Dysmenorrhea medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]
Primary Dysmenorrhea
Pathophysiology
Primary dysmenorrhea occurs during regular ovulatory cycles. Women with primary dysmenorrhea have increased activity of the uterine muscle with increased contractility and increased frequency of contractions. Prostaglandins are released during menstruation due to destruction of the endometrial cells and the resultant release of their contents.
Release of prostaglandins and other inflammatory mediators in the uterus (womb) is thought to be a major factor in primary dysmenorrhea (Wright et al. 2003). Prostaglandin levels have been found to be much higher in women with severe menstrual pain than in women who experience mild or no menstrual pain. Drugs which inhibit the production of prostaglandins, such as the non-steroidal anti-inflammatory drugs (NSAIDs) Naproxen, Ibuprofen and Mefenamic Acid, can provide relief for the discomfort and other associated symptoms of excessive prostaglandin release, such as nausea, vomiting, and headache.
Clinical Features
The cramping associated with dysmenorrhea usually begins a few hours before the start of bleeding and may continue for a few days. The pain is usually described as being in the lower abdomen, possibly radiating to the thighs and lower back. Other symptoms associated with primary dysmenorrhea are nausea and vomiting, fatigue, diarrhoea, lower backache, and headache.
Treatment
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, are very effective in the treatment of primary dysmenorrhea (Andreoli et al. 2004). As earlier stated, their effectiveness comes from their ability to inhibit prostaglandin synthesis. However, many NSAIDs can cause gastrointestinal upset as a side effect. Patients who cannot take most common NSAIDs may be prescribed a cyclo-oxygenase-2 (COX2) inhibitor.
Oral contraceptives are second-line therapy unless a woman is also seeking contraception, then they would become first-line therapy. Oral contraceptives are 90% effective in improving primary dysmenorrhea and work by reducing menstrual blood volume and suppressing ovulation. It may take up to 3 months for the oral contraceptives to become effective. Norplant and Depo-provera are also effective since these methods often induce amenorrhea.
Alternative treatments
For the 10% of patients who do not respond to NSAIDs and/or oral contraceptives, a wide range of alternative therapies have been proven effective, including transcutaneous electrical nerve stimulation (TENS), acupuncture, omega-3 fatty acids, transdermal nitroglycerin, thiamine, and magnesium supplements.
Chiropractic care has been an effective treatment approach (Chapman-Smith, 2000). Treating subluxations in the spine may cause the nerves leaving the spine to be less aggravated and so decrease symptoms of dysmenorrhea, as well as other symptoms such as chronic stomach aches and headaches. However, the Cochrane Review of 2007-04-19 [1] states "Authors' conclusions: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhea."
Accupuncture is used to try to treat dysmenorrhea and studies have shown that it "reduced the subjective perception of dysmenorrhea" (Jun 2004). However, the small number of studies leaves doubt about the effectiveness of acupuncture for gynaecological conditions (White 2003).