dysmenorrhea%20-%20primary
DYSMENORRHEA - PRIMARY
Primary dysmenorrhea is a painful menstruation without demonstrable pelvic disease.
Symptoms include intermittent painful spasms, crampy labor-like pain localized over the lower abdomen & the suprapubic area which may radiate to the lower back or inner thighs.
The pain may also be described as a dull ache or as a stabbing pain.
Accompanying symptoms include nausea and vomiting, diarrhea, headaches, lightheadedness, fatigue, fever, nervousness & fainting.

Pharmacotherapy

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • The 1st-line agents in most women with primary dysmenorrhea
    • Only 2-3 days/month administration gives a definite advantage over daily administration of oral contraceptives (OCs)
  • Most effective when started 1-2 days before the onset of menses and continued for the usual duration of cramps
  • Adolescents and young adults who cannot predict the onset of their period should be instructed to start NSAIDs as soon as menses begins, or as soon as they have any menstruation-associated symptoms
  • Actions: Inhibit the production and release of prostaglandin
  • Effects: Approximately 70% of women experience moderate-complete relief, although individual trials show wide variations in range
    • Relief usually occurs within 30-60 minutes
    • Gastrointestinal (GI) side effects are reduced when taken with or after food or milk
    • No particular NSAID has been reliably shown to be more effective than others
  • Pharmacologic properties and the severity of side effects determine the choice and dosage of the treatment
    • Aspirin is usually not used because of its lack of anti-inflammatory action at usual doses (it may also increase menstrual flow)
    • Indomethacin provides excellent relief of pain but its side effects often limit its use
    • NSAIDs that are associated with low risk of serious GI side effects (eg Ibuprofen or Naproxen) are usually preferred
  • There is a variation in individual response; therefore, patients who have poor or partial response to one NSAID may respond well to a different agent; may also consider increasing the NSAID dose
    • Eg May start with a propionic acid derivative (eg Ibuprofen) then switch to a fenamate (eg Mefenamic acid) if pain relief is inadequate
  • The new class of NSAIDs and cyclooxygenase-2 (COX-2) selective inhibitors are also effective and may cause fewer GI side effects when compared to traditional NSAIDs
  • Contraindications: Peptic ulceration; hypersensitivity to Aspirin or any other NSAID which includes those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by Aspirin or any other NSAID

Oral Contraceptives (OCs)

  • 1st-line therapy for patients who also desire birth control
  • Many adolescents and their parents are not aware that OCs reduce menstrual pain and therefore, they may be resistant to prescription of these drugs
  • Counseling patients about the benefit of OCs may also help motivate compliance
  • Actions: Suppress endometrial prostaglandin production by inhibiting ovulation (no endogenous progesterone production) and by preventing normal synchronous endometrial growth and differentiation
    • Decrease menstrual flow and uterine contractions thus reducing dysmenorrhea 
  • Effects: Effective in about 90% of patients with primary dysmenorrhea
  • It may take up to 3 cycles of treatment for menstrual pain to noticeably diminish
    • Consider adding an NSAID for breakthrough pain
  • If estrogen-progestin contraceptive use did not provide adequate relief after 3 standard cycles, alternative treatment may include continuous estrogen-progestin contraceptives or a long-acting progestin-only therapy 
  • Contraindications: Current pregnancy, history of venous or arterial thrombosis, cardiovascular (CV) disease, cerebrovascular disease, hepatic dysfunction, systemic lupus erythematosus (SLE), cholestatic jaundice, undiagnosed vaginal bleeding, breastfeeding (until weaning or for 6 months after birth), breast carcinoma, endometrial cancer
  • Safe for adolescents and help improve acne and prevent unintended pregnancy
  • Various oral contraceptives are available. Please see the latest MIMS for specific formulations and prescribing information.

Other Hormonal Contraception

  • Depot Medroxyprogesterone acetate and Levonorgestrel-releasing intrauterine system (LNG-IUS) are useful because it is the progestin part of OCs that is effective in treating dysmenorrhea
  • LNG-IUS and Depot Medroxyprogesterone have a local effect in the endometrium which is to induce endometrial atrophy, may also cause amenorrhea
  • LNG-IUS does not suppress ovulation unlike Medroxyprogesterone which suppresses ovulation
  • LNG-IUS is recommended for the treatment of idiopathic menorrhagia
  • Etonogestrel subdermal implant improves dysmenorrheal symptoms in 81% of women between 18-40 years
  • Combined Ethinyl estradiol and Norelgestromin vaginal ring has been shown to reduce the incidence of dysmenorrhea from 25.9% to 5.7% after 6 treatment cycles

Combination of Nonsteroidal Anti-inflammatory Drugs and Oral Contraceptives (NSAIDs and OCs)

  • Combination therapy may be useful in refractory cases and may be effective in patients who remain symptomatic on either drug alone 
    • NSAIDs and OCs are each effective in relieving dysmenorrhea and they work via different mechanisms of actions

Non-Pharmacological Therapy

Relief of Mechanical Symptoms
  • Applying heat to the lower abdomen with hot compress, heating pad, or hot water bottle seems to offer some relief

Complementary & Alternative Therapies

  • Acupuncture
    • One small study showed up to 91% improvement in symptoms and 41% decrease in analgesic use
  • Tocolytics
    • Eg Nitroglycerin (Glyceryl trinitrate), Nitric oxide, Calcium (Ca) antagonists (eg Nifedipine, Verapamil) and β-adrenergic receptor antagonists (eg Terbutaline)
    • May be effective in treating primary dysmenorrhea as it blocks uterine contractility
    • Have been shown to relieve intrauterine pressure but do not alleviate the accompanying symptoms (eg nausea)
    • Nifedipine may be given in difficult cases of dysmenorrhea
    • More studies are needed to prove efficacy and superiority over NSAID and hormonal options for symptomatic relief
  • Laparoscopic presacral neurectomy
    • Two small studies showed it was 33-88% effective up to 12 months after treatment
  • Laparoscopic uterine nerve ablation by cautery or carbon dioxide (CO2) laser
    • Indicated for patients with severe refractory dysmenorrhea after prompt re-evaluation of diagnosis, investigation for secondary causes and specialist referral
  • Magnesium (Mg) supplements
    • In 1 study, up to 84% decrease in symptoms especially on days 2 and 3 of cycle was shown
  • Omega-3 fatty acids
    • Small study showed the treatment group had lower scores on pain scale
  • Thiamine (Vit B1)
    • In a study of a population that may have had preexisting nutritional deficiency, thiamine provided cure for up to 2 months after therapy in 87% of patients
  • Transcutaneous electrical nerve stimulation (TENS) unit
    • May be an option for treating women with chronic pelvic pain  
    • In some studies, it has provided at least moderate relief in 42-60% of patients, reduced the requirement of NSAID and worked faster than Naproxen in 1 study 
  • Transdermal Nitroglycerin
    • In 1 small study, it showed 90% efficacy but 20% of patients reported headache
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