Dysmenorrhoea

Introduction
Greek words :dys difficult / painful / abnormal
meno month
rrhea flow
One of the most common gynaecological conditions that
affect the quality of life of many women in their
reproductive years
1. Primary dysmenorrhoea Absence of any underlying
uterine condition
2. Secondary dysmenorrhoea pelvic pathology is present.
Pain - an unpleasant sensory and emotional experience associated
with actual or potential tissue damage.
Pathophysiology of primary
dysmenorrhoea
Multifactorial
Several theories - Three main categories
1. Uterine contraction and vasoconstriction
Strongest scientific basis
Increased prostaglandin F2, leukotrienes, vasopressin and
reduction in prostacyclin
Uterine contractions and reduced blood flow
2. Modulation and stimulation of pain fibres
Type C pain neurons are stimulated by the anaerobic
metabolites generated by an ischaemic endometrium
Leukotrienes - increase the sensitivity of pain fibres
3. Behavioural and psychological factors
Mostly - Combination of these mechanisms
Pathophysiology of secondary
dysmenorrhoea
Common causes
1. Endometriosis
Most common cause
No correlation between disease severity and the severity of pain
the exact
2. Chronic pelvic inflammatory disease
3. Adenomyosis
4. Intrauterine polyps
5. Sub mucosal fibroids
6. Intrauterine contraceptive devices
Less common causes of secondary
dysmenorrhoea
Allen-Masters syndrome (scarring secondary to
laceration of the broad ligaments, usually during
childbirth),
Congenital uterine abnormalities
Cervical stenosis
Asherman syndrome
Uterine retroversion
Pelvic congestion syndrome
Ovarian cysts and tumours
Clinical presentation
Primary dysmenorrhoea
Typically presents 612 months after menarche
Pain is cramping in nature
Lower abdomen or pelvis but may radiate to the back or down the
thighs.
It may commence before the onset of bleeding
Usually lasts 872 hours.
Associated symptoms nausea, vomiting, fatigue and headache
Secondary dysmenorrhoea
Usually occurs a number of years after the menarche
Pain may occur throughout the luteal phase of the menstrual cycle
as well as during menstruation.
Deep dyspareunia
Examination
Primary dysmenorrhoea
Findings are usually normal

Secondary dysmenorrhoea
May be abnormal, reflecting the underlying disease
Vaginal discharge
Pelvic tenderness (uterus, adenexae, POD)
Enlarged uterus, uterine mass
Adenexal mass
Investigations
If history and examination findings are suggestive of
primary dysmenorrhoea, further investigations are rarely
warranted

Further investigations are needed if,

Atypical symptoms
Abnormal examination findings
If a trial of therapy in suspected primary dysmenorrhoea is
unsuccessful
Investigations
1. Pelvic ultrasound (abdominal + TVS)
2. Laparoscopy
(35% of laparoscopies for pelvic pain or suspected secondary
dysmenorrhoea were negative)
Gold standard for the diagnosis of endometriosis and PID

3. Hysteroscopy
4. CT or MRI for selected cases
5. WCC, CRP
6. Endocervical & vaginal swab cultures
7. CA 125
Treatment
Primary dysmenorrhoea
Treatments are predominantly based on the three main theories
of aetiology

Secondary dysmenorrhoea
Treatment of the underlying disease

A preferred approach is to individualize therapy based on a

womans concomitant symptoms (menorrhagia), age and
need for contraception.
Targeting uterine contraction and
vasoconstriction
Non-steroidal anti-inflammatory drugs (NSAIDs)
Act by blocking prostaglandin production
NSAIDs are significantly more effective for pain relief than
placebo (Cochrane review)
No evidence to suggest a greater benefit of any specific
NSAID
Adverse effects gastric reflux
Targeting uterine contraction and
vasoconstriction
Oral contraceptive pill
Combination of ovulation inhibition and reduced
prostaglandin production by endometrial glands
Long been held to be a successful treatment for
dysmenorrhoea
(A recent Cochrane review concluded that there is limited
evidence for improvement of symptoms)
Added benefit of contraception
Adverse effects weight gain, venous thromboembolism
and cardiovascular effects
Levonorgestrel-releasing intrauterine
system
Used for both contraception and as a treatment for
menstrual disorders
Effects on menstruation atrophy of endometrial glands
Reductions in dysmenorrhoea have been reported as
secondary outcomes in other trials
Effective in the treatment of secondary dysmenorrhoea
associated with endometriosis and adenomyosis
Can be used in women in whom estrogen is
contraindicated
 Other medical treatments
Calcium channel blockers
Glyceryl trinitrate
Still under evaluation

Many women do respond to medical therapy

But, there is an overall failure rate of 2025%.
Targeting pain pathways
Surgical interruption of visceral pain pathways in women
with failed medical therapy
Two main surgical techniques
1. Uterosacral nerve ablation
Uterosacral ligaments are transected, causing interruption to the
visceral afferent nerves from the pelvis

2. Presacral neurectomy
Presacral plexus of visceral nerves is removed
Both procedures can be carried out laparoscopically
Targeting pain pathways
A Cochrane review found only limited evidence to
support this approach
Uterosacral nerve ablation was not associated with any
improvement of pain in the short term
Some evidence of improvement in pain in the long term (more
than 12 months post-procedure)
Slightly improved results with presacral neurectomy
But more frequent adverse effects constipation, urinary
urgency and painless labour
Laparoscopic uterosacral nerve ablation (LUNA)
No significant difference in pain scores
The multimodal approach to pain
management
High frequency transcutaneous electrical nerve
stimulation (TENS)
Shown to be effective in treating dysmenorrhoea in a small
number of trials
4260% of women at least moderate relief
Dietary therapy
Vitamin B1 (taken at a dose of 100 mg daily)
Magnesium
May be of benefit
Acupuncture
Chinese herbal medicine
Some evidence exists, but trials are often small
Behavioural therapies

Relaxation training
Biofeedback techniques
Pain management sessions,
Some evidence of efficacy (Cochrane review)
But trials were small and of variable methodological quality
Other therapies
Cervical dilatation and ventrosuspension
Their role in management has been discredited
Now rarely used
Hysterectomy
Used occasionally as a treatment for refractory dysmenorrhoea
The evidence base limited
May be warranted in women with severe symptoms where other
therapies have failed
Who have coexisting symptoms such as menorrhagia
Who have completed their family