childbirth.
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