Primary and secondary dysmenorrhea
Painful menstruation in obstetrician-gynecologists is called dysmenorrhea and is the most common gynecological disease. The prevalence varies widely, from 17% to 90%. Some women experience minor pain, while other women’s lives (up to 15%) deteriorate significantly during menstruation, resulting in them having to give up work on those days or skip school.
Obstetrician-gynecologists distinguish between primary and secondary dysmenorrhea. Primary dysmenorrhea is an independent disease that is not accompanied by violations of the structure and function of the pelvic organs. This is a diagnosis of exclusion, that is, after a detailed examination, no violations were found, but the woman still experiences pain in the first days of the menstrual cycle.
Primary dysmenorrhea occurs 6 to 12 months after menarche (first period), but in some adolescents it can last up to 2 years after. Its prevalence decreases with increasing age in most women.
Patients describe pain that occurs shortly before or at the onset of bleeding and lasts up to 72 hours. The pain is localized in the suprapubic region and may radiate to the upper thigh or back, or both. Pain intensity usually peaks 24 to 36 hours after the onset of menstruation and rarely lasts more than a few days. Additional symptoms include nausea, vomiting, bloating, and diarrhea.
Symptoms indicating dysmenorrhea (not just pain)
Risk factors for primary dysmenorrhea:
age under 30;
body mass index less than 20;
menarche before the age of 12;
longer menstrual cycles;
irregular or heavy menstruation;
family history of dysmenorrhea.
The prevalence of moderate to severe primary dysmenorrhea generally decreases with women’s age, and childbirth also results in a decrease in the prevalence and severity of primary dysmenorrhea. BUT! Improvements are not observed in women whose pregnancy ended in miscarriage or abortion.
Classic symptoms of primary dysmenorrhea:
• menstrual pain began within a few months or within 2 years after menarche;
• pain begins just before or at the beginning of menstruation;
• pain in the lower abdomen and may radiate to the back, inner thighs, or both;
• pain rarely lasts more than 72 hours;
• pain is episodic and spasmodic;
• the pain is the same from one menstrual cycle to the next;
• additional symptoms: nausea and vomiting, fatigue, headaches, dizziness and sleep disturbances.
Why does it occur
Primary dysmenorrhea seems to be the result of increased secretion of prostaglandins (special substances that stimulate intense contractions of the uterine muscle). These substances are controlled by the level of progesterone (hormone of the 2nd phase of the menstrual cycle). With a lack of this hormone, the level of prostaglandins increases, and they become more active. These same substances increase the contraction of the muscles of the intestine – hence the diarrhea and bloating.
Treatment: hormonal and not only
Because primary dysmenorrhea occurs in adolescence and often continues into adulthood, different treatment options may be appropriate for the same woman depending on the stage of life.
Combined oral contraceptives (COCs) are effective for treating dysmenorrhea in about 70-80% of women. Suppression of ovulation leads to a decrease in the production of substances that cause a strong contraction of the uterus. Long-term hormonal contraceptives (patches, intrauterine devices) may be more effective than cyclic drugs (combined contraceptives). Progesterone-only preparations also appear to be effective treatments for primary dysmenorrhea.
Non-steroidal anti-inflammatory drugs (NSAIDs) are considered first-line treatment for primary dysmenorrhea and provide effective pain relief for the vast majority of women. They work in two directions:
suppress the production of prostaglandins by the same mechanism as lowering body temperature during fever. A decrease in the level of prostaglandins in the walls of the uterus is associated with a return to normal uterine contractility and a decrease in menstrual pain.
non-steroidal anti-inflammatory drugs (NSAIDs) have the added benefit of direct analgesic activity at the level of the central nervous system. A recent meta-analysis of 70 studies that evaluated NSAIDs for their relative efficacy as well as their side effects and safety profiles in women with dysmenorrhea found that flurbiprofen (Strepsils, Rakstan-Sanovel), thiaprofenic acid, and nimesulide (Nise, Nimesil) were the most optimal NSAIDs.
Non-steroidal anti-inflammatory drugs should be taken as needed, it is best to follow the dosing schedule, and even can be started 1-2 days before the onset of menstruation.