• What is Dysmenorrhea?
  
  Dysmenorrhea basically means painful menses. It is one of the most frequent gynecological complaints for which females seek medical help. It may be severe enough to interfere in performance of daily activities and cause absence from work for 1 or more days. The pain starts a few days before menses or may accompany it, and usually subsides as bleeding tapers off.
  
   
• Incidence of Dysmenorrhea

  The incidence of dysmenorrhea is common in females in the late teens and twenties, and it usually declines with age. About 40-70% of females suffer from dysmenorrhea and around 10 to 15% experience menstrual pain severe enough to interfere with their normal activities causing absence from school or work.
  
   

• What causes Dysmenorrhea?
  
  Medically dysmenorrhea is classified into 2 categories:
   
  • Congestive dysmenorrhea is accompanied with congestion of uterus. Various inflammatory diseases such as inflammation of ovaries and fallopian tubes, pelvic adhesions result in increased blood flow to the uterus and ovaries so that they become tense before the onset of menses resulting in pain.
  • Spasmodic dysmenorrhea which occurs due to the spasmodic contractions of the uterus. It is believed that a female hormone, progesterone may be responsible for this. Progesterone not only stimulates the contractions of the smooth muscle of cervix (lower part of the uterus) but at the same time also increases the production of prostaglandin F2 alpha which further increases the pain.
    
    Membranous dysmenorrhea is a severe form of spasmodic dysmenorrhea and is associated with the passage of membranous casts in the flow.
    
     
• Types of Dysmenorrhea
  
  Dysmenorrhea can be broadly divided into two types:
   
  • Primary Dysmenorrhea: This type of menstrual pain is present in otherwise healthy females i.e. they do not have any disease related to the uterus or other pelvic organs. Increase in the levels of a pain mediator called prostaglandin is supposed to cause increased uterine contractions resulting in pain.
  • Secondary Dysmenorrhea: This type of pain results due to the presence of some underlying disease of the uterus or the pelvic organs (such as endometriosis, pelvic inflammatory disease, fibroids, pelvic adhesions or uterine displacement)
    
     
• Who is at risk?

  Dysmenorrhea is common in females who:

  • begin menstruating at 11 years of age (early menarche)
  • have menstrual periods of longer duration (> 7 days)
  • lead a sedentary life
  • have a family history of dysmenorrhea
  • have profuse menses
  • are overweight or obese
  • smoke
  • are prone to stress and anxiety
     

• What are the causes?
  
  The causes of dysmenorrhea include:
   
  • Pre-menstrual syndrome
  • Pelvic inflammatory disease
  • Fibroids
  • Endometriosis
  • Ovarian cyst
  • Pelvic adhesions
  • Cervical stenosis (narrowing of the cervix)
  • Displacement of uterus
  • Use of intra-uterine contraceptive devices
  • Stress and anxiety (psychogenic dysmenorrhea)
    
     
• What are the symptoms?
   
  • Congestive dysmenorrhea
     
    • Pain usually begins 3-5 days before the beginning of menses.
    • It is usually present in the back or lower abdomen.
    • It is always relieved by the menstrual flow.
    • Pain may be accompanied by bowel changes (usually constipation) and flatulent distension.
       
  • Spasmodic dysmenorrhea
     
    • Pain starts on the 1^st day of menstrual flow.
    • It is usually experienced as an excruciating pain in the lower abdomen lasting for half to one hour.
    • Severe pain on the other hand is irregular and spasmodic and may be associated with nausea, vomiting, fainting or collapse. This pain followed by a less pronounced pain in the lower abdomen, pubis, inner portion and front of the thighs and lasts for not more than 12 hours.
    • Sometimes a premenstrual discomfort may be felt on the day before the flow.
    • Spasmodic dysmenorrhea may be associated with some degree of menstrual irregularity
    • Amount of blood loss is usually less than the average flow and sometimes pain is relieved by passage of blood clot.
    • This type of dysmenorrhea usually improves after marriage and is cured after pregnancy.
       
  • Membranous dysmenorrhea
     
    • It is an extreme form of spasmodic dysmenorrhea but is very rare.
    • It usually runs in families and the pain tends to recur after pregnancy.
       

     

• When to consult the doctor
  
  Mild pain is usually normal but if the pain is very severe and interferes with the normal activities one needs to take medical help. Immediately consult your doctor if:
   
  • Pain persists and is not relieved even after taking treatment.
  • Pain is so severe as to cause absence from work or school.
  • Pain is associated with severe vomiting, fainting or collapse.
    
     
• What are the investigations to be done?
  
  After taking a complete history and performing physical examination (including pelvic examination) the doctor may advise some investigations to find out the cause of secondary dysmenorrhea. These include:
   
  • Dilatation and Curettage is a minor procedure which is done to obtain endometrial tissue (inner lining of the uterus)
  • Ultrasound can help to show mild pelvic lesions
  • Hysterosalpingography, laparoscopy and hysteroscopy may be done to observe the status of uterus, ovaries and fallopian tubes.
    
     
• Management of Dysmenorrhea
  
  Management of dysmenorrhea include:
   
  • General measures: Certain lifestyle changes can help in relieving the symptoms of dysmenorrhea. These include:
     
    • Regular physical exercises such as waist bending, walking and pelvic floor exercises. These help to improve the blood flow in the pelvic area (uterus) and builds optimal pelvic musculature. Regular exercising can help reducing the intensity of the future menstrual pain.
    • Take some fish oil supplements as they have been found to be beneficial in relieving the symptoms.
    • Take less salt or salt free diet for 10 days before the onset of menses to prevent swelling in the body.
    • Avoid taking heavy (fat rich) meals. Take a fiber rich diet if suffering from constipation.
    • Apply heat to the affected area by heat pads, hot water bottle or sit in a hot bath for 10-15 minutes. It will help to relieve pain.
    • Massage the affected area, as it will help to relax the pelvic muscles.
    • Try to continue daily routine as much as possible. In fact, moving around helps to expel the menstrual products and the prostaglandins (a hormone which is which is responsible for contractions of the uterus) present in them thereby relieving pain.
    • Practice some yoga or relaxation techniques as these have been found to be effective in relieving stress and relax the pelvis and low back muscles.
    • When taking rest, elevate your feet or try to bend your knees and lie on the side.
    • Avoid alcohol and caffeine containing beverages
    • Do not use tampons or IUD (intra uterine devices) as these can worsen the pain.
       
  • Treatment: The main objective of treatment is to relieve pain.
     
    • Painkillers to relieve menstrual pain and breast pain.
    • Take calcium supplements as advised by the doctor. Calcium prevents menstrual pain by maintaining a normal muscle tone.
    • Synthetic estrogens are given to produce anovulatory and painless periods
    • Constipation is treated by laxatives.

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