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Chen Xiao Chen, MS, RN, PhD Candidate
University of Wisconsin-Madison
When a period is more than a punctuation mark:
Contemporary Perspectives on
Dysmenorrhea Management
Outline
Background Definition
Classification
Impact
Pathophysiology
Clinical Assessment
Management of Dysmenorrhea Pharmacological Treatment
Complementary Alternative Treatments
Other Treatments
Definition
Symptoms:
Abdominal pain that occurs just before or during
menstruation.
Other symptoms: low back pain, radiation of pain to the
upper thighs, nausea, vomiting, diarrhea, bloating.
(IASP, 1994; IASP, 2011; Smith, & Kaunitz, 2013)
Definition (con’t) Dysmenorrhea vs. Premenstrual Syndrome (PMS)
(Chen, Kwekkeboom, & Ward, 2014)
Classification
Primary Dysmenorrhea
No structural lesion.
Secondary Dysmenorrhea:
Associated with underlying pathology
e.g., endometriosis, uterine fibroids, pelvic inflammatory
diseases.
(IASP, 1994; IASP, 2011)
Risk / protective factors
Risk factors:
Young age
Nulliparity
Family history
Smoking
Longer and heavier menstrual flow
Protective factors
Use of oral contraceptives
(Ju, Jones, & Mishra, 2014)
Impact
Prevalence: 16% - 91% of women of reproductive age.
The leading cause of lost work hours in women.
10–30% of women miss work because of dysmenorrhea.
A loss of 600 million working hours.
A loss of up to 2 billion dollars annually.
Negative impact on physical activity, productivity, health-
related quality of life, productivity.
(Chantler, Mitchell, & Fuller, 2009; Coco, 1999, Dawood, 1988; Iacovides, Avidon, Bentley, & Baker, 2013)
Impact Links between Dysmenorrhea and Other Chronic
Pain Conditions
Dysmenorrhea
• Commonly co-occurs with other chronic pain conditions.
• Can exacerbate other chronic pain conditions.
• Its treatment can relieve symptoms associated with other
chronic pain conditions.
• May increases risks for future pain.
(Altman et al., 2006; Amital et al., 2010; Berkley, 2013; Mannix, 2008; Olafsdottir et al., 2012;
Yunus et al., 1989; Shaver et al., 2006)
Dysmenorrhea
• Causes significant changes (structural & functional)
in the brain.
• Increases sensitivity to pain.
• May explain gender disparity in pain.
Impact (con’t) Links between Dysmenorrhea and Other Chronic
Pain Conditions
(Brinkert, et al., 2007; Berkley, 2011; Berkley, 2013; Giamberardino et al., 2001; Giamberardino et al., 1997;
Giamberardino, 2008; Tu et al., 2009; Tu et al., 2010; Tu et al., 2013; Iacovides, Baker, Avidon, & Bentley, 2013;
Vincent et al., 2011)
Pathophysiology
Membrane phospholipids
Prostaglandins
Dysrhythmic uterine contractions, ischemia, hypoxia, hyper-sensitization of
the peripheral nerve
Symptoms of Dysmenorrhea
(Chan, Dawood, & Fuchs, 1981; Dawood, 1984; Dawood, 1988; Dawood, 2006)
Clinical Assessment of Dysmenorrhea
History
Physical Examination
Pelvic ultrasound
Laparotomy or laparoscopy (gold standard for diagnosis of
endometriosis)
(Smith & Kaunitz, 2013; Speer, 2014)
Treatments of Dysmenorrhea
Pharmacological Treatments
Complementary/Alternative Medicine (CAM)
Other Treatments
Pharmacological Treatments
NSAIDs
Well established as effective therapy.
More effective than acetaminophen.
No evidence suggests any particular NSAIDs is more
effective than others.
Ideally, administered prior to
the onset of menses.
(Marjoribanks et al., 2010, Smith et al., 2013; Speer 2014; Tu, 2007)
Pharmacological Treatments (con’t)
Combined oral contraceptives are effective for prevention of
dysmenorrhea.
Continuous regimens may provide better control than
traditional cyclic regimens.
(Smith & Kaunitz, 2013; Smith & Kaunitz, 2014; Speer, 2014)
Levonorgestrel intrauterine system (IUD, LNg20/ Mirena R)
is associated with improvement in menstrual pain.
(Dean & Goldberg, 2014; Smith & Kaunitz, 2013; Smith & Kaunitz, 2014)
Pharmacological Treatment (con’t)
The injectable contraceptive depot medroxyprogesterone
acetate (DMPA) given every 3 months to induce anovulation.
Pharmacological Treatment (con’t)
(Smith & Kaunitz, 2013; Smith & Kaunitz, 2014)
Complementary Alternative Medicine (CAM)
High-frequency transcutaneous electrical nerve stimulation (TENS)
is effective in relieving menstrual pain.
Dietary and herbal supplements
Magnesium, Vitamin B1, Vitamin B6, Vitamin E, Omega 3 Fatty
acid are possibly effective.
Acupuncture may be effective, but the related studies are limited by
methodological flaws.
Behavioral interventions may be effective, but results should be
viewed with caution.
Spinal manipulation is unlikely to be beneficial.
(Cho & Hwang, 2010; Kannan & Claydon, 2014; Proctor, Hing, Johnson, & Murphy, 2006; Proctor, Smith, Farquhar, & Stones, 2002; Proctor & Murphy,
2001; Proctor, Smith, Farquhar, & Stones, 2002; Proctor, Murphy, Pattison, Suckling, & Farquhar, 2007; Smith & Kaunitz, 2014; Smith, Zhu, He, & Song, 2011)
Other treatments
Topical heat leads to significant reductions in pain severity.
Surgical cutting uterine nerves is likely to be ineffective or
harmful.
(Kannan & Claydon, 2014; Proctor, Smith, Farquhar, & Stones, 2002; Smith & Kaunitz, 2014)
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