​ INTRODUCTION

DYSMENORRHEA: Dysmenorrhea is a cyclical lower abdominal or

pelvic pain which may additionally radiate to the back and thighs; it
starts before or during menstruation, or both. Cramps and pain are felt
in the pelvic after regular ovulation is established. It begins soon after
menarche . It is most common gynecological problem among adolescent
and adult female 17 .. Prevalence of dysmenorrhea ranging between
50% to 90% notably among international locations worldwide.21 In India
prevalence of dysmenorrhea in college college students is 70%.(11)

Menstrual disorder is a common complication by late adolescents, 75%

of females undergoes some complications related to menstruation (1).
Dysmenorrhea is a common complication in women of reproductive age.
Affected girls revel in sharp, intermittent pain commonly focused in the
supra- pubic area. Pain may radiate to the back of the legs or the lower
lower back. Systemic signs of dysmenorrhea is nausea, vomiting,
diarrhea, fatigue, mild fever and headache or lightheadedness are
maximum typical signs and symptoms . Pain starts within few hours of
the begin of the menstruation and peaks till 2 days because of heaviest
flow. (3). It is commonly possible to distinguish dysmenorrhea from pre
menstrual syndrome (PMS) based mostly on patients records. The pain
related to PMS is typically related to breast tenderness and pelvic
bloating as rather than pelvic cramping pain. PMS symptoms begin in
earlier than the menstrual cycle and disappear after menstrual float
starts (3). Painful menstruation with pelvic pathology is described as
secondary dysmenorrhea.7
.Dysmenorrhea is most frequent amongst college students and is related
to high school absenteeism, potential to take part in and experience
every day sports, and regulations in social activities/functioning.8 Older
women tended to lower prevalence of primary dysmenorrhea in compare
to adolescent females.13
Based in this pathogenesis, the maximum standard drugs used to
alleviate dysmenorrhic ache is non-steroidal anti inflammatory drugs
inclusive of ibuprofen and diclofenac sodium.14
Dysmenorrhea occurs more in females who are not using oral
contraceptives. A correlation (p <0.01) is observed among early
menarche and an increased severity of dysmenorrhea. (5)

TYPES OF DYSMENORRHEA
Dysmenorrhea has divided into 2 types .
1) primary
2) secondary

1.Primary dysmenorrhea:Primary dysmenorrhea is defined as painful

menses in which there can be no identifiable pelvic pathology.(normal
pelvic anatomy) usually starts during adolescents(2)

2.secondary dysmenorrhea :secondary dysmenorrhea is menstrual pain

related with any pathology ,and it's onset may be years after menarche.

3.premenstrual syndrome
Premenstrual syndrome (PMS)is a psychoneuroendocrine disorder of
not known etiology ,often noticed just before to menstruation.

1.primary dysmenorrhea
Incidence: The incidence of primary dysmenorrhea is 15–20 % With the
use of oral contraceptives and non-steroidal anti inflammatory drugs,
there may be a marked reduction of the symptom. In india, study
reported that prevalence of primary dysmenorrhoea is 75% among
adolescents girls.6

Causes of pain: The mechanism of initiation of uterine pain in primary

dysmenorrhea is tough to understand . But the following are too regularly
related. ​
Mostly restricted to adolescents. ​
Almost normally limited to ovulatory cycles. ​
The ache is typically cured following pregnancy.
 The pain is associated with dysrhythmic uterine contractions and
uterine hypoxia.
1. Psychosomatic elements of anxiety and tension during adolescents;
decreases the pain threshold.
2. Abnormal anatomical and sensible factor of myometrium. In cases
with primary dysmenorrhea uterine myometrial hyperactivity has been
observed.
The outer myometrium and the subendometrial myometrium are
discovered to be tough structurally and functionally. The subendometrial
layer of myometrium is called Junctional Zone (JZ). There is marked
hyperperistalsis of the JZ in females with endometriosis and
adenomyosis. In women with dysmenorrhea huge changes in JZ are
visible. These consist of irregular thickening and hyperplasia of smooth
muscle and less vascularity. This is known as Junctional location
hyperplasia. Dysperistalsis and hyperactivity of the uterine JZ are the
main mechanisms of primary dysmenorrhea.
3. Variation within the autonomic nervous control of the uterine muscle.
There is overactivity of the sympathetic nerves → hypertonicity of the
circular fibers of the isthmus and inner os. The relieve of pain following
dilatation of the cervix or following vaginal transport can be described by
the harm of the adrenergic neurons which fail to regenerate.

4. Role of prostaglandins In ovulatory cycles, below the activity of

progesterone, prostaglandins (PGF2 α, PGE2 ) are synthesized from the
secretory endometrium. Prostaglandins are released with maximum
production during dropping of the endometrium. PGF2 is a strong
vasoconstrictor which causes ischemia of myometrium.

5. Role of vasopressin:In women with primary dysmenorrhea release of

vasopressin increased during menses. This shows the persistance of
ache in cases even treated with antiprostaglandin tablets. Vasopressin
increases prostaglandin synthesis and moreover will increase
myometrial activity. It causes uterine hyperactivity and dysrhythmic
contractions → ischemia and hypoxia → pain.

6. Endothelins causes myometrial smooth muscle contractions,

particularly in the endomyometrial Junction (JZ). Endothelins in
endometrium can prompt PFG2α. Local myometrial ischemia caused by
endothelins and PGF2α aggravate uterine dysperistalsis and
hyperactivity.

7. Platelet-activating detail (PAF) is also related to the etiology of

dysmenorrhea as its concentration is found excessive. Leukotrienes and
PAFs are vasoconstrictors and stimulate myometrial contractions.

Clinical functions: ​The pain starts earlier or at the onset of

menstruation. The severity of ache generally lasts for few hours, may
also extend from 24 hours to 48 hours. There have been 23 signs and
symptoms grouped underneath 4 areas, including, gastrointestinal Signs
(GI), psychological signs and symptoms (PS), eliminational signs (ES),
and different bodily symptoms. The gastrointestinal symptoms had been
lack of appetite, accelerated urge for food, nausea, vomiting, anorexia,
and gaseous distension of abdomen. The mental signs and symptoms
have been depression, excitability, irritability, lack of ability to
concentrate on work, and anxiousness. Elimination signs had been:
constipation, diarrhea, frequency of micturition, and profuse sweating.
Other physical symptoms have been lethargy and tiredness, headache,
sleeplessness, accelerated sleep, fullness and tenderness of breasts,
feeling of heaviness in the lower abdomen, ache and swelling inside the
ankle and knee joints, and swelling of face.
These 23 signs and symptoms related to menstruation and
dysmenorrhea was ranked from the maximum found on the day earlier
than menstruation and to the day after stoppage of menstruation. This
ranking was done on the basis of the percentage of girls who underwent
every symptoms .
Three maximum common signs and symptoms present on each days,
that is, the day earlier and first day of menstruation had been lethargy
and tiredness (first), depression (second), and lack of ability to pay
attention on work (third), while, the ranking of these symptoms on the
day of menstruation showed headache and anorexia as the eighth
common symptom. Irritability has been the second-maximum common
symptom during the day before menstruation, and it end up much less
on the first day of menstruation and the day after menstruation. Swelling
of face become the least experienced trouble by the females, among the
total of 23 listed symptoms.10 Although using oral contra- ceptives is
another famous relieving factor of dysmenorrhea.12

2) SECONDARY
DYSMENORRHOEA
Secondary dysmenorrhea is menstrual pain related to underlying
pathology, and its onset can be years after menarche. It may be
because of any problems consisting of endometriosis, pelvic
inflammatory disorder, intra-uterine devices, abnormal cycles or infertility
issues, ovarian cysts, adenomyosis, uterine myomas or polyps,
intrauterine adhesions, or cervical stenosis(1)
Prevalence of secondary dysmenorrhoea is lower than the primary
dysmenorrhoea. Roghieh kharaghani et al reported that prevalence of
secondary dysmenorrhoea among adolescents is 18% in Iran.9

About 5–8% of women hence suffer from intense premenstrual

syndrome (PMS);.Mood and behavioural signs, together with irritability,
anxiety, depressed temper, tearfulness, and mood swings, are the most
distressing, but somatic lawsuits, inclusive of breast tenderness and
bloating, can also be difficult.(24)
Symptoms are triggered through ovulation and reduce within the first
few days of menses.( 23)

Clinical features​: The ache is dull, situated in the lower back and in
front without any radiation. It typically seems 3–5 days earlier to mensus
and relieves with the start of bleeding. The onset and period of pain
depends at the pathology producing the pain. There is no systemic
complication unlike primary dysmenorrhea. The patients may also have
got a few discomfort even in between periods.
PREMENSTRUAL SYNDROME (PMS)
Premenstrual syndrome (PMS) is a psychoneuroendocrine sickness of
unknown etiology, often observed just previous to menstruation. There is
cyclic look of a massive range of signs during the past 7–10 days of the
menstrual cycle.

Dysmenorrhea is very common in young girls.

The prevalence of dysmenorrhea according to severity as follows;
Without dysmenorrhea-13%
1-4 mild dysmenorrhea-22.92%
5-7 moderate dysmenorrhea-57.08%
8-12 severe dysmenorrhea-20.00%

The WALIDD scale..In this study,WALIDD is used the questionnaire for

dysmenorrhea is a validated & versatile 4 item questionnaire.The
WALIDD estimates the prevalence of dysmenorrhea recognizes the
existence (objective and subjective manifestation of dysmenorrhea).In
the questionnaire, there are 2 questions focused on subjective and same
number of question to rule out objective manifestation individual
questions based on subjective & objective have 4 options to give a
response, which are recorded from 0 to 3 points summing up the scores
by a simple additive manner,also generating mild, moderate & severe
scores ,each varying from 0 to 12 points.Use of WALIDD scores: if the
score of the questions is between 1-4 then it is diagnosed as mild
dysmenorrhea and if the score of the questions is between 5-7 then it is
diagnosed as moderate dysmenorrhea and 8-12 scores were diagnosed
as severe dysmenorrhea.

Risk factors

Family history ;the risk of dysmenorrhea is higher in those who have a

history of dysmenorrhea in their family.
In the study by wiam Rifati and Trini sudiarti(2020) it was reported that
family history of dysmenorrhea was dominant determinant for
dysmenorrhea among adolescents.(OR=6.80)

Emotional factors (pressure) It is visible that stress increases the risk of

dysmenorrhea in girls.In the observe with the aid of Prashant Naik et al
(2015) it was reported that there has been a great changes in
dysmenorrhea throughout stress and non stress circumstance in college
going females.
BMI In this research via madhubala said that relation between
dysmenorrhea and BMI was discovered to be significant (p<0.01) with
increased occurrence within the low BMI group.Hense, poor nutritional
level of adolescent females leads to increase dysmenorrhea.

Excessive sugar consumption habit, age, sexual intercourse, early

menarche and heavy menstrual periods increase the occurrence of
dysmenorrhea.

Another hazard element of dysmenorrhea in female is cigarette

smoking.It is seen that nicotine reduced endometrial blood circulation &
its common in women with dysmenorrhea & smoking is known cause of
vasoconstriction.Hense smoker reviews extra menstrual issues such as
prolong durations than do not smokes.
Numerous medical researches spotlight the effectiveness of
physiotherapy in the aid of dysmenorrhea.Most recent report
recommend that a physiotherapy procedure obtains a positive final
results in maximum of the affected person (with the workout and kinesio
faucet software).