Dysmenorrhea, painful uterine cramping during menses, is the most common cause of chronic pelvic pain(1,2). Dysmenorrhea is reported in greater than 50% of women and is the primary complaint for women of reproductive age resulting in disability, loss of work, emotional and psychological distress and ultimately affecting quality of life(1,2). Dysmenorrhea is often associated with Irritable Bowel Syndrome (IBS) and Perimenstrual Syndrome (PMS)(2). There are two types of dysmenorrhea, primary and secondary.
Primary dysmenorrhea, which tends to be the more common type in adolescent females, is functional, meaning it is associated with normal ovulatory cycles, no pelvic pathology, and has a clear physiologic etiology(1). Pelvic abnormalities, such as uterine anomalies or endometriosis, are only identified in roughly 10% of adolescents with severe dysmenorrheal symptoms(1). Primary dysmenorrhea is thought to be a result of prostaglandin overproduction within the endometrium(1). After ovulation, w-6 fatty acids accumulate in the cell membrane. Then, just before menses begins, prostaglandins (especially arachadonic acid) are withdrawn and w-6 fatty acids are released(1). This release initiates a cascade of reactions, which produce prostaglandins (PG) and leukotrienes (LT) in the uterus. PG and LT are biochemical byproducts of ovulation and inflammatory modulators that are known to cause myometrial contractions and vasoconstriction resulting in local tissue ischemia and finally ending with a cramping pain(1,2). Chan and Hill’s study on PG activity showed that PG activity was 2-fold in dysmenorrheic versus nondysmenorrheic subjects(1,3).
Secondary dysmenorrhea affects approximately 10% of women and is a result of uterine abnormalities such as polyps, fibroids, endometriosis, adenomyosis, and uterine anomalies. Endometriosis is the most common cause of secondary dysmenorrhea and has numerous theories behind its development(1). Regardless of etiology, this estrogen-dependent disorder has inappropriate aromatase activity, estrogen production, and COX-2 expression(1). The increase in COX-2 results in an increase in production of PGs inducing aromatase activity ultimately leading to a positive feedback loop.
According to Altman et al. the reproductive system includes systemic endocrine responses, internal structures, and external structures(2). Thus, pain can emerge from a multitude of things such as inflammation, infections, ischemia or tissue exacerbations(2). Secondary to the structures within the pelvic region and nearby organs leading to potential complaints of pelvic pain it is common for the patient to seek out multiple healthcare physicians(2). Pelvic pain is often described as discrete or diffuse, sharp or dull, constant or intermittent, abdominal pressure or general achiness, cramping or sudden and excruciating pain(2). The patient may report dyspareunia (pain with intercourse) or pain with bowel movements(2). Those with pelvic pain typically complain of pain with prolonged standing or sitting and report an inability to sleep or exercise(2). Often times the complaints are that the patient is not able to complete their daily tasks or miss work due to the debilitating, severe pain(2).
Despite the high prevalence of dysmenorrhea many do not seek medical advice or are undertreated. A thorough history and physical exam by the medical professional are paramount to successfully diagnosing and treating dysmenorrhea. Establishing if the patient is having ovulatory cycles can be done by gathering information including the interval between menses and the presence or absence of premenstrual symptoms. A “P, Q, R, S, T” approach toward the patient’s pain history is often utilized as an assessment tool(1).
- P= provocative and palliative factors
- Q= quality, sharp, and stabbing versus dull, aching like
- R= radiation and relief
- S= severity of pain
- T= temporal relationship to the menstrual cycle
A complete physical exam should be performed and designed around the potential etiologies of chronic pelvic pain. The medical professional should elicit trigger points, examine the abdominal and pelvic regions in an attempt to reproduce pain. Utilizing a body diagram for documentation of painful areas can be the most useful.
Include but are not limited to consumption of Vitamin E, Magnesium, Rose Tea, TENS, and acupuncture(1).