Menstrual Cramps

1. Definition
   1. Dysmenorrhea: Painful Menses
   2. Translation: Difficult Monthly Flow
2. Epidemiology
   1. Menstruating women who experience Dysmenorrhea: 50-75%
   2. Women with severe Dysmenorrhea: 10%
   3. Highest Incidence in adolescents
3. Risk Factors
   1. Age under 20 years
   2. Tobacco Abuse
   3. Dieting
   4. Mood Disorder: Major Depression or Anxiety
   5. Menorrhagia
   6. Nulliparity
4. Types of Dysmenorrhea
   1. Primary Dysmenorrhea (90%)
      1. Onset occurs within 6 to 12 months of Menarche
      2. Lifetime Prevalence of severe Dysmenorrhea: 50-60%
      3. Women incapacitated for 1-3 days of each cycle: 10%
      4. Idiopathic with no clear pelvic pathology
   2. Secondary Dysmenorrhea: Acquired organic pelvic disease
      1. Common causes
         1. Endometriosis
         2. Pelvic Inflammatory Disease (PID)
      2. Other causes
         1. Postsurgical adhesions
         2. Uterine Myomata (Uterine Fibroids)
         3. Endometrial Polyps
         4. Adenomyosis
         5. Cervical stenosis
         6. Congenital uterine anomaly
         7. Intrauterine Device (IUD)
5. Etiology: Primary Dysmenorrhea
   1. Prostaglandin-mediated high intensity contractions
   2. Vasopressin-mediated contractions
      1. Reduces uterine blood flow via Vasoconstriction
      2. May result in ischemic pain
   3. Prostaglandin mediated nerve terminal hypersensitivity
6. History Suggestive of Secondary Dysmenorrhea
   1. Changed Dysmenorrhea character, location or intensity
   2. History of prior Sexually Transmitted Disease
   3. Prior abdominal or pelvic surgery
   4. Pelvic Pain persisting throughout cycle
   5. Infertility
   6. Abnormal Menstrual Bleeding
   7. Endometriosis type Rectal Pain or Dyspareunia
7. Symptoms
   1. Cramping or colicky lower abdominal or Pelvic Pain
      1. Pain begins within a few hours of menstrual flow
      2. Radiation of pain to lower back and thighs
   2. Gastrointestinal symptoms
      1. Nausea or Vomiting
      2. Bloating
      3. Diarrhea
   3. Other associated symptoms
      1. Weakness
      2. Fatigue
      3. Headache
   4. Palliative factors
      1. Oral Contraceptive use
      2. Following childbirth
8. Signs
   1. Normal Pelvic exam
      1. Suggests Primary Dysmenorrhea
   2. Uterosacral nodularity
      1. Suggests Endometriosis
   3. Thickened Adnexal Masses
      1. Suggests Pelvic Inflammatory Disease
   4. Enlarged, irregular Uterus
      1. Suggests Uterine Fibroids
   5. Enlarged, boggy Uterus
      1. Suggests Adenomyosis
9. Evaluation: If findings suggest secondary cause
   1. Abdominal examination
   2. Pelvic examination
   3. Examination of Vaginal Discharge
   4. Sexually Transmitted Disease screening
      1. Gonorrhea
      2. Chlamydia
   5. Pelvic Ultrasound
      1. Ovarian Cysts
      2. Endometrioma
      3. Advanced Endometriosis (Stage 3 or 4)
10. Management: General measures
    1. Thiamine 100 mg PO daily
    2. Vitamin E 2500 IU daily
       1. Started 2 days before Menses and continued for 5 days
    3. Omega-3 Fatty Acid Supplement 2 grams daily
       1. Harel (1996) Am J Obstet Gynecol 174:1335-8
    4. Toki-shakuyakusan (TSS): Japanese herbal supplement
    5. Acupuncture or Acupressure
       1. Helms (1987) Obstet Gynecol 69:51-6
    6. Trancutaneous Electric Nerve Stimulation (TENS)
    7. Low level heat patch placed inside underwear
       1. Complete relief in 70% of patients (35% with Placebo)
       2. Akin (2001) Obstet Gynecol 97:343-9
11. Management: Medications
    1. Nonsteroidal Anti-inflammatory drugs (NSAIDs)
       1. Ibuprofen 400 to 600 mg PO qid
       2. Naproxen (Naprosyn) 250 mg PO qid or 500 mg PO bid
       3. Naproxen Sodium (Anaprox) 275 mg PO qid
       4. Mefenamic acid (Ponstel)
          1. Option 1: 500 mg for first dose, then 250 mg PO qid
          2. Option 2: 500 mg PO tid
       5. NSAIDS are highly effective in Dysmenorrhea
          1. Zhang (1998) Br J Obstet Gynaecol 105:780-9
    2. Hormonal Contraceptive use
       1. Estrogen and Progesterone options
          1. Standard Oral Contraceptives
          2. Seasonal Oral Contraceptive Cycle
          3. Intravaginal use of Oral Contraceptive
             1. Sulak (2002) Am J Obstet Gynecol 186:1142-9
          4. Contraceptive Patch is not as effective as OCPs
             1. Audet (2001) JAMA 285:2347-54
       2. Progesterone only options
          1. Depo Provera
          2. Levonorgestrel IUD (Mirena)
             1. Baldaszti (2003) Contraception 67:87-91
    3. Other medications that may be effective
       1. Nifedipine PO
       2. Terbutaline IV
12. Management: Refractory cases
    1. Consider gynecology consultation for laparoscopy
    2. Danazol or Leuprolide may be used in severe cases
13. References
    1. French (2005) Am Fam Physician 71(2):285-91
    2. Proctor (2002) Clin Evid 7:1639-53