- Email: [email protected]
Dysmenorrhoea
MENSTRUAL PROBLEMS
Dysmenorrhoea Manish Gupta Kirsten Duckitt
Dysmenorrhoea can be defined as cyclical lower abdominal or pelvic pain, which may radiate to the back or thighs, occurring before and/or during menstruation. More literally, it means painful or difficult monthly flow. Dysmenorrhoea is usually classified as primary or secondary. • Primary dysmenorrhoea occurs in the absence of any obvious underlying disease. • Secondary dysmenorrhoea is usually due to underlying pathology (Figure 1). Dysmenorrhoea is a common complaint amongst women, affecting 40–70% of women of reproductive age. By the time a woman visits a health-care professional it may have disrupted her life considerably; some studies suggest that up to 45% of young women have missed time at work or school due to dysmenorrhoea.
Secondary dysmenorrhoea The above factors are also implicated in the pathogenesis of secondary dysmenorrhoea. However, the link is less clear, and treatments for primary dysmenorrhoea are less likely to work in secondary dysmenorrhoea.
History and examination Assessment of severity and lifestyle disruption: the first step in the management of dysmenorrhoea for the primary care physician is to listen. How is the dysmenorrhoea affecting the woman's lifestyle? Are there underlying psychological issues that have prompted the consultation? Often reassurance and explanation will be all that is required. It is important to ask about self-medication as many women with dysmenorrhoea will buy over-the-counter drugs. A brief enquiry will also help to establish the severity of the problem and/or whether the self-medication has helped at all.
Pathogenesis Primary dysmenorrhoea The cause of primary dysmenorrhoea is uncertain but a number of factors have been implicated. Uterine hyperactivity – the pain of dysmenorrhoea is often described as ‘labour’ or contraction-like. There is some evidence to suggest that that there is an increase in uterine activity and increased uterine contractility. At a cellular level, patients with dysmenorrhoea show smooth muscle hyperplasia, which adds credence to the theory of uterine hyperactivity. Prostaglandins – women with dysmenorrhoea have increased levels of PGF2α and PGE2. The prostaglandins act as oxytocics on the uterus and may cause pain. Vasopressin is a vasoconstrictor that also stimulates uterine contractility. This increase in uterine contractility maybe responsible for the pain of dysmenorrhoea.
Primary dysmenorrhoea usually starts within 6–12 months of the menarche, when ovulatory cycles are being established. Women complain of lower abdominal or pelvic pain, which can radiate to the back and thighs, before or during menstruation. It can last from 8 to 72 hours. There does not seem to be excessive bleeding.
Causes of secondary dysmenorrhoea • • • • • • • •
Manish Gupta is a Specialist Registrar in Obstetrics and Gynaecology. He graduated from St. Mary’s Hospital, London and the University of Bristol, and has trained in London and at King George V Memorial Hospital in Sydney. Kirsten Duckitt is an Obstetrician and Gynaecologist currently practising in Northern British Columbia, Canada. She qualified from Cambridge University and UCH/ Middlesex Hospital, London. Until October 2004 she was a Consultant Obstetrician at the John Radcliffe Hospital, Oxford. Her interests include guideline development and systematic reviews.
WOMEN’S HEALTH MEDICINE 2:3
Endometriosis Fibroids Adenomyosis Endometrial polyps Pelvic inflammatory disease Ovarian pathology Intrauterine contraceptive device Cervical stenosis (rare)
1
10
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
There may be associated symptoms, such as: • headache • nausea • vomiting • diarrhoea. On examination there are no abnormal findings.
Randomized trials of pain relief for dysmenorrhoea
% pain relief with analgesic
100
Secondary dysmenorrhoea usually has a later age of onset and may be a new symptom even in the fourth or fifth decade. Although the woman may have had painful periods before, she will often complain that the pain has changed or is different in character from her usual pain. She may often complain of other gynaecological symptoms (e.g. dyspareunia, intermenstrual bleeding, postcoital bleeding, menorrhagia) as well as the other nonspecific symptoms mentioned above. • There may be a history of vaginal discharge or infertility, suggesting pelvic inflammatory disease or endometriosis. • On examination, the uterus may be bulky and enlarged and tender to palpate due to fibroids or adenomyosis. • There may be tenderness over the uterosacral ligaments indicating endometriosis (Figure 2). • There may be an adnexal mass, indicating ovarian or tubal pathology. • She may have had an intrauterine contraceptive device fitted recently. However, the absence of abnormal findings does not mean that pathology is not present. It is always important to take a full gastrointestinal history, especially a history of constipation, loose stools, bloating and the passing of mucus per rectum. There is a known association of dysmenorrhoea with irritable bowel syndrome.1 Treating irritable bowel syndrome may also treat the dysmenorrhoea and avoid unnecessary investigation and inappropriate treatments such as laparoscopy.
75
50
Naproxen Ibuprofen 25
Mefenamic acid Aspirin
0 0
25
50
75
100
% pain relief with placebo 3
Investigations Primary dysmenorrhoea: in a woman with primary dysmenorrhoea, no investigation is usually necessary but testing for chlamydia would be prudent, especially in young, sexually active women. Secondary dysmenorrhoea: in women with secondary dysmenorrhoea, investigations should be directed at finding the cause of the pain. • A pelvic ultrasound is necessary to look for fibroids, polyps or other pelvic pathology. • Swabs should be taken for chlamydia (an important cause of pelvic inflammatory disease). • If there is a strong suspicion of endometriosis, a laparoscopy may be required to provide a definitive diagnosis.
Treatment of primary dysmenorrhoea Non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice, especially for primary dysmenorrhoea.2 NSAIDs inhibit prostaglandin synthesis and probably work by decreasing uterine prostaglandin levels and therefore decreasing uterine contractility. All NSAIDs are effective (see Figure 3) and can reduce pain by up to 70%. One systematic review found that aspirin was significantly more effective than placebo for pain relief but not as effective as ibuprofen, naproxen and mefenamic acid.3 The number needed to treat for aspirin was 10 but only 2–3 for other NSAIDs (see Figure 4). Naproxen and ibuprofen were significantly better in terms of the need for rescue analgesia than aspirin or mefenamic acid. Starting treatment premenstrually (rather than at the onset of pain) does not confer additional benefit. Gastrointestinal toxicity is a concern with NSAIDs. It is important to ask about risk factors for NSAID-induced ulceration (Figure 5), and if any are present a protective agent should be prescribed.4
2 Endometriosis can cause dysmenorrhoea. This woman has typical dark deposits (haemosiderin from entrapped menstrual debris) on the right uterosacral ligament. White deposits are also common, but dark lesions are more likely to be associated with pain, probably because they produce prostaglandin F2α. (Courtesy of www.endogyn.com)
WOMEN’S HEALTH MEDICINE 2:3
Other analgesics may be used if NSAIDS are contraindicated. Paracetamol and co-proxamol are effective treatments for dysmenorrhoea but have a variable efficacy. In one trial, paracetamol 11
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
Effectiveness of analgesics for pain relief of primary dysmenorrhoea1 Analgesic
No. of trials
No. of patients
% Improved with analgesic
% Improved with placebo
Relative benefit (95% CI)
NNT (95% CI)
Naproxen
13
1706
59
17
3.4 (2.9 to 4.0)
2.4 (2.2 to 2.7)
Ibuprofen
9
599
70
31
2.2 (1.9 to 2.7)
2.6 (2.2 to 3.2)
Mefenamic acid
3
518
64
31
2.1 (1.7 to 2.6)
3.0 (2.4 to 4.0)
Aspirin
5
416
29
18
1.6 (1.1 to 2.2)
9.2 (5.3 to 35)
Data from Zhang and Wan Po.
1
Reproduced with permission from http://www.jr2.ox.ac.uk/bandolier
4
Locally applied heat (e.g. a hot-water bottle) seems to be effective, especially when combined with ibuprofen.9
was as effective as ibuprofen and in two randomized controlled trials of 98 patients there was no difference between co-proxamol and naproxen.5
Acupuncture: some patients may benefit from acupuncture, which in one trial showed a significant benefit in terms of pain relief.8
The combined oral contraceptive (COC) pill is effective in reducing the pain of dysmenorrhoea. It induces endometrial thinning and inhibits ovulation, which reduces uterine prostaglandins. It may be particularly useful in those women who require contraception as well or have heavy periods. A Cochrane review of the efficacy of the COC pill in primary dysmenorrhoea found there was significantly improved pain relief when compared to placebo in some trials. However, when only randomized controlled trials were considered, they were found to be small and of poor quality and the results were therefore inconclusive.6 It may take three cycles for effects to be seen and ‘tricycling’ the COC pill (taking it consecutively for three cycles) may also help, as the woman has a painful period less often.
Laparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy have been tried for the treatment of dysmenorrhoea. Although two small studies have shown LUNA to be effective in the short term, the long-term effects are still uncertain. Presacral neurectomy may be effective for the treatment of dysmenorrhoea in the long term but is associated with more adverse effects such as constipation.10 Dietary supplements cannot be recommended at present, although in one randomized controlled trial vitamin B1 (100 mg daily) did show some benefit.11 Referral: if there is an inadequate response to first-line therapy (such as simple NSAIDs or the combined oral contraceptive pill) it may be best to refer to a hospital specialist (Figure 6).
The levonorgestrol-releasing intrauterine system has been shown to be beneficial in the treatment of dysmenorrhoea and should be considered in those women who require contraception and in whom menstrual flow is heavy.7 It is usually better for older multiparous women as it is easier to fit. Transcutaneous electrical nerve stimulation (TENS) may help to ease the pain of dysmenorrhoea. It works by altering the body’s ability to receive or perceive pain. Both high-frequency and lowfrequency TENS are more effective than placebo in randomized controlled trials, but there is insufficient evidence comparing the efficacy of the two.8
Risk factors for NSAID-induced ulceration • Previous history of gastroduodenal ulcer, gastrointestinal bleeding or perforation • Use of other medications known to increase the chance of gastrointestinal bleeding (e.g. steroids or warfarin) • Other serious comorbidity such as renal or hepatic impair ment • Prolonged use of maximum doses of NSAIDs Locally applied heat seems to be effective in easing the pain of dysmenorrhoea, especially when combined with ibuprofen.
5
WOMEN’S HEALTH MEDICINE 2:3
12
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
REFERENCES 1 Crowell M D, Dubin N H, Robinson J C et al. Functional bowel disorders in women with dysmenorrhoea. Am J Gastroenterol 1994; 89: 1973–7. 2 Marjoribanks J, Proctor M L, Farquhar C. Non-steroidal antiinflammatory drugs for primary dysmenorrhoea. (Cochrane review). In: The Cochrane library, Issue 3, 2004. 3 Zhang W Y, Li Wan Po A. Efficacy of minor analgesics in primary dysmenorrhoea: a systematic review. Br J Obstet Gynaecol 1998; 105: 780–9. 4 NICE Clinical Guideline 17. Dyspepsia: management of dyspepsia in adults in primary care. London: National Institute for Clinical Excellence, 2004. 5 Proctor M, Farquhar C. Dysmenorrhoea. Clin Evid 2002; 7: 1639–53. 6 Proctor M L, Roberts H, Farquhar C M. Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 7 Luukkainen T, Toivonen J. Levonorgestrol-releasing IUD as a method of contraception with therapeutic properties. Contraception 1995; 52: 269–76. 8 Proctor M L, Smith C A, Farquhar C M, Stones R W. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 9 Akin M D, Weingand K W, Hengehold D A et al. Continuous lowlevel topical heat in the treatment of dysmenorrhoea. Obstet Gynaecol 2001; 97: 343–9. 10 Proctor M L, Farquhar C M, Sinclair O J, Johnson N P. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 11 Proctor M L, Murphy P A. Herbal and dietary therapies for primary and secondary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004.
Dysmenorrhoea should be referred for further investigation when: • • • • •
it starts with the first menses it is associated with anovulatory cycles the pain is getting worse the pain is not relieved with standard analgesics pelvic pathology is suspected from the examination or investigations • there is a personal or family history of endometriosis 6
Treatment of secondary dysmenorrhoea The treatment for secondary dysmenorrhoea concentrates on treating the underlying cause. • If an endometrial polyp or submucous fibroid is present it is best to resect these hysteroscopically. • An intrauterine contraceptive device is best removed. The levonorgestrol-releasing intrauterine device may be used if an intrauterine device is still desired for contraception. As well as reducing menstrual flow there is some evidence that it reduces dysmenorrhoea. • Dysmenorrhoea caused by pelvic inflammatory disease or endometriosis is amenable to medical treatment as for primary dysmenorrhoea. Pelvic inflammatory disease, if suspected, should be treated with the appropriate antibiotics. In certain cases, progestogens, danazol and GnRH analogues may be used under specialist supervision to treat endometriosis. Laparoscopic surgery for endometriosis is effective in reducing the pain associated with endometriosis and may be useful in reducing the pain associated with adhesions due to pelvic inflammatory disease.
FURTHER READING O’Brien P M S, Cameron I, Maclean A. Disorders of the menstrual cycle. London: RCOG Press, 2002. (A fairly comprehensive book on everything you need to know about menstruation. Has large chapters on the basic science of menstruation and menstrual disorders.)
Learning points • Dysmenorrhoea is a common symptom presenting to both the primary care practitioner as well as the hospital specialist. • The economic burden worldwide is incalculable. • NSAIDS are the most effective treatment to date. • The combined oral contraceptive is also effective, especially if there are issues regarding contraception and menstrual flow. • Treating the underlying cause is necessary for secondary dysmenorrhoea. This will usually mean referral to a hospital gynaecologist.
WOMEN’S HEALTH MEDICINE 2:3
13
© 2005 The Medicine Publishing Company Ltd
Dysmenorrhoea Manish Gupta Kirsten Duckitt
Dysmenorrhoea can be defined as cyclical lower abdominal or pelvic pain, which may radiate to the back or thighs, occurring before and/or during menstruation. More literally, it means painful or difficult monthly flow. Dysmenorrhoea is usually classified as primary or secondary. • Primary dysmenorrhoea occurs in the absence of any obvious underlying disease. • Secondary dysmenorrhoea is usually due to underlying pathology (Figure 1). Dysmenorrhoea is a common complaint amongst women, affecting 40–70% of women of reproductive age. By the time a woman visits a health-care professional it may have disrupted her life considerably; some studies suggest that up to 45% of young women have missed time at work or school due to dysmenorrhoea.
Secondary dysmenorrhoea The above factors are also implicated in the pathogenesis of secondary dysmenorrhoea. However, the link is less clear, and treatments for primary dysmenorrhoea are less likely to work in secondary dysmenorrhoea.
History and examination Assessment of severity and lifestyle disruption: the first step in the management of dysmenorrhoea for the primary care physician is to listen. How is the dysmenorrhoea affecting the woman's lifestyle? Are there underlying psychological issues that have prompted the consultation? Often reassurance and explanation will be all that is required. It is important to ask about self-medication as many women with dysmenorrhoea will buy over-the-counter drugs. A brief enquiry will also help to establish the severity of the problem and/or whether the self-medication has helped at all.
Pathogenesis Primary dysmenorrhoea The cause of primary dysmenorrhoea is uncertain but a number of factors have been implicated. Uterine hyperactivity – the pain of dysmenorrhoea is often described as ‘labour’ or contraction-like. There is some evidence to suggest that that there is an increase in uterine activity and increased uterine contractility. At a cellular level, patients with dysmenorrhoea show smooth muscle hyperplasia, which adds credence to the theory of uterine hyperactivity. Prostaglandins – women with dysmenorrhoea have increased levels of PGF2α and PGE2. The prostaglandins act as oxytocics on the uterus and may cause pain. Vasopressin is a vasoconstrictor that also stimulates uterine contractility. This increase in uterine contractility maybe responsible for the pain of dysmenorrhoea.
Primary dysmenorrhoea usually starts within 6–12 months of the menarche, when ovulatory cycles are being established. Women complain of lower abdominal or pelvic pain, which can radiate to the back and thighs, before or during menstruation. It can last from 8 to 72 hours. There does not seem to be excessive bleeding.
Causes of secondary dysmenorrhoea • • • • • • • •
Manish Gupta is a Specialist Registrar in Obstetrics and Gynaecology. He graduated from St. Mary’s Hospital, London and the University of Bristol, and has trained in London and at King George V Memorial Hospital in Sydney. Kirsten Duckitt is an Obstetrician and Gynaecologist currently practising in Northern British Columbia, Canada. She qualified from Cambridge University and UCH/ Middlesex Hospital, London. Until October 2004 she was a Consultant Obstetrician at the John Radcliffe Hospital, Oxford. Her interests include guideline development and systematic reviews.
WOMEN’S HEALTH MEDICINE 2:3
Endometriosis Fibroids Adenomyosis Endometrial polyps Pelvic inflammatory disease Ovarian pathology Intrauterine contraceptive device Cervical stenosis (rare)
1
10
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
There may be associated symptoms, such as: • headache • nausea • vomiting • diarrhoea. On examination there are no abnormal findings.
Randomized trials of pain relief for dysmenorrhoea
% pain relief with analgesic
100
Secondary dysmenorrhoea usually has a later age of onset and may be a new symptom even in the fourth or fifth decade. Although the woman may have had painful periods before, she will often complain that the pain has changed or is different in character from her usual pain. She may often complain of other gynaecological symptoms (e.g. dyspareunia, intermenstrual bleeding, postcoital bleeding, menorrhagia) as well as the other nonspecific symptoms mentioned above. • There may be a history of vaginal discharge or infertility, suggesting pelvic inflammatory disease or endometriosis. • On examination, the uterus may be bulky and enlarged and tender to palpate due to fibroids or adenomyosis. • There may be tenderness over the uterosacral ligaments indicating endometriosis (Figure 2). • There may be an adnexal mass, indicating ovarian or tubal pathology. • She may have had an intrauterine contraceptive device fitted recently. However, the absence of abnormal findings does not mean that pathology is not present. It is always important to take a full gastrointestinal history, especially a history of constipation, loose stools, bloating and the passing of mucus per rectum. There is a known association of dysmenorrhoea with irritable bowel syndrome.1 Treating irritable bowel syndrome may also treat the dysmenorrhoea and avoid unnecessary investigation and inappropriate treatments such as laparoscopy.
75
50
Naproxen Ibuprofen 25
Mefenamic acid Aspirin
0 0
25
50
75
100
% pain relief with placebo 3
Investigations Primary dysmenorrhoea: in a woman with primary dysmenorrhoea, no investigation is usually necessary but testing for chlamydia would be prudent, especially in young, sexually active women. Secondary dysmenorrhoea: in women with secondary dysmenorrhoea, investigations should be directed at finding the cause of the pain. • A pelvic ultrasound is necessary to look for fibroids, polyps or other pelvic pathology. • Swabs should be taken for chlamydia (an important cause of pelvic inflammatory disease). • If there is a strong suspicion of endometriosis, a laparoscopy may be required to provide a definitive diagnosis.
Treatment of primary dysmenorrhoea Non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs of choice, especially for primary dysmenorrhoea.2 NSAIDs inhibit prostaglandin synthesis and probably work by decreasing uterine prostaglandin levels and therefore decreasing uterine contractility. All NSAIDs are effective (see Figure 3) and can reduce pain by up to 70%. One systematic review found that aspirin was significantly more effective than placebo for pain relief but not as effective as ibuprofen, naproxen and mefenamic acid.3 The number needed to treat for aspirin was 10 but only 2–3 for other NSAIDs (see Figure 4). Naproxen and ibuprofen were significantly better in terms of the need for rescue analgesia than aspirin or mefenamic acid. Starting treatment premenstrually (rather than at the onset of pain) does not confer additional benefit. Gastrointestinal toxicity is a concern with NSAIDs. It is important to ask about risk factors for NSAID-induced ulceration (Figure 5), and if any are present a protective agent should be prescribed.4
2 Endometriosis can cause dysmenorrhoea. This woman has typical dark deposits (haemosiderin from entrapped menstrual debris) on the right uterosacral ligament. White deposits are also common, but dark lesions are more likely to be associated with pain, probably because they produce prostaglandin F2α. (Courtesy of www.endogyn.com)
WOMEN’S HEALTH MEDICINE 2:3
Other analgesics may be used if NSAIDS are contraindicated. Paracetamol and co-proxamol are effective treatments for dysmenorrhoea but have a variable efficacy. In one trial, paracetamol 11
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
Effectiveness of analgesics for pain relief of primary dysmenorrhoea1 Analgesic
No. of trials
No. of patients
% Improved with analgesic
% Improved with placebo
Relative benefit (95% CI)
NNT (95% CI)
Naproxen
13
1706
59
17
3.4 (2.9 to 4.0)
2.4 (2.2 to 2.7)
Ibuprofen
9
599
70
31
2.2 (1.9 to 2.7)
2.6 (2.2 to 3.2)
Mefenamic acid
3
518
64
31
2.1 (1.7 to 2.6)
3.0 (2.4 to 4.0)
Aspirin
5
416
29
18
1.6 (1.1 to 2.2)
9.2 (5.3 to 35)
Data from Zhang and Wan Po.
1
Reproduced with permission from http://www.jr2.ox.ac.uk/bandolier
4
Locally applied heat (e.g. a hot-water bottle) seems to be effective, especially when combined with ibuprofen.9
was as effective as ibuprofen and in two randomized controlled trials of 98 patients there was no difference between co-proxamol and naproxen.5
Acupuncture: some patients may benefit from acupuncture, which in one trial showed a significant benefit in terms of pain relief.8
The combined oral contraceptive (COC) pill is effective in reducing the pain of dysmenorrhoea. It induces endometrial thinning and inhibits ovulation, which reduces uterine prostaglandins. It may be particularly useful in those women who require contraception as well or have heavy periods. A Cochrane review of the efficacy of the COC pill in primary dysmenorrhoea found there was significantly improved pain relief when compared to placebo in some trials. However, when only randomized controlled trials were considered, they were found to be small and of poor quality and the results were therefore inconclusive.6 It may take three cycles for effects to be seen and ‘tricycling’ the COC pill (taking it consecutively for three cycles) may also help, as the woman has a painful period less often.
Laparoscopic uterine nerve ablation (LUNA) and laparoscopic presacral neurectomy have been tried for the treatment of dysmenorrhoea. Although two small studies have shown LUNA to be effective in the short term, the long-term effects are still uncertain. Presacral neurectomy may be effective for the treatment of dysmenorrhoea in the long term but is associated with more adverse effects such as constipation.10 Dietary supplements cannot be recommended at present, although in one randomized controlled trial vitamin B1 (100 mg daily) did show some benefit.11 Referral: if there is an inadequate response to first-line therapy (such as simple NSAIDs or the combined oral contraceptive pill) it may be best to refer to a hospital specialist (Figure 6).
The levonorgestrol-releasing intrauterine system has been shown to be beneficial in the treatment of dysmenorrhoea and should be considered in those women who require contraception and in whom menstrual flow is heavy.7 It is usually better for older multiparous women as it is easier to fit. Transcutaneous electrical nerve stimulation (TENS) may help to ease the pain of dysmenorrhoea. It works by altering the body’s ability to receive or perceive pain. Both high-frequency and lowfrequency TENS are more effective than placebo in randomized controlled trials, but there is insufficient evidence comparing the efficacy of the two.8
Risk factors for NSAID-induced ulceration • Previous history of gastroduodenal ulcer, gastrointestinal bleeding or perforation • Use of other medications known to increase the chance of gastrointestinal bleeding (e.g. steroids or warfarin) • Other serious comorbidity such as renal or hepatic impair ment • Prolonged use of maximum doses of NSAIDs Locally applied heat seems to be effective in easing the pain of dysmenorrhoea, especially when combined with ibuprofen.
5
WOMEN’S HEALTH MEDICINE 2:3
12
© 2005 The Medicine Publishing Company Ltd
MENSTRUAL PROBLEMS
REFERENCES 1 Crowell M D, Dubin N H, Robinson J C et al. Functional bowel disorders in women with dysmenorrhoea. Am J Gastroenterol 1994; 89: 1973–7. 2 Marjoribanks J, Proctor M L, Farquhar C. Non-steroidal antiinflammatory drugs for primary dysmenorrhoea. (Cochrane review). In: The Cochrane library, Issue 3, 2004. 3 Zhang W Y, Li Wan Po A. Efficacy of minor analgesics in primary dysmenorrhoea: a systematic review. Br J Obstet Gynaecol 1998; 105: 780–9. 4 NICE Clinical Guideline 17. Dyspepsia: management of dyspepsia in adults in primary care. London: National Institute for Clinical Excellence, 2004. 5 Proctor M, Farquhar C. Dysmenorrhoea. Clin Evid 2002; 7: 1639–53. 6 Proctor M L, Roberts H, Farquhar C M. Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 7 Luukkainen T, Toivonen J. Levonorgestrol-releasing IUD as a method of contraception with therapeutic properties. Contraception 1995; 52: 269–76. 8 Proctor M L, Smith C A, Farquhar C M, Stones R W. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 9 Akin M D, Weingand K W, Hengehold D A et al. Continuous lowlevel topical heat in the treatment of dysmenorrhoea. Obstet Gynaecol 2001; 97: 343–9. 10 Proctor M L, Farquhar C M, Sinclair O J, Johnson N P. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004. 11 Proctor M L, Murphy P A. Herbal and dietary therapies for primary and secondary dysmenorrhoea (Cochrane review). In: The Cochrane library, Issue 3, 2004.
Dysmenorrhoea should be referred for further investigation when: • • • • •
it starts with the first menses it is associated with anovulatory cycles the pain is getting worse the pain is not relieved with standard analgesics pelvic pathology is suspected from the examination or investigations • there is a personal or family history of endometriosis 6
Treatment of secondary dysmenorrhoea The treatment for secondary dysmenorrhoea concentrates on treating the underlying cause. • If an endometrial polyp or submucous fibroid is present it is best to resect these hysteroscopically. • An intrauterine contraceptive device is best removed. The levonorgestrol-releasing intrauterine device may be used if an intrauterine device is still desired for contraception. As well as reducing menstrual flow there is some evidence that it reduces dysmenorrhoea. • Dysmenorrhoea caused by pelvic inflammatory disease or endometriosis is amenable to medical treatment as for primary dysmenorrhoea. Pelvic inflammatory disease, if suspected, should be treated with the appropriate antibiotics. In certain cases, progestogens, danazol and GnRH analogues may be used under specialist supervision to treat endometriosis. Laparoscopic surgery for endometriosis is effective in reducing the pain associated with endometriosis and may be useful in reducing the pain associated with adhesions due to pelvic inflammatory disease.
FURTHER READING O’Brien P M S, Cameron I, Maclean A. Disorders of the menstrual cycle. London: RCOG Press, 2002. (A fairly comprehensive book on everything you need to know about menstruation. Has large chapters on the basic science of menstruation and menstrual disorders.)
Learning points • Dysmenorrhoea is a common symptom presenting to both the primary care practitioner as well as the hospital specialist. • The economic burden worldwide is incalculable. • NSAIDS are the most effective treatment to date. • The combined oral contraceptive is also effective, especially if there are issues regarding contraception and menstrual flow. • Treating the underlying cause is necessary for secondary dysmenorrhoea. This will usually mean referral to a hospital gynaecologist.
WOMEN’S HEALTH MEDICINE 2:3
13
© 2005 The Medicine Publishing Company Ltd