DYSMENORRHEA

Definition:

Severe, cramping pain in the lower abdomen that occurs just before or during menses.

Types of dysmenorrhea

Etiology 

      1. The etiology of primary dysmenorrhea is attributed to increased uterine activity which manifested by:

• Increased resting tone. 
• Increased contractility. 
• Increased frequency of contractions. 

      2. Prostaglandins are released as a result of endometrial cell lysis.
      3. The etiology of secondary dysmenorrhea is attributed to certain conditions:

• Fibroids: Benign tumors developed within the uterine wall or attached to it. 
• Adenomyosis: The endometrium (tissue lining the uterus) begins to grow within the muscular wall. 
• STI: Sexual Transmitted Disease. 
• Endometriosis: Fragments from the endometrial lining that are found on other pelvic organ.

Assessment of menstrual cramps :

• Menstrual cramps can be documented by measuring the pressure within the uterus and number & frequency of uterine contractions. 
• During normal menstrual period, the average woman has contractions of low pressure (50-80 mm Hg), lasting (15-30 sec.) at frequency of (1-4 contractions every 10 minutes). 
• Women with intense pain , their menstrual cramps may exceed 400 mm Hg, lasting longer than 90 sec. and occurs less than 15 sec. apart.

Factors influencing menstrual cramps: 

1. Narrow cervical canal. 
2. RVF. 
3. Lack of exercise. 
4. Psychological factors as emotional stress. 
5. Adenomyosis and endometriosis. 
6. Uterine fibroids.

Management of Primary Dysmenorrhea 

1. General and psychological treatment: 

• Discussion and reassurance after menarche that primary dysmenorrhea is associated with ovulatory cycles 
• It is common for pain to disappear or decrease after the birth of the 1st child. 
• The intensity of pain may be aggrevated by fear and its is not indicator to any serious problem.

2. Drug therapy:

• Non-Hormonal Treatment in the form of: NSAIDs are most common used to decrease levels of prostaglandins (anti prostaglandins) and have analgesic effect. 
• Hormonal treatment in the form of oral contraceptive pills: as a second line of treatment by decreasing endometrial growth resulting in limiting the production of prostaglandins. 

3. Physical therapy treatment:

1) Hot packs:

• On the lower abdomen and lower back for 10-15 minutes from a comfortable position. 
• It increase blood flow to the contracting muscles and so reduces muscle spasm and pain.

2) Acupressure: 

• It is a Traditional Chinese Medicine (TCM) modality used by applying pressure to specific acupuncture points over the body to balance internal function. 
• Points used: 

1. SP 6: It is located on the medial aspect of the calf, three cuns) above the medial malleolus posterior to the border of tibia. 
2. SP 8: It is located on the mediolateral aspect of the calf, three cuns below the SP9 point (which is located on the medial aspect of the lower leg, in the depression of the lower border of the medial condyle of the tibia). 

• Press the selected point by your thumb or the patient’s thumb by herself in a circular motion clockwise for 5 minutes and on the other limb in counterclockwise direction for another 5 minutes and repeat for 20 minutes.

3) Acupuncture:

• It is a technique that focus on restoring the balance of qi (body’s vital energies). 
• It is applied by placing sterile thin needles along the acupoints mentioned above . 
• After that, needles can be manipulated through manual needling, electrical stimulation, heat or laser. 

4) Low level laser therapy LLLT

• LLLT decreases the production of prostaglandins through acceleration of the blockers of prostaglandins. 
• It has double actions: 1 st : Stimulating endorphine production, 2 nd : Inhibit prostaglandin synthesis. 
• It decreases nerve conduction velocity thus decreases pain perception. 
• It stimulates the gate control theory of pain. 
• Technique: we have two sites of application:

1. From crook lying position, apply three shoots on the suprapubic region, direct contact and the head is perpendicular for 60 seconds. 
2. From prone or sitting position, apply three shoots on each side paraspinal from L4-S3, 60 seconds each

• Parameters: Maximum power 5 milliwatts, Wave length 904 nm.

5) TENS

• It blocks pain perception through gate control theory of pain. 
• It stimulates the release of the body opoids (endorphins and enkephalins) which are considered as the natural pain killers of the body.
• Techniques:

1. Dual channel V shaped technique 
- Using three surface electrodes. 

1 st electrode A, is located on the antrolateral aspect of the umbilicus to the left (negative). 
2 nd electrode B, is located on the antrolateral aspect of the umbilicus to the right (negative). 
3 rd electrode C, on the most intense area of pain at midline below umbilicus (positive). 
Parameters: Frequency: 80-120 Hz, Pulse width: 150 ms, Duration for 1 hour several times a day at minimal intensity. 

2. Dual channel crisscross 
- Using four surface electrodes. 

• 1st electrode A1: On the abdomen at most anterolateral area of pain below umbilicus on the right. 
• 2nd electrode A2: On abdomen at most anterolateral area of pain .

6)Kinesio-taping

• The Kinesio-Tape is composed of elastic strand wrapped by 100% cotton fibers and allow a longitudinal stretch of 55-60 % of its resting length. 
• KT adjusts the electromagnetic flows on skin indirectly stimulating muscles or organs under the skin, normalizing muscle function, increasing lymphatic and vascular flow, decreasing pain. 
• The effect of KT is suppression of pain by stimulation of tactile fibers in the skin through gate control theory of pain 
• It is applied on the lower abdomen, stimulating tactile fibers of skin, suppressing pain sensitization to prostaglandins thus reduce menstrual pain.

• Technique: Relaxation in the lower abdomen is achieved by application of KT over the genital zone and viscerotome S1 of the genital organs and over the uterus.

7) Aerobic exercise

• Aerobic exercise can decrease menstrual pain by the release of endorphins, relaxation, stress relief and improving blood flow. 
• Isometric exercises (including abdominal and pelvic exercises) are used to decrease the severity and duration of pain and the rate of use of medication. 
• Stretching exercises for hip flexors and hip adductors are done premenstrual to relief symptoms. 
• Aerobic exercise can be done in the form of walking on treadmill or in fresh air at 70-85% of maximal heart rate, 30 minutes, 3 days/week. 

8) Relaxation tecniques and Yoga

• Relaxation and meditation lead to increase in threshold of pain and improve body’s endurance and balance. 
• Cobra, Cat, Cow and Fish yoga poses are useful best for heavier menstrual days. Each stretch should be held for 30 to 60 seconds without pain or discomfort. 
• It is preferable to perform them after a warm bath. 
• All poses are accompanied by deep breathing.

The most common used Yoga poses during menstruation

9) Aromatherapy

• It is the therapeutic use of essential oils from plant. 
• Most common oils used are lavender and parrafin. 
• They are used for relaxation, reduction of stress and pain and increasing sense of well being.
• It is used through inhalation, topical use, and oral use.

10) Life style changes and diet modification (Advices) 

• Stop smoking because it leads to increase duration of dysmenorrhea. 
• Daily vitamin E supplements are recommended. 
• Reduce the amount of salt in your diet to avoid water retention. 
• Choose pure fruit juices or mineral water rather than sugary drinks. 
• Eat more chicken and fish. 
• Eat high fiber foods and plenty of salads and vegetables. 
• Take a supplement containing gamma linolenic acid (GLA) such as evening primrose oil or vitamin B6 to help maintaining hormonal balance.