Obstetric & Gynaecology Malaysia


Dysmenorrhoea=Painful menstruation

The pain of dysmenorrhea is crampy and usually located in lower abdomen or pelvic area; some women also have severe pain in the back or thighs. The pain usually begins just before or as menstrual bleeding begins, and gradually diminishes over 1 to 3 days. Pain usually occurs intermittently, ranging from mild to disabling. Other symptoms that may accompany cramping include nausea, diarrhea, dizziness, fatigue, headache, or a flu-like feeling.

More than 50% of women complained of menstrual pain or varying degrees for 1 to 2 days each month. 

There are 2 types of dysmenorrhea ie 

  • primary dysmenorrhoea 
  • secondary dysmenorrhoea

Primary dysmenorrhea is pain that comes from having menses. Primary dysmenorrhea is usually caused by a natural chemical called prostaglandins that are formed in the lining of the uterus during menstruation. These prostaglandins cause muscle contractions in the uterus, which cause pain and decrease blood flow and oxygen to the uterus. Prostaglandins may also contribute to the nausea and diarrhea that some women experience. Often, primary dysmenorrhea begins soon after a girl starts her menses. In many women with primary dysmenorrhea, menstruation becomes less painful as they get older.  Primary dysmenorrhea may resolved after childbirth.  

Secondary dysmenorrhoea is caused by disorder in the female reproductive systems. It may begin later in life. The pain tend to get worse over time.  The pain may get worse as the menstrual period continues and may not go away after it ends. Causes of secondary dysmenorrhoea are endometriosis, uterine adenomyosis, or uterine fibroids.

Endometriosis cause menstrual pain because endometriosis tissues break down and bleed in response to hormones. Scar tissue called adhesion may formed inside the pelvis where the bleeding occurs. Adhesions can cause organs to stick together, resulting in pain.

In uterine adenomyosis, tissues that normally line the uterus begins to grow in the muscle of the uterus.

Fibroid located inside the wall of the uterus can cause pain especially if the fibroid grow rapidly causing degenerative changes.

There are a number of treatments available for women with dysmenorrhea.

Nonsteroidal anti-inflammatory drugs (NSAIDs) — NSAIDs are a class of medications that are very effective in reducing pain associated with dysmenorrhea. Some NSAIDs are available without a prescription. NSAIDs are most effective if they are started as soon as bleeding or other menstrual symptoms begins, and then taken on a regular schedule for two to three days. Injudicious use of NSAIDs drugs for more than 5 days in a month may put the user at risk of kidney impairment.

Oral contraceptive pills (OCP)— OCPs and other forms of hormonal birth control (eg, patch, vaginal ring, injection, hormone-releasing intrauterine device, contraceptive implant) also represent effective treatments for women with dysmenorrhea. These treatments work by thinning the lining of the uterus, where prostaglandins are formed, thereby decreasing the uterine contractions and menstrual bleeding that contribute to pain and cramping. 

Hormonal contraception usually reduces dysmenorrhea within several months of starting it. 

Women who start a hormonal birth control treatment continuously often have intermittent light bleeding or spotting, especially during the first 2 to 3 months of treatment; this usually declines with time. When bleeding occurs, it is usually lighter and associated with less severe cramping compared with before the treatment.

Non-pharmacologic treatments are:

Applying heat to the lower abdomen with a heating pad, hot water bottle, or self-heating patch can significantly reduce pain, often as well as treatment with an NSAID. It is important to avoid burning the skin with a heating pad or hot water bottle that is too hot.

Dietary, vitamin, and herbal treatments — A variety of supplement therapies eg ginger, cucurmin, vitamin B1 & B12, vitamin D3, vitamin E, Calcium or Magnesium have been studied for the relief of dysmenorrhea . 

Exercise seems to reduce menstrual symptoms, including pain, in some studies 

Complementary or alternative medicine. There is some evidence that complementary medicine practices such as yoga or acupuncture are effective in reducing painful periods. Further information about complementary and alternative medicine is available from the National Center for Complementary and Integrative Health (https://nccih.nih.gov/).

The most effective treatments for dysmenorrhea include NSAIDs and/or hormonal birth control treatments. If one of these treatments does not sufficiently relieve pain within 2-3 months, another treatment may be offered. As an example, if a woman tries NSAIDs but does not improve or cannot tolerate the treatment, a hormonal birth control treatment may be recommended instead of or in addition to the NSAID (or vice versa).

If neither NSAIDs nor a hormonal birth control treatment adequately improve pain, the next step depends upon the woman's age, symptoms, and other medical conditions. The options include:

●Diagnostic laparoscopy may be recommended to determine if endometriosis, or another condition, could be causing the pain. 

●Trial with a gonadotropin-releasing hormone (GnRH) agonist, such as leuprorelin acetate ( Lucrin) or the GnRH antagonist, elagolix (Orilissa). If dysmenorrhea improves within 2-3 months of starting treatment, it was probably caused by endometriosis.

No surgery has been shown to provide long-term relief of pain of primary dysmenorrhoea. As a result, surgical treatments for primary dysmenorrhea are not generally recommended