Dysmenorrhea

(2005)

Philippine Obstetrical and

Gynecological Society, Inc.
POGS Bldg., 56 Malakas St., Diliman, Quezon City
Tel # 921-7557, 435-2384/85 Telefax # 921-9089
Email address: pogs@pworld.net.ph
Website: www.pogs.org.ph

Officers and Board Members

President
Vice President Ma. Corazon Zaida Noblejas-Gamilla, M.D.
Secretary Lourdes Blanco-Capito, M.D.
Treasurer Ditas Cristina D. Decena, M.D.
P.R.O. Sylvia delas Alas-Carnero, M.D.
Christina S. Padolina, M.D.
Trustees
Mayumi S. Bismark, M.D.
Gil S. Gonzalez, M.D.
Enrico Gil C. Oblepias, M.D.
Blanca C. De Guia, M.D.
Ma. Carmen Hernandez-Quevedo, M.D.
Regta L. Pichay, M.D.
Immediate
Past President Rogelio P. Mendiola, MD
 Dysmenorrhea

Algorithm for the Management of Primary Dysmenorrhea

Primary
Dysmenorrhea

2


• NSAIDs
• COX-2 inhibitors
• OCPs
• Lifestyle Mo­difi­­cation and
Stress Ma­nage­­ment

3 4


Y
Effective?  Follow-up care

N
5


Laparoscopy for
the diagnosis
and surgical
management of
endometriosis

Figure 1

97
Dysmenorrhea

Algorithm for the Management of Secondary Dysmenorrhea

Due to Endometriosis

Endometriosis

2


1st line drugs:

• Danazol
• GnRH agonists
• Progestins

4
3


Follow-up care;
Y Additional
Effective?  diagnostic
evaluation

N
5


Laparoscopy
via laparotomy

Figure 2

98

Dysmenorrhea
Author: Sylvia delas Alas-Carnero, M.D., FPOGS
Dysmenorrhea is painful menstrual cramps. Primary
dysmenorrhea is menstrual pain without pelvic patho­logy,
whereas secondary dysmenorrhea is painful menses with
underlying pathology.
Current understanding on primary dysmenorrhea impli-
cates an excessive or imbalanced amount of prostanoids
and possible eicosanoids released from the endometrium
during menstruation. The uterus is in­duced to contract
frequently and dysrrhythmically. Likewise, arachidonic
acid is released following the reduction of progesterone
prior to menstruation, initiating flux of inflammatory pros-
taglandins and leukotrienes in the uterus. At the same
time, cyclooxy­genase metabolites of arachidonic acid,
prostaglandins E2 and F2, cause vasoconstriction and
myometrial contractions. Uterine hypercontractility, re-
duced ute­rine blood flow, and increased peripheral nerve
hyper­sensitivity induce pain in menstrual cramps.
In the US, approximately 40% of adult females have men-
strual pain, and 10% are incapacitated for 1-3 days each
month. While primary dysmenorrhea is not life threaten-
ing, it is the most common reason women miss work.
Dysmenorrhea is a leading cause of absenteeism for
women younger than 30 years. Diagnose dysmenor­rhea
only after serious causes of pelvic pain are excluded.
In the evaluation of dysmenorrhea, laboratory studies are
indicated to exclude serious causes of pelvic pain and
include the following:
1. quantitative human chorionic gonadotropin
2. complete blood count
3. urinalysis
4. ESR
5. stool guiac
Pelvic ultrasound is the imaging study of choice for ini-
tial evaluation of pelvic disease. Clinical indications for
ultrasound include the following:
1. pregnancy-related bleeding
2. evaluation of palpable mass
3. evaluation of infection
4. pelvic pain
5. localization of IUD or foreign body
6. trauma
Gynecologic consultation with visualization of the pelvic
organs is the definitive procedure of choice for evalu-
ation.
Among adolescent with dysmenorrhea, the first line of
treatment are NSAIDs. COX-2 specific inhibitors are ben-
eficial since they are comparable to nonspecific NSAIDs
in terms of onset, magnitude and duration of analgesic
effect, but with demonstrable improved GI safety profile.
If unrelieved, adolescents with pelvic pain are treated with
cyclic combination of monophasic OCPs and NSAIDs.
An option for women who do not wish to become preg-
Dysmenorrhea
nant, continuous use of oral contraceptives, without the
hormone free interval, is a safe and effective method to
relieve symptoms and ultimately induce amenorrhea. If
pain still does not respond to NSAIDs and OCPs, lapa­
roscopy is recom­mended for the diagnosis and surgical
management of endometriosis.
For adult women in whom endometriosis is the sus­pected
cause of pain, laparoscopic confirmation of the diagnosis
is unnecessary and a trial of 1st line, including 2nd line
medical therapies, such as danazol, GnRH agonists and
progestins is justified. The choice between the combined
progestogens, danazol, and GnRH depends principally
upon their side effect pro­files be­cause they relieve pain
associated with endo­metriosis equally. No single agent
can be demonstrated to be truly efficacious. Research
on selective progesterone receptor modulators has been
promising, preliminary investigations show effectiveness
in reducing symptoms as well as minimal side effects.
However, further investigation of these agents is still
required. When surgery is necessary, laparos­copic ap­
proach seems to offer comparable clinical outcomes
to those performed via laparotomy, but with significant
reduced morbidity.
Recently, there has been an increase in popularity of
natural remedies. The trend is towards lifestyle modifi-
cation and searching for alternative approaches to the
management of this debilitating condition.
Dietary habits have been correlated with dysmenor-
rhea. Those with primary dysmenorrhea were found to
consume less fruit, eggs, and fish than those without
menstrual pain. Studies on vitamin E at a dose of
200 IU twice per day for 5 days during the beginning
of menstruation significantly reduces the severity
and duration of dysmenorrhea. Tocopherol has been
shown to reduce release of arachidonic acid from
phos­­pholipids, resulting in decrease in formation of
infla­mmatory prostaglandins. Alpha-tocopherol, which
crosses the blood-brain barrier, also has modulating
effects on neurotransmitters. Likewise, Omega-3 fatty
acids found in fish oils trigger secretion of less potent
leukotrienes and anti-inflammatory prostaglandins, by
competing with Omega-6 species, mainly arachidonic
acid, for the enzyme prostaglandin synthase, resulting
in decreased menstrual pain. Another diet therapy in the
form of Vitamin B1 appears to be effective at a dose of
100 mg/day. Although dietary therapies are pro­mising,
overall no strong recommendations can be made due to
both the small number and small size of trials. Further
investigation is therefore warranted.
Aromatherapy was found to be effective in decreasing
the severity of menstrual cramps and can be offered as
part of the nursing care for women experiencing dys-
menorrhea. Substances such as Lavender, clary sage,
and rose in almond oil are applied topically in the form
abdominal massage.
Association between stress and dysmenorrhea has been
99
Dysmenorrhea
the subject of recent studies. The risk of dysmenorrhea
was found to be more than twice as great among women
with high stress compared to those with low stress.
Stress in the follicular phase of the preceding cycles had
a stronger association with dysmenorrhea than stress
in the luteal phase of the preceding cycles. Therefore,
stress reduction programmes aimed at reproductive aged
women, especially those with a history of dysmenorrhea,
may be considered as possible preventive strategies to
reduce the occurrence of dysmenorrhea.
Patients with pelvic pain should see their primary care
physician for follow-up care, since treatment is ongo-
ing and additional diagnostic evaluation for continued
symptoms may be required. In today's climate of man­
aged care, refer to primary care physician. Having a
back-up list of clinics that provide health care to pa­tients
who do not have access to a primary care phy­si­cian is
extremely helpful.
Dysmenorrhea may be misdiagnosed and underly-
ing pathology missed if initial laboratory studies and
physical examination with close follow-up care are not
provided. Anxiety, depression, or both may result. In­-
­fer­tility secondary to underlying pathology is a possi­ble
complication.
Prognosis for primary dysmenorrhea is excellent with
the use of antiprostaglandins. Some studies have noted
relief as high as 80%. Surgical treatment for primary dys-
menorrhea has had variable success and is deter­mined
by the gynecologist.
Table 1. Cyclic Pain: Primary and Secondary
Dysmenorrhea
Primary Secondary
Dysmenorrhea Dysmenorrhea
History Pain usually starts The patient may
within 24 hours of have onset of pain
menses and may a week or more
last for 48-72 prior to the onset
hours of menses, and
pain may continue
for a few days after
ces­sation of flow
Physical Vital signs are nor- Vital signs may
Exami- mal; Pelvic exami- vary depending on
nation nation may dis- the underlying
close a tender ute- etiology. Pelvic
rus but no cervical examination may
motion tenderness reveal an enlarged
or adnexal abnor- uterus tender
malities on palpation. Adne-
xal tenderness and
enlargement may be
noted. There may
be nodularities in
the uterosacral liga-
ments and recto-
vaginal septum

Causes Elevated produc- Endometriosis,

tion of prostaglan- Adenomyosis,
dins and other pelvic infection,
mediators in the intrauterine device,
uterus cervical stenosis,
congenital uterine
or vaginal abnor-
malities, leiomyoma

Risk Nulliparity Pelvic infection

Factors Obesity Sexually transmit-
Cigarette smoking ted diseases
Positive family Endometritis
history
Stress

Treat- Prostaglandin syn- Treatment of

ment thase inhibitors; specific underlying
Oral contraceptive disorder
pill;
Narcotics;
Acupuncture;
TENS

100
 Dysmenorrhea
Recommended Therapeutics
(Drugs Mentioned in the Treatment Guideline)
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class.

Analgesics Indomethacin Flanax/Flanax Forte

Infree Naprosyn Lle/
Non-Narcotic Analgesics Ketoprofen Naprosyn Lle Forte
Drugmaker’s Biotech Piroxicam
Coxibs Ketoprofen Drugmaker’s Biotech
Etoricoxib Ketotop Piroxicam
Arcoxia/Arcoxia AC Orudis EC Feldene/Feldene Flash
Celecoxib Orudis IV Flamastat
Celebrex Ketorolac Macroxam
Celexib Kortezor Parixam
Flamar Remopain Pirostad
Toradol Proximax
NSAIDS Mefenamic Acid Proglumetacin
Aceclofenac Algifort Afloxan
Clanza Analcid Tenoxicam
Acemetacin Aprostal Tilcotil
Rantudil Atmose
Diclofenac Calibral Para-Aminophenol Derivatives
Abicfen Dli Mefenamic Acid Paracetamol
Cataflam Dolfenal Aldep
Cataflam Qs Dolmetine Alvedon
Denkoran Dolsten Baropyrine
Difenax Drugmaker’s Biotech Biogesic
Dolfastad Mefenamic Acid Calpol/Calpol Six Plus
Doloflam Eurostan Crocin
Drugmaker’s Biotech Gardan DLI Paracetamol
Diclofenac Gisfen Dolexpel
Neo-Pyrazon/Neo-Pyrazon SR Icelax Drugmaker’s Biotech
Nepenthe Istan Paracetamol
Voltaren Mecid-A Geran
Voltaren Emulgel Medianon Medgenol
Glucosamine sulfate Mefedon Meforagesic
Viartril-S Mefenax Naprex
Ibuprofen Pacimic Naprinol
Advil Pharex Mefenamic Acid Neo-Kiddielets
Alaxan Ponstan Opigesic
Alaxan FR Ralgec Pharex Paracetamol
Anoflam Revalan Pynal
Dolan FP Ritemed Mefenamic Acid Rexidol
Drugmaker’s Biotech Paracetamol + Selmac Ritemed Paracetamol
Ibuprofen Sigarax Saridon
Idyl SR Spegic Temperal
Laberfen Stangesic Tempra/Tempra Forte
Medicol Tynostan Tylenol
Midol Zapan Ultragesic
Muskelax Meloxicam Paracetamol/Vitamin B-Complex
Nurofen Syrup Meloflam Dolo-Neurobion
Relaxid Melora Paracetamol/Chlorzoxazone
Restolax Mobic Parafon Forte
Restolax Forte Naproxen
Selxan Agapro Salicylates
Skelan Forte Alpron Aspirin (Acetylsalicylic acid)
Indomethacin Drugmaker’s Biotech Bayer Aspirin
Drugmaker’s Biotech Naproxen Cortal

101
Dysmenorrhea
OPIATES & ANTAGONISTS Progestogens (Progestins)
Allylestrenol
Opiates & Antagonists Turinal
Butorphanol Dydrogesterone
Stadol Duphaston
Fentanyl Femoston*
Durogesic Hydroxyprogesterone caproate
Sublimaze Proluton Depo
Morphine sulfate Medroxyprogesterone acetate
Hizon Morphine Sulfate Depo-Provera
Relimal CR Depotrust
Nalbuphine Lyndavel
Nubain Premelle 2.5/Premelle 5*
Tramadol Premelle Cycle 5 *
Dolcet Provera
Dolotral Norethisterone
Milador Noristerat
Milador Inj Primolut N
Milador-Retard
Siverol GnRH agonists
Tdl Leuprorelin acetate
Tramal Luprolex
Goserelin acetate
Oral Contraceptives Zoladex/Zoladex LA
Desogestrol
Cerazette Antiestrogens (Ovulation
Desogestrel/Ethinylestradiol Inducers)
Gracial Bromocriptine mesylate
Marvelon 28 Parlodel
Mercilon Provasyn
Drospirenone/Ethinylestradiol
Angeliq
Yasmin
Gestodene/Ethinylestradiol
Gynera
Meliane
Minulet
Levonorgestrel/Ethinylestradiol
Femenal
Lady
Logynon
Microgynon 30
Nordette
Nordiol 21
Rigevidon 21 + 7
Seif
Tri-Regol
Trinordiol
Trust Pill
Lynestrenol
Daphne
Exluton
Norethisterone/Ethinylestradiol
Kliogest
Micropil
Norgestrel/Ethinylestradiol
Femenal

Androgens
Danazol
Ladogal

102