PRIMARY DYSMENORRHEA - (Functional Dysmenorrhea)
Cyclic pain associated with ovulatory cycles without demonstrable lesions affecting reproductive structures.
The pain is thought to result from uterine contractions and ischemia, probably mediated by prostaglandins produced in secretory endometrium; therefore, primary dysmenorrhea is almost always associated with ovulatory cycles. Contributing factors may include the passage of tissue through the cervix, a narrow cervical os, malposition of the uterus, lack of exercise, and anxiety about menses. This common disorder usually starts during adolescence and tends to decrease with age and after pregnancy.
Symptoms and Signs - Low abdominal pain is usually crampy or colicky but may be a dull constant ache and radiate to the lower back or legs. The pain may start before or with menses, tends to peak after 24 hours, and usually subsides after 2 days. Sometimes endometrial casts (membranous dysmenorrhea) or clots are expelled. Headache, nausea, constipation or diarrhea, and urinary frequency are common; vomiting occurs occasionally. PMS symptoms (see above) may persist during part or all of the menses.
Treatment - A woman should be assured that her reproductive organs are normal. Many women do not need drugs, but for women with substantially bothersome symptoms, the most effective drugs are prostaglandin synthetase inhibitors (eg, ibuprofen, naproxen, mefenamic acid). A drug may be more effective if started 24 to 48 hours before and continued 1 or 2 days after menses begins. If pain continues to interfere with normal activity, suppression of ovulation with low-dose estrogen-progesterone oral contraceptives is advisable. Antiemetics may be used. Adequate rest and sleep and regular exercise may help.
SECONDARY DYSMENORRHEA - (Acquired Dysmenorrhea)
Pain with menses caused by demonstrable pathology.
Endometriosis is a common cause of dysmenorrhea; adenomyosis may also cause it. A few women have an extremely tight cervical os (secondary to conization, cryocautery, or thermocautery); pain occurs when the uterus attempts to expel tissue through the os. A pedunculated submucosal fibroid or an endometrial polyp extruding from the uterus occasionally causes cramping pain. Pelvic inflammatory disease may cause diffuse continuous low abdominal pain that tends to increase with menses. Sometimes, a cause cannot be found.
Treatment - The first line of treatment is medical (eg, prostaglandin synthetase inhibitors, oral contraceptives, danazol, progestins). If possible, the underlying disorder or anatomic abnormality is corrected, thus relieving symptoms. Dilation of a narrow cervical os may give 3 to 6 months of relief (and allows diagnostic curettage if needed). Myomectomy, polypectomy, or dilation and curettage may be needed. Interruption of uterine nerves by presacral neurectomy and division of the sacrouterine ligaments may help selected patients. Hypnosis may be useful.
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