Dysmenorrhea is the medical term for painful menstrual periods, which is a common gynaecological condition that impacts women globally. It can be divided into primary and secondary dysmenorrhea.
Primary dysmenorrhea refers to lower abdominal pain during menstruation that is not associated with any underlying medical conditions. On the other hand, secondary dysmenorrhea is typically linked to other pelvic or uterine issues.
This column aims to delve deeper into the multifaceted aspects of dysmenorrhea, including its causes, diagnosis, evaluation and management, and highlighting the importance of an interprofessional approach in addressing primary dysmenorrhea and of promptly identifying and referring cases of secondary dysmenorrhea, as well as its overall impact on women’s health.
Key factors
The pain of dysmenorrhea is primarily caused by contractions in the uterus, which is a muscle. When the uterus contracts, it helps to shed the lining that has built up in preparation for pregnancy, which occurs every month along with ovulation.
This is a normal part of the menstrual cycle. The science behind these contractions and the associated pain involves several key factors, such as:
> Prostaglandins
These are hormone-like substances that trigger muscle contractions in the uterus, helping it to shed the built-up lining. Higher levels of prostaglandins are associated with more severe menstrual cramps. Prostaglandins can also cause symptoms such as nausea, diarrhoea and headaches.
> Hormonal changes
The menstrual cycle is regulated by hormones like oestrogen and progesterone. Fluctuations in these hormones can affect the severity of any menstrual cramps. For instance, in the days leading up to menstruation, oestrogen and progesterone levels fall, which prompts the release of prostaglandins.
> Uterine activity
Some women have a more active uterus, meaning that it contracts more vigorously. This can lead to more intense pain. The position of the uterus can also affect pain level. For example. a tilted uterus might result in more pressure and pain.
> Underlying gynaecological conditions
Secondary dysmenorrhea is caused by certain conditions like endometriosis, pelvic inflammatory disease, endometrial polyps, fibroids, membranous dysmenorrhea, and the presence of an intrauterine contraceptive device (IUCD).
These conditions can cause additional inflammation, scarring or anatomical changes that increase pain. Non-gynaecological causes such as irritable bowel syndrome, urinary tract Infections, interstitial cystitis, or musculoskeletal pain of the muscles or pelvic joints, can exacerbate pain in the pelvis.
> Psychological factors
The perception of pain varies from person to person. Factors like stress and psychological wellbeing can influence how intensely period pain is felt.
> Lifestyle factors
Diet, exercise and stress levels can also play a role in the severity of menstrual cramps. For example, a diet high in omega-3 fatty acids and low in animal fats may help reduce pain, and regular exercise can improve blood flow and reduce stress.
Some get it, some don’t
Dysmenorrhea can affect women regardless of their age or race. The frequency of dysmenorrhea varies widely, with the severity of the pain also ranging from mild to debilitating.
The condition can in turn, lead to other symptoms, including gastrointestinal discomfort, irritability, headache, anxiety, depression and back pain. These can all significantly impact women’s quality of life and lead to absenteeism from work or school.
To grasp the essence of dysmenorrhea, it’s important to understand its underlying mechanisms. In general, it is estimated that between 45% and 95% of menstruating women experience some degree of menstrual pain during their reproductive years. However, the severity of pain and its impact on daily activities can vary widely among individuals.
Primary dysmenorrhea is mainly attributed to the excessive production of prostaglandins in the uterine lining, leading to increased uterine contractions and subsequent pain during menstruation. Secondary dysmenorrhea, on the other hand, results from underlying conditions, both gynaecological and non-gynaecological in nature.
Several studies globally have also documented menstrual changes, such as heavier menses, menstrual irregularities and dysmenorrhea, after a Covid-19 infection or vaccination. Research is still ongoing into this issue, but meanwhile, healthcare providers and women should be aware that Covid-19 or the related vaccines might be a factor in their menstrual issues.
Diagnosis to prognosis
Diagnosing dysmenorrhea begins with a thorough history and physical examination. Primary dysmenorrhea typically presents with a normal physical examination. Secondary dysmenorrhea may exhibit specific signs and symptoms, such as abnormal bleeding or pelvic masses, which can aid in its diagnosis.
While the diagnostic process for primary dysmenorrhea mainly relies on the patient’s medical history and physical examination, secondary dysmenorrhea necessitates further investigation. These may include ultrasound, pregnancy tests, swabs for sexually-transmitted infections, cervical cytology samples, and in some cases, more advanced imaging techniques like magnetic resonance imaging (MRI) or laparoscopy.
Managing dysmenorrhea often involves a combination of pharmacological and non-pharmacological treatments. Common pharmacological treatments include non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs).
Non-pharmacological approaches such as exercise, heat therapy and dietary modifications can also be beneficial. It’s worth noting that the effectiveness of alternative treatments like acupuncture remains inconclusive. With appropriate treatment, primary dysmenorrhea generally has a positive outcome.
Mild to moderate dysmenorrhea usually responds well to NSAIDs. Severe dysmenorrhea may still respond to NSAIDs, but might require higher doses or combination/adjuvant therapies. In cases of persistent dysmenorrhea, further investigations are needed to identify and address the underlying cause.
In primary dysmenorrhoa, optimising one’s nutrition with supplements and balancing the hormones can sometimes reduce painful menses significantly. The outcome for secondary dysmenorrhea depends on the type, location and severity of the underlying condition.
Addressing the patient’s needs
Primary dysmenorrhea typically does not lead to complications. It is generally characterised by the intensity of pain affecting a woman’s wellbeing and daily activities. Secondary dysmenorrhea, on the other hand, may lead to complications that can include infertility, pelvic organ prolapse, heavy bleeding and anaemia, depending on the underlying cause.
Educating women about the importance of balanced nutrition, taking vitamins such as B complex and mineral supplements such as magnesium, regular physical activity, and the use of proper painkillers, can help reduce the severity of dysmenorrhea.
Awareness and timely follow-up with healthcare providers are essential for effective management. An interprofessional approach to managing dysmenorrhea is vital. This involves various healthcare professionals working together to address the patient’s needs and provide appropriate treatment, allowing them to maintain their daily activities.
In summary, understanding dysmenorrhea requires a comprehensive exploration of its causes, diagnosis and treatment options. Both pharmacological and non-pharmacological approaches can be effective in managing this common gynaecological concern.
Additionally, early diagnosis and intervention play a crucial role in improving the quality of life for individuals experiencing dysmenorrhea.
By Datuk Dr Nor Ashikin Mokhtar
Published in Star Newspaper, 22 Jan 2024
