Prevalence and effective treatment for Dysmenorrhea and menstrual cramp pain

Prevalence and effective treatment for Dysmenorrhea and menstrual cramp pain

Miya Chambley

Alabama A&M University

Literature Review

Dysmenorrhea or menstrual pain is the medical name given to pain during the menstrual cycle. To review the prevalence and treatments related to dysmenorrhea, the cause, and the type of medical condition need to be understood. In this study, the type, cause, and effective treatment for menstrual pain will be studied.

Dysmenorrhea:

Dysmenorrhea is the medical word used for pain attached to menstruation. Such pain is often caused by the contraction of the uterine and starts with the onset of menstruation and lasts for more or less three days (MY, 1990). Apart from the pain around the pelvic or abdomen region, there are other symptoms associated with it are diarrhea, nausea, and back pain.

Based on their origin, dysmenorrhea has been classified into two types, primary and secondary. Primary dysmenorrhea specifies the common menstrual pain, whereas secondary dysmenorrhea is caused by the disorder in the reproductive organs.

Primary Dysmenorrhea:

Primary dysmenorrhea refers to the pain that occurs in the lower abdomen just before or after the onset of menstruation. This type of dysmenorrhea is 90% common and typically occurs during adolescence. Women who experience such pain are reported to have an increased level of endometrial prostaglandin, which causes enhanced uterine tone, and stronger, frequent uterine contractions.

Prevalence of Primary dysmenorrhea:

Primary dysmenorrhea is the most commonly reported problem associated with menstruating women. This occurrence of such pain is so common that often it is not reported during the medical examination or interviews. (Yu, 2014) However, the informed prevalence of such pains is as high as 90%. According to a prospective study conducted on college students in one year, 72% of the observed periods were painful, mostly at the start of the menstruation cycle. The study also reported that 60% of the observed women experienced a period of severe pain.

Furthermore, primary dysmenorrhea was reported to be the primary factor behind absenteeism from school and work. A study conducted on women studying in college reported that almost 42% of subjects showed absenteeism or minimal activity once a month; however, the absentees reported ranged from 34 to 50%. (Harel, 2012) Furthermore, another study showed that primary dysmenorrhea was responsible for a loss of 600 million work hours and a 2$ billion dollar lost in productivity each year.

Factors Associated with Primary Dysmenorrhea:

The study showed that there are certain serious factors that have been linked with severe periods of dysmenorrhea, such as early age for menstruation, prolonged menstruation period, overweight, high alcohol consumption, and smoking. However, some studies have not found any substantial linkage between severe dysmenorrhea and obesity and alcohol consumption. Another report, which was conducted through a cross-sectional sample of 1,147 metropolitan adolescents, presented that trying to lose weight was connected with enhanced menstrual pains. Furthermore, no physical activity was found to be associated with increased pain.

There was inconsistent data to validate the view that dysmenorrhea diminished after child-birth. In one study (Sundell G, 1990) presented evidence of reduced prevalence and intensity of dysmenorrhea after parity, but other studies did not support the view. (MY, 1990) Provided that potential for decreasing dysmenorrhea might offer inspiration for women to implement healthy lifestyle changes, such as reduction or ceasing alcohol and smoking consumption.

Causes of Primary dysmenorrhea:

Though the causes of primary dysmenorrhea are not surely reported, the most common symptoms can be described by the action of uterine prostaglandins, also known as PGF. Throughout endometrial removal of dead cells, the degenerated endometrial cells discharge PGF, when menstruation begins. PGF after release stimulates the myometrial retrenchments, sensitization of nerve endings, and ischemia. Production of arachidonic acids and the path cyclooxygenase gets triggered by a drop in progesterone concentration near the end of the secretory phase (Iacovides, 2015). In the late secretory phase, the levels of PG are three times higher than in the proliferative phase. Moreover, during the menstrual phase, the level of PG is again observed to be higher than usual; this higher concentration of PGE2 and PGF2 are observed in women suffering from primary dysmenorrhea.

This theory has been strongly supported by the clinical data, achieved from women who experience severe dysmenorrhea. According to the report, women with severe dysmenorrhea have a higher level of PGF, specifically during the first two days of the menstrual cycle. There are some studies (Ortiz, 2010)which have associated increased levels of leukotrienes and vasopressin, but the connection is still not established.

Clinical Presentation and Diagnostic:

Primary dysmenorrhea usually occurs during the adolescences during the timespan of three years after the first menstruation. (Osayande, 2014) The dysmenorrhea symptoms usually do not start after the first three or six months of menarche. Women experiencing dysmenorrhea feel sharp, recurrent contractions of pain generally centered in the suprapubic area. The pain might be in the lower back or in legs. The fairly common symptoms associated with it are nausea, vomiting, lightheadedness, fever, and headache. The pain usually advances after a few hours of the start of the menstruation cycle and its intensity increases with the flow during the first or day two of the cycle.

Physical examination and thorough patient history are adequate to diagnose primary dysmenorrhea. The history shows the typical cramping pain associated with the menstrual cycle, and the physical examination is normal. The chances of secondary dysmenorrhea can be ruled out by inquiring about the age at which the menstrual cycle begins, the length of the cycle, the consistency and timing of the pain. Moreover, dysmenorrhea can be differentiated from Premenstrual Syndrome (PMS) by considering the patient's history. Since the pain associated with PMS is connected with breast tenderness and abdominal swelling, rather than lower abdominal pain.

The PMS symptoms can be observed before the starting of the menstrual cycle and settle shortly after the flow of menstrual begins. Moreover, the pain related to Endometriosis may seem as progressive dysmenorrhea, but it is often supplemented by pain felt during intercourse and might impact the fertility rate. Apart from the timing of the pain, a patient’s family history might also help in differentiating the endometriosis from primary dysmenorrhea.

Possible treatments for Primary dysmenorrhea:

The most commonly administered treatment that shows individual improvement in women suffering from primary dysmenorrhea is the NSAID treatment (Kaplan, 2013). Many studies point to a successful pain release in 64 to 100% of the patients. (Harel, 2012) These known drugs have a record of efficiency confirmed by numerous studies over the past 20 years. Another actual and well-studied choice for treatment, especially among women who want to control the birth process, is oral contraceptives. Studies have shown that oral contraceptive has proven to be an effective treatment for 90% of women suffering from primary dysmenorrhea (Dmitrovic R. K., 2012). There is another alternative, for 10% of the women who do not respond to such treatments, stretching from laparoscopic procedure to acupuncture, but the evidence to support both these treatments is insufficient.

Non-Steroidal Anti-Inflammatory Drugs:

The most commonly adopted and first choice for the treatment of primary dysmenorrhea is an NSAID. The medicines under this category work by inhibiting the production and discharge of prostaglandins. As stated earlier, prostaglandins are the source of painful uterine contractions and are known as a consistent symptom for primary dysmenorrhea, along with diarrhea and nausea. The choices under the category of NSAID are many, and no specific NSAID has been confirmed to be more effective than others in treating this particular condition. The response time for treatment with NSAID is noted to be 35 to 60 minutes. However, the response is subjective, and it is advised to use a different agent belonging to a different class if the ache is not relieved after the usage of the first agent.

NSAIDs have proven to be quite effective and are widely available without the use of prescription, but there are many women who are not developing an effective routine for the treatment. (Yu, 2014) The study pointed out that almost 25% of women experiencing primary dysmenorrhea administered less than the suggested dosage of medication, and 43% were not able to grasp the maximum daily frequency. It is advised that patients should be questioned about over the counter drugs, including the amount of the dosage, specifically from younger patients.

Oral Contraceptives:

Oral contraceptive is the second option for women suffering from primary dysmenorrhea, specifically for women who also wish to have birth control. The mechanism of oral contraceptives is totally different from that of NSAIDs. The system of oral contraceptives has been divided into two steps; in the first step, the menstrual fluid volume is reduced, and in the second step, the ovulation process is being suppressed. (Dmitrovic R. K., 2012) Studies have shown that such treatment for primary dysmenorrhea is 90% effective. (Pearlstein, 2012) Studies trying to prove the efficiency of triphasic preparations over the monophasic or on progesterone component have been found inadequate, and all oral contraceptive has been found effective parallel to the placebo.

The patients administered with oral contraceptives should be informed about the three-cycle it takes to diminish the pain. Furthermore, along with oral contraceptives, it is better to prescribe the NSAID for pain relief during the interim period. (Osayande, 2014) A study conducted on 308 pubescent females, with severe symptoms of primary dysmenorrhea, administered with oral contraceptives, were 8 times more likely to be a consistent user of such medications. It is believed that advising young women about the potential benefits of oral contraceptives might improve their motivation to fulfill daily medication. Moreover, the patients should be inquired about their medical history, specifically cardiovascular disease, hepatic, thrombosis, and current pregnancy status.

The combination of NSAID and oral contraceptive are considered an effective treatment, specifically for rebellious cases. Furthermore, electric nerve stimulation Units (TENS), laparoscopic presacral neurectomy, omega-3, transdermal nitroglycerine, and thiamine offer relief to primary dysmenorrhea, but the number of studies on these options was small and less followed up.

Alternative Medicine:

Though there is not sufficient data that support the usage of herbal or supplementary material to cure dysmenorrhea, these alternative methods are the first choice of many women experiencing the pain (Mirabi, 2014). The common ingredients or herbs used for treating the pain associated with dysmenorrhea are vitamin e, fennel, chamomile tea, cinnamon tea, rhubarb, and melatonin. The dietary supplements that are commonly administered to control the pain are zinc-sulfate, omega-3 capsules, and vitamin-B1. The research evidence for the safety of these supplements is insufficient, and further research is recommended. (Rahbar, 2012) The study suggests that thiamin, omega-3, and vitamin E are likely to be effective in curing the pain. Furthermore, Chinese Traditional Medicine (TMC) is another alternative method widely used in Asian countries. However, the evidence to support the administration of TMC was partial by poor methodological quality. (Liu, 2011)Cochrane review on acupuncture for treating primary dysmenorrhea concluded that the effectiveness of acupressure or acupuncture is unknown.

Secondary Dysmenorrhea:

Secondary dysmenorrhea discusses the painful menses that is caused by the pelvic pathology or documented medical condition. Endometriosis is one of the major causes of secondary dysmenorrhea in adolescent women and is mostly associated with patients who have a long history of persistent dysmenorrhea, despite being treated with NSAID or different hormonal agents.

Endometriosis as the main cause of Dysmenorrhea:

Endometriosis is defined as an estrogen-dependent inciting disease described by abnormal growth endometrial stromal tissues and glands. (Bulletti, 2010)The disease is reported to affect 5 to 15% of women during the reproductive age. Some women suffering from endometriosis do not tend to have any symptoms, whereas other women present symptoms such as dysmenorrhea, reduced fertility, and dyspareunia.

Endometriosis is considered a benevolent disease. However, there are many studies that suggest endometriosis as an autonomous risk factor for endometrioid ovarian carcinoma and clear-cell carcinoma (Gadducci, 2014).

Causes of secondary dysmenorrhea or endometriosis:

It has been observed that the concentration of PGs is greater in menstrual blood of the women suffering from endometriosis. (Bulletti, 2010) Bulletti, establish that in women suffering from endometriosis pain, the occurrence, basal pressure, and the amplitude of uterine retrenchments are higher. Thus the women with endometriosis experience high-intensity pain during their menstrual cycle. Moreover, the endometriotic abrasions and bonds might also be the cause of endometriotic pains.

The most accepted theory for the cause of endometriosis is that the ebb tide of menstrual tissue comes into the pelvic peritoneal cavity and implants into intra-abdominal areas. (Bendon, 2012) The theory is reinforced by the fact that the most affected site is nearest to the fallopian tubes. Moreover, endometriosis is common among women without discharge obstruction such as a slanting vaginal septum, imperforate hymen, and cervical stenosis.

Women suffering from secondary dysmenorrhea or endometriosis have a high capacity flow of menstrual blood and endometrial tissues. (Pittatore, 2014) Most women also have some components of reversing menstruation. Studies suggest that women carrying plasminogen activator inhibitor genes are more prone to endometriosis implantation, specifically after retrograde menstruation (Zanatta, 2010).

Based on the coelomic metaplasia theory, endometriotic cells are developed when the coelomic epithelium of the peritoneal cavity starts retaining multi-potential cells. This theory is considered the best way to describe the rare condition of endometriosis among the pre-puberty girls, and women with Mullerian agenesis. (Kobayashi, 2014) Another theory suggests that endometrial tissue could be transported through lymphatic and vascular channels, which can be used to illuminate the rare case of extra-abdominal endometriosis.

Moreover, more recent studies and researches suggest an immunologic element for the developmental process of endometriosis. It has been observed that the concentration of tumor necrosis factor-a, macrophages, interleukin-6, and leptin are higher in the intestinal fluid of the women suffering from endometriosis.

Prevalence and risk factor of endometriosis:

Since endometriosis is a disease that has its decency on estrogen, that affects mostly the women with reproductive age, with a high rate of prevalence among women aged between 25 to 29. (Janssen, 2013) Since the women suffering from endometriosis are often characterized with no symptoms the prevalence of the disease among the general population is hard to access. (Ballweg, 2015)Studies suggest that almost 25 to 38% of the women experiencing chronic pelvic pain are diagnosed with endometriosis and the refractory endometriosis has been identified among 50% to 70% of these patients. According to some studies, the percentage of reproductive women being affected by such disease is 10%. (Bulletti, 2010) About 20 to 25% of women with infertility were diagnosed with endometriosis and 70 to 90% of women with severe pelvic pain.

According to an estimate, the disease leads to $2,801 in health care costs. Based on a survey conducted nation wise 50% of the women diagnosed with endometriosis spend their entire day on the bed during the span of 12 months because of their health.

Reports suggest that women who have first –degree relatives with a severe condition of endometriosis have six times more chances of getting endometriosis. (Mcleod, 2010) A recent more controlled study has reported that a familial impact on the occurrence of endometriosis is not substantial. Early age menstruation and late menopause are some of the key factors for endometriosis as they lead to increased exposure of menstruation. Furthermore, low body mass index, high alcohol, and caffeine consumption are also some of the factors being associated with an increased risk of endometriosis.

Diagnosis:

The diagnosis of endometriosis is primarily based on the pain, menstruation history, and physical examination of the patient. Histologic confirmation is usually attained with the discovery of extra uterine and endometrial cells in the laparoscopy. Furthermore, transvaginal ultrasonography can identify the cystic endometriomas, which is measured as a modality of choice, though the test fails to uncover the minute endometrial implants.

Differential diagnosis is another way to diagnose endometriosis in adolescents, as there can be co-existing diseases such as urinary tract infections, pelvic inflammatory diseases, and gastrointestinal system, pregnancy, and obstructive anomalies. The visible symptoms can vary from restricted abdominal pain, dyspareunia, and dysmenorrhea. The thorough examination will allow ruling out the anomalies of the genital tract. Moreover, the trans-abdominal ultrasound examination on the patient, while full-bladder, will rule out the chances of abnormalities in uterus and ovaries.

Treatment:

The treatment process of endometriosis might be surgical or medical. The surgical methods such as laparoscopy are considered to be the most effective treatment for curing the pain associated with endometriosis. The medical procedures include the administration of drugs or hormones to reduce the intensity of the pain. Like the primary dysmenorrhea, the first line of treatment for endometriosis or secondary dysmenorrhea is NSAID (Prizment, 2010), which is then trailed by hormone therapy. As endometriosis is often confused with primary dysmenorrhea, a confirmed diagnostic through laparoscopy can define the line of treatment for the patient. Suppressive medication in addition to the empiric therapy is an option that can be chosen.

Non-steroidal Anti Inflammatory Drugs:

The comparison of naproxen with placebo was established in a randomized controlled trial during the Cochrane review for evaluating NSAID for treating endometriosis (Brown, 2017). It was established that there was no apparent difference in ache relief among naproxen and placebo. Moreover, there was no supportive evidence about the supremacy of any one NSAID in the treatment.

NSAID is the first choice of treatment because they are efficient for women suffering from primary dysmenorrhea, also because they are readily available and safe for consumption. Though endometriosis is categorized as a condition of secondary dysmenorrhea, research shows that choosing NSAID as the first line of treatment seems a logical option.

Estrogen/ Progestin combination contraceptives:

Research and studies have shown that oral contraceptives are much more effective than regular placebos in reducing pain experienced by women with endometriosis. (Chapron C. S.-P., 2011) A randomized, double-blind meticulous trail on 100 women suffering from endometriosis validated that low dosage of amalgamation oral contraceptives tends to improve the pain associated with endometriosis as compared to placebo. (Vercellini, 2011)Study indicates that the amalgamation of oral contraceptive was seemed to be less efficient during six months when compared to gonadotropin-releasing hormone (GnRH) referents, though both tend to advance the symptoms after the period of 12 months. GnRH therapy is widely administered for adult women but is not recommended for young girls because it tends to reduce bone mineral density. (Casper, 2017) It has been established that using an amalgamation of oral contraceptives have fewer adverse effects as compared to GnRH analog.

Another study compared Ethinyl estradiol/Etonogestrel vaginal ring with the norelgestromin/Ethinyl estradiol transdermal patch on women suffering from endometriosis. (Schrager, 2013) The study pointed out that both treatments tend to reduce pain. However, the ring was considered more efficient for dysmenorrhea. Furthermore, the satisfaction level of patients administering the ring was much higher and continuous usage of such treatment caused advance bleeding than its usage in intervals.

Contraceptives with Progesterone:

As compared to placebo oral Provera (medroxyprogesterone) or Depo-Provera were found to improve the symptoms associated with endometriosis. (Nooh, 2016) Improvement in pain was administered in trial comparing lower dose-depot medroxyprogesterone with GnRH analog leuprolide. The trails showed that administering medroxyprogesterone caused less bone loss and hypoestrogenic adversarial effects than leuprolide. Furthermore, two more studies compared dienogest with the GnRH analog, which also showed signs of improvement in pain associated with endometriosis. Etonogestrel subdermal implant was also found to be an effective treatment for endometriosis pain. Furthermore, small studies have also pointed to levonorgestrel-releasing intrauterine systems also tends to improve the pain.

Gonadotropin Releasing Hormone analogues:

After NSAID or combinations of oral contraceptives are found to be ineffective, the next step in the treatment of endometriosis is the GnRH analogue, such as leuprolide or goserelin. (DiVasta, 2013) The GnRH analogue therapy rejects the regulation of pituitary, which causes medical menopause, and is considered to relieve the pain associated with endometriosis. But, this therapy has been associated with some adverse effects such as bone loss, night sweats, and hot flashes experienced by many women. Furthermore, to counter the medical menopause condition, physicians administer low dose estrogen and progestin commonly.

Danazol:

Another treatment that has been administered to reduce the pain associated with endometriosis is the use of danazol, an androgen (Godin, 2015). However, the side-effects of using this treatment such as acne, male pattern baldness, and hirsutism, often avert the patients from administering it. The packaging of this drug includes the warning of possible thrombosis and teratogenicity.

Surgical Options:

Researches have pointed out that there are some surgical methods, which can prove significant in controlling the pain associated with endometriosis (Falcone, 2018). The physicians can locate the area of endometriosis and examine their size and growth during surgery; it is also possible that they might remove the endometriosis patches for that time.

Surgical options should be carefully planned because often they are irreversible and might affect women’s fertility. Some of the surgical options that might be provided to the patient are given as

Laparoscopy:

Laparoscope is a small instrument with an attached light, which is inserted in the abdomen after it has been inflated slightly with a harmless gas, to administer the growth of endometriosis (Duffy, 2014). In order to remove the endometriosis patches, the surgeons then make two more small incisions in the abdomen area and introduce lasers either to remove the lesions through a process known as excising or to eradicate the lesions through intense heat, a process known as cauterizing. During the surgery, the physician sometimes confiscates the scar tissue as it might contribute to the pain associated with endometriosis.

The main aim of such surgical treatment is to confiscate endometriotic tissues without damaging the healthy tissue around it. (Giudice, 2010)Studies have shown that with laparoscopy most women get relief from pain but that is for short term only, as pain often returns. Surgery can be helpful in relieving the pain only if lesions responsible for pain are removed completely. Some studies show that surgical treatment for endometriosis is best suited for women who have moderate endometriosis rather than in women experiencing minor endometriosis. Women experiencing minimal endometriosis often have changed pain perception once the lesions are removed (Cheong, 2008).

Laparotomy:

It is a major surgical procedure that involves the removal of endometriosis patches. However, sometimes the lesions are too minute to be detected during laparotomy (Galaal, 2018). During the procedure, the surgeon removes the uterus in a process known as hysterectomy. Depending upon the extent of damaged endometriosis tissue, the surgeon might also remove the ovaries and fallopian tubes beside the uterus, and this process of removal of ovaries and fallopian tubes is called a bilateral salpingo-oophorectomy.

During the procedure, the ovaries are tried to keep in place because of the vital role they play in the overall health and quality of life of women. Such treatment is the last option for endometriosis patients as undergoing total hysterectomy will not guarantee about the pain relief and lesions regrowth.

Surgery to cut pelvic nerve:

This is opted when the pain associated with endometriosis is substantial and originated from the center of the abdomen. In this procedure, the nerves present in the pelvic region are cut to decrease the intensity of the pain. This procedure can be also performed while conducting a laparotomy or laparoscopy. There are several reported clinical trials that have pointed out that such treatment is often ineffective in relieving the pain associated with endometriosis (Chapron C. S., 2012). Therefore, this procedure is not recommended or even included in the management of endometriosis.

The two procedures employed to cut the pelvic nerves are presacral neurectomy and laparoscopic uterine nerve ablation. In some patients, the physicians imply the hormone therapy, before or after the surgical procedure, in order to minimize the pain and continue the treatment.

Managing infertility related to Endometriosis:

In the case of mild endometriosis, most physicians recommend a laparoscopy to remove the growth of endometriotic tissue and to improve the fertility rate among women (Bulletti, 2010). The studies indicate improvement in the pregnancy rate among the women undergoing such a procedure, but the success rate has not yet been confirmed.

If treatment through laparoscopy does not result in pregnancy, then a physician might opt for vitro fertilization (IVF) to improve the rate of fertility. Any additional hormonal therapy administered for reducing endometriosis pain will disrupt ovulation and suspend the pregnancy. It is not advisable to perform a second laparoscopy for improving the fertility rate unless the pain symptoms avert undertaking IVF. Studies have shown that numerous surgeries to remove the growth from the ovaries, might decrease ovarian function and obstruct the attainment of IVF.

IVF is a process of combining egg and sperm in a laboratory environment to create an embryo. The fertilized embryo is then placed in a woman's uterus. The process of IVF is an aided reproductive technology that might be the finest option for women affected by infertility caused to endometriosis (Senapati, 2011). The first step in the process of IVF is the superovulation of women by undertaking hormonal therapies, which activate the body to produce numerous eggs at a time.

Once the eggs get matured, a physician collects them through a probe that is steered by an ultrasound. The collected eggs are then fertilized with man’s sperm in a dish and placed in an incubator. After allowing 3 to 4 days to the embryo in an incubator it is then transferred into the women’s uterus for further development.

Apart from IVF other forms of hormonal therapies such as ACOG are not as successful, as they don’t require the administration of an oral contraceptive or GnRH analog to cure infertility associated with endometriosis (Somigliana, 2017). Opting for such hormonal therapies will further delay the process of ovulation and interrupt the pregnancy.

The hormones administered during the IVF process are not helpful in curing the endometriosis lesion, which implies that the pain associated with endometriosis might recur after delivering. Furthermore, the studies suggest that IVF therapies do not guarantee pregnancy and the studies are still in the process to cure infertility related to endometriosis.

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