3/24/10

What is dysmenorrhoea (and

does it matter…?)
•  Dysmenorrhoea is painful cramping, usually in the
lower abdomen, occurring shortly before or during
Dysmenorrhoea menstruation, or both
•  Primary dysmenorrhoea occurs in the absence of any
identifiable underlying pelvic pathology
by
•  Secondary dysmenorrhoea is associated with
A.J. Yates underlying pelvic pathology (such as endometriosis,
fibroids, or endometrial polyps).

Some facts and figures Aims and objectives

•  Dysmenorrhoea is the most common gynaecological symptom
reported by women
•  It affects between 50% and 90% of menstruating women. The
wide variation in reported prevalence rates is probably due to
differences in definition
•  It can lead to absence from school or work; 13–51% of women
report ever having been absent and 5–14% report being
frequently absent because of dysmenorrhoea
•  Despite the high prevalence of dysmenorrhoea and the impact
it has on quality of life and general well-being, few women
seek medical treatment for dysmenorrhoea.
•  Consider the underlying causes of primary
dysmenorrhoea
•  Look at common orthodox treatments for
dysmenorrhoea
•  Look at herbs and supplements that can help
alleviate the symptom of dysmenorrhoea
•  Consider our differential diagnosis
•  Review some case studies.

What can cause primary

The orthodox approach
dysmenorrhoea?
•  Strong, frequent uterine contractions lead to •  Lifestyle changes
ischaemia of the uterine muscle •  NSAID’s
•  Can be caused by in imbalance of
•  Oral contraception
prostaglandins and endogenous hormones
•  Other factors may contribute: •  Medroxyprogesterone acetate
–  Poor diet •  Mirena IUD
–  Digestive problems •  Laparoscopic uterine nerve ablation
–  Lack of exercise
•  Hysterectomy.
–  Stress.

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Eicosanoids
•  A family of hormone-like substances which regulate
ovulation, menstruation, and labour
•  Include prostaglandins, leukotrienes and
thromboxane
•  Identified by different series:
–  Series 1 are derived from linoleic acid and γ-linolenic acid,
and are anti-inflammatory
–  Series 2 are derived from arachidonic acid and are largely
pro-inflammatory
–  Series 3 are derived from eicosapentaenoic acid and reduce
abnormal blood clotting.
Prostaglandins
•  A number of different eicosanoids have a role to play
the menstrual cycle
•  Some prostaglandins are pro-inflammatory, and their
levels are elevated in women that suffer from
dysmenorrhoea
•  PGE1 is also known as the ‘good’ prostaglandin, and
is anti-inflammatory
•  At the end of the day, getting the balance right is key
•  But how are these substances formed…?

Okay… So what do we need to know…?

•  Changing the amounts of source materials for
the different eicosanoids can change the ratios
of series 1 and series 2 prostaglandins
•  These source materials are derived from our
diet
•  Increasing sources of linoleic acid and α-
linolenic acid relative to arachidonic acid will
have an anti-inflammtory effect.

Which are the sources? Aims of phytotherapy

•  Examples of sources to encourage: •  Consider the use of:
–  Dark green leafy vegetables
–  Anodynes
–  Pumpkin seeds, linseeds
–  EPO, soya bean oil, star flower oil –  Uterine tonics
–  Fish oils (especially good for omega 3) –  Emmenagogues
–  Relaxants
•  Examples of sources to discourage: –  Circulatory stimulants
–  Meat
–  Hormone regulation
–  Eggs.
–  Digestive support.

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Anemone pulsatilla Alchemilla vulgaris

Artemisia vulgaris Valeriana officinalis

Viburnum spp. Zingiber officinale

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Achillea millefolium Vitex agnus-castus

Taraxacum officinale Supplementation

•  Number one priority is to get the diet right
•  Some nutrients are thought to regulate
prostaglandin levels and/or reduce pain:
–  EFA’s from EPO or fish oils
–  Magnesium
–  Calcium
–  Zinc
–  Vitamin B6
–  Vitamin E.

Differential diagnosis Case study 1

•  The following can involve secondary •  Female, aged 29 years
dysmenorrhoea: •  PC – dysmenorrhoea & menorrhagia
–  Endometriosis •  PMH – been on the contraceptive pill since aged 16
–  Chronic PID years due to above symptoms. Treated for
endometriosis aged 20 years – laparoscopy two years
–  IUD
later showed NAD. Miscarriage aged 26 years.
–  Pelvic congestion syndrome Symptoms worsened six months ago – GP has just
•  If in doubt, refer. prescribe analgesics and advised her to “keep a
diary”.

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Case study 1 (cont)
•  NS – suffers with insomnia; usually only
manages five or six hours sleep a night.
•  DS – weight stable; 2 x BM/day. Has had IBS
but asymptomatic for past two years. Has a
tendency to eat lots of wheat and chocolate at
present due to stress.
•  P/E – some tenderness in suprapubic region
and left iliac fossa. Patient complained of
feeling bloated. No lymphadenopathy.
Case study 1 (cont)
•  Rx 2
Vitex agnus-castus 1:1 – 20
TOTAL = 20 ml
Sig – 20 gtt od mane
•  Rx 3 (not to be taken with main mix)
Anemone pulsatilla (specific) 1:1 – 20
Valeriana officinalis 1:1 – 40
Viburnum prunifolium 1:1 – 40
TOTAL = 100 ml
Sig – 5 ml every two hours prn
Case study 1 (cont)
•  Third consultation
•  Generally patient is happy with the treatment.
All symptoms are still improved, although
period is still longer than usual (14 days), and
needs the pain mix regularly.
•  GP has arranged for a laparoscopy.
•  Repeated Rx.
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Case study 1 (cont)
•  Rx 1 main mix:
Alchemilla vulgaris 1:5 – 20
Anemone pulsatilla (specific) 1:1 – 15
Centella asiatica 1:4 – 20
Cimicifuga racemosa 1:1 – 15
Taraxacum officinale (radix) 1:3 – 10
Viburnum prunifolium 1:1 – 20
Zingiber officinale 1:2 – 5
TOTAL = 105 ml x 3
Sig – 5 ml tds ac caq
Case study 1 (cont)
•  Second consultation:
•  GRS – Had just had a period; bleeding had been
lighter. Pain mix had worked really well – hadn’t
needed to take any analgesics.
•  NS – sleep improved (patient felt that pain had been
contributing to her insomnia). Mood has been up &
down (is still feeling stressed).
•  DS – NAD. Advised to increase fruit & veg, and try
to cut down protein intake. Had started taking a
multi-vitamin & mineral plus hemp seed oil.
•  Rx – repeated all Rx, but added a calming tea.
Case study 1 (cont)
•  Fourth consultation
•  Telephone conversation with patient.
Laparoscopy had shown patient to be suffering
from PID.
•  Referred to a consultant, so patient decided to
suspend herbal treatment.
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Case Study 2
•  Female, aged 39 years
•  PC – PMS: mainly dysmenorrhoea about five
days before period until two days after. Also
suffers from nausea, mood swings, and
mastalgia about the same time, and suffers
from some menorrhagia during the period.
•  PMH – treated for GU & PU aged 26 years.
History of depression; currently been on SSRI
for the past two years.
Case study 2 (cont)
•  Rx 1 main mix:
Anemone pulsatilla (specific) 1:1 – 15
Cimicifuga racemosa 1:1 – 15
Glycyrrhiza glabra 1:1 – 10
Taraxacum officinale (folia) 1:1 – 20
Taraxacum officinale (radix) 1:1 – 15
Viburnum prunifolium 1:4 – 20
Zingiber officinale 1:2 – 5
TOTAL = 100 ml x 2
Sig – 5 ml tds ac caq
Case study 2 (cont)
•  Second consultation:
•  GRS – not had any PMS symptoms (would normally
have had them by now). Is due a hysterectomy next
month but is going to postpone.
•  DS – diet improved (is taking hemp seed oil).
Asymptomatic (but is still taking omeprazole).
•  NS – mood stable; will talk to GP about reducing
amount of SSRI.
•  Rx – repeated x5 (except pain mix as not needed yet).
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Case stud 2 (cont)
•  DH – currently taking an SSRI & omeprazole. Was
given a medroxyprogesterone acetate injection
fourteen months ago due to her dysmenorrhoea, but
then bled continuously for nine months. Due a
hysterectomy, but did not have it due to bleeding.
•  DS – generally okay with the omeprazole.
•  NS – mood stable; some insomnia.
•  P/E – tenderness in epigastric, umbilical, suprapubic
regions, and right iliac fossa. No lymphadenopathy.
Case study 2 (cont)
•  Rx 2
Vitex agnus-castus 1:1 – 20
TOTAL = 20 ml
Sig – 20 gtt od mane
•  Rx 3 (not to be taken with main mix)
Anemone pulsatilla (specific) 1:1 – 20
Valeriana officinalis 1:1 – 40
Viburnum prunifolium 1:1 – 40
Zingiber officinale 1:2 – 5
TOTAL = 105 ml
Sig – 5 ml every two hours prn
Case study 2 (cont)
•  Third consultation
•  GRS – still no PMS symptoms. Dysmenorrhoea is
less, and is relieved by pain mix. Menorrhagia is
reduced.
•  SH – friend recently died.
•  DS – diet poor at the moment, but generally
improved.
•  NS – sleep disturbed at the moment, but is generally
okay.
•  Rx – repeated Rx x5, but added another calming tea.
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Case study 2 (cont)
•  Fourth consultation.
•  GRS – all symptoms improved. Only needed
pain mix on one day. Bleeding lighter.
•  DS – diet has improved. Has gained four kg
and feels better for it.
•  NS – mood stable, sleep improved. Has now
weaned herself off of the SSRI.
•  SH – started doing yoga and meditation.
•  Repeated Rx x5.
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Case study 2 (cont)
•  Fifth consultation.
•  GRS – symptoms unchanged. Feels that she
can manage them and does not feel the need
for a hysterectomy.
•  All other symptoms fine.
•  Is due to move from the area – will take a
stock of herbs, but will try without them once
settled. Will contact me if she requires further
treatment or details of a herbalist in the area.