Dysmeno 2

Management of Dysmenorrhea
Paula J. Adams Hillard, MD
Slide Source: Contraception Online www.contraceptiononline.org
Management of Dysmenorrhea Dysmenorrhea is defined as painful menstruation. Primary dysmenorrhea usually begins during adolescence and occurs in women with normal pelvic anatomy. Dysmenorrhea is the most common cause of absence from school and work in the adolescent age group. Secondary dysmenorrhea is dysmenorrhea that occurs due to genital tract pathology, such as uterine leiomyomata or endometriosis. Treatment approaches include the use of nonsteroidal antiinflammatory drugs (NSAIDs) to block the production and action of prostaglandins, which are responsible for the cramping and pain. Hormonal contraceptives are also a useful treatment, and act by decreasing menstrual blood loss and the endometrial production of prostaglandins.
Pathogenesis of Dysmenorrhea
During Menstruation: prostaglandin synthesis markers of inflammation
Causes of dysmenorrhea: uterine blood flow uterine contractility Peripheral nerve hypersensitivity
Dawood MY. Obstet Gynecol. 2006;108:428-441.
Pathogenesis of Dysmenorrhea
Source: Contraception Online (www.contraceptiononline.org) 2007 Baylor College of Medicine, Houston, Texas, USA
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Increased prostaglandin synthesis and inflammatory processes during menstruation result in uterine contractions and vasoconstriction. This uterine hypercontractility and ischemia lead to pain and other symptoms, including diarrhea. As such, agents that reduce prostaglandins, such as nonsteroidal antiinflammatory drugs and hormonal contraceptives, are used to treat dysmenorrhea. Reference: Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428-441.
Diagnosis of Primary Dysmenorrhea

Onset in early adolescence Symptoms begin immediately before or at the
onset of menstrual bleeding

Pain not present at other times in the cycle Most severe on first and/or second day of
menses
Diagnosis of Primary Dysmenorrhea Primary dysmenorrhea begins in early adolescence, within 1 to 2 years of menarche, with the onset of ovulatory cycles. Dysmenorrhea is characterized by fluctuating, spasmodic menstrual cramps that typically begin a few hours before or at the onset of menstrual flow. The symptoms of primary dysmenorrhea are usually most intense in the first 2 to 3 days of flow. The pains are suprapubic in location, but may also radiate to the thighs. The cramps may be accompanied by backache, nausea or vomiting, and diarrhea. Severe dysmenorrhea is frequently a cause of absences from school or work. The typical history and absence of any positive findings in a general physical examination are key diagnostic features. The history characteristically includes the proximity of the onset of primary dysmenorrhea to menarche, the characteristic description and location of crampy pain, the onset of symptoms with the beginning of menstrual flow, and the duration of pain confined to the first few days of menses. A pelvic examination is not required in the presence of this characteristic history. If pain is not relieved with appropriate treatment with nonsteroidal antiinflammatory drugs, pelvic ultrasonography can be used to demonstrate normal anatomy and, substituting for a
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pelvic examination, is typically unrevealing in young adolescents who are unable to tolerate the exam. References: Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428-441. Hillard PJ. Consultation with the specialist: dysmenorrhea. Pediatr Rev. 2006;27:64-71.
Characteristics of Secondary Dysmenorrhea

Low anterior pelvic pain May begin before onset of menses and last
through the end of menstruation
May be noncyclic May be accompanied by pelvic tenderness or
a pelvic mass
French L. Am Fam Physician. 2005;71:285-291.
Characteristics of Secondary Dysmenorrhea Secondary dysmenorrhea involves lower pelvic pain that occurs during menstruation, but may also occur during other phases of the cycle. It often results from another genital tract pathology and may be accompanied by pelvic tenderness or a pelvic mass. For example, women with uterine fibroids, endometriosis, or pelvic inflammatory disease may experience symptoms of secondary dysmenorrhea. Reference: French L. Dysmenorrhea. Am Fam Physician. 2005;71:285-291.
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Incidence of Dysmenorrhea in Young Women

Symptom Grade Wilson & Keye (N=88) Mean age 15 Sundell et al. (N=460) Age 19 Age 24
0 (none) 1 (mild) 2 (moderate) 3 (severe) Absenteeism*
9% 27% 41% 23% 26%
28% 35% 23% 15% 51%
33% 35% 22% 10% 34%
*Missed school or work.

Wilson CA, et al. J Adolesc Health Care. 1989;10:317-22; Sundell G, et al. Br J Obstet Gynaecol. 1990;97:588-94.
Incidence of Dysmenorrhea in Young Women The prevalence of dysmenorrhea is greatest in adolescent girls and young women. Symptoms of dysmenorrhea often decrease with increasing age and after giving birth. A longitudinal study conducted in Sweden by Sundell et al. investigated the incidence and severity of dysmenorrhea in females at age 19 with a 5-year follow-up assessment. Dysmenorrhea was defined as: Grade 0, menstruation not painful, daily activity unaffected; Grade 1, menstruation painful but seldom inhibits womans normal activity, analgesics seldom required, mild pain; Grade 2, daily activity affected, analgesics required and give relief so absence from work/school unusual, moderate pain; Grade 3, activity clearly inhibited, poor effect of analgesics, somatic symptoms (e.g., headache, tiredness, nausea, vomiting, diarrhea, severe pain). The first assessment was based on questionnaire data from 596 women; the second assessment was based on questionnaire data returned by 489 women from the original study group. The incidence of severe dysmenorrhea declined over time, and mild or moderate dysmenorrhea remained almost the same in young women first assessed at age 19 and assessed a second time at age 24. The functional impact imposed by severe dysmenorrhea was evident from school and work absenteeism, which was 51% at age 19 and 34% at age 24 years. The prevalence and severity of dysmenorrhea was decreased in parous young women compared with those who were nulliparous. A study conducted by Wilson et al. in the United States (N=88) found that 91% of surveyed high school adolescents (ages 1418) had dysmenorrhea. Among respondents, symptoms affected academic work (55%) and sometimes resulted in missed classes (26%).
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References: Sundell G, Milsom I, Andersch B. Factors influencing the prevalence and severity of dysmenorrhea in young women. Br J Obstet Gynaecol. 1990;97:588-594. Wilson CA, Keye WR Jr. A survey of adolescent dysmenorrhea and premenstrual symptom frequency: a model program for prevention, detection, and treatment. J Adolesc Health Care. 1989;10:317-322.
Incidence of Dysmenorrhea Among Patients in Primary Care Settings

Percent age of Women Reporting
60
54%
40
22%
20
14%
10%
Always
Often
Sometimes
Never
Frequency of Dysmenorrhea
Jamieson DJ, Steege JF. Obstet Gynecol. 1996;87:55-58.
Incidence of Dysmenorrhea Among Patients in Primary Care Settings Women between the ages of 18 and 45 years (n=581) who were visiting select obstetrics and gynecology and family practices in a community were queried about pelvic pain via a questionnaire. The mean age of the women was 32 years, and three-quarters were white. Some degree of dysmenorrhea was reported by 90% of the participants. Of the women who reported dysmenorrhea, 26% experienced pain 3 days per month, and 7% reported missing 1 days of work per month. Over-the-counter pain medication was used by 74% of the women to treat their symptoms. Reference: Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol. 1996;87:55-58.
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Treatment Approaches for Dysmenorrhea

Nonsteroidal antiinflammatory drugs (NSAIDs) Hormonal contraceptives Combination oral contraceptives Injectable depot medroxyprogesterone
acetate
Levonorgestrel-releasing intrauterine system Danazol Gonadotropin-releasing hormone agonists Complementary and alternative approaches
Treatment Approaches for Dysmenorrhea Nonsteroidal antiinflammatory drugs (NSAIDs) should be considered first-line therapy for dysmenorrhea. Many women use over-the-counter NSAIDs for pain relief before soliciting assistance from a clinician. Women who do not experience relief with an NSAID and desire contraception, may benefit from the use of a hormonal contraceptive such as an oral combination contraceptive, injectable depot medroxyprogesterone acetate, or the levonorgestrel-releasing intrauterine system (IUD). These methods reduce the amount and duration of menstrual flow, resulting in alleviation of menstrual symptoms such as pain. NSAIDs may also be used in conjunction with these hormonal methods. Although danazol and gonadotropin-releasing hormone (GnRH) agonists can be used to suppress the menstrual cycle, these agents are associated with significant side effects and increased costs. Limited evidence supports the use of locally applied heat, supplements (magnesium, calcium, vitamin B6, vitamin E), herbal remedies (rose tea, sweet fennel, fish oil, krill oil), acupuncture, acupressure, and transcutaneous electrical nerve stimulation (TENS) in the treatment of dysmenorrhea. Women who do not experience relief from an NSAID or do not desire contraception may benefit from use of these methods alone or in combination with other therapies. Reference: Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428-441.
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Treatment Approaches for Dysmenorrhea: Nonsteroidal Antiinflammatory Drugs

Effective, over-the-counter generic
medicines for dysmenorrhea

Naproxen Ibuprofen Ketoprofen Other, commonly used over-the-counter
medications do not have proven efficacy

Treatment Approaches for Dysmenorrhea: Nonsteroidal Antiinflammatory Drugs Nonsteroidal antiinflammatory drugs (NSAIDs) are the most commonly used treatments for dysmenorrhea. NSAIDs decrease menstrual pain by decreasing intrauterine pressure and by lowering prostaglandin F2 levels in menstrual fluid. They also have direct analgesic properties at the central nervous system level. Because they are used for short periods in otherwise healthy young women, they are generally well tolerated and free of serious toxicity. Gastrointestinal upset is the most common adverse effect associated with NSAIDs, and patients receiving these medications should be instructed to take them with food; clinicians should be mindful of the possibility of more serious adverse effects, including gastrointestinal bleeding and renal dysfunction. While some NSAIDs have been promoted as being particularly effective for dysmenorrhea, data supporting this contention are not strong. NSAIDs that achieve peak serum concentrations within 30 to 60 minutes and have a faster onset of action (e.g., ibuprofen, naproxen, meclofenamate) may be preferred. Despite some preliminary data suggesting efficacy in patients with primary dysmenorrhea, the newer cyclooxygenase-2 inhibitors have not been demonstrated to be superior to conventional therapies. References: Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428-441. Calis KA. Dysmenorrhea. eMedicine [online]. Available at: http://www.emedicine.com/med/topic606.htm. Accessed February 27, 2007. Marjoribanks J, Proctor ML, Farquhar C. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea. Cochrane Database Syst Rev. 2003;(4):CD001751.
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Using Over-the-Counter NSAIDs to Treat Dysmenorrhea: Patient Counseling

Prophylactic dosing Loading dose Duration of action Scheduled dosing versus PRN (i.e., as
needed)
NSAIDs = nonsteroidal antiinflammatory drugs
Using Over-the Counter NSAIDs to Treat Dysmenorrhea: Patient Counseling Ibuprofen, ketoprofen, and naproxen are over-the-counter nonsteroidal antiinflammatory drugs (NSAIDs) that have been specifically approved by the U.S. Food and Drug Administration (FDA) for treatment of dysmenorrhea. These NSAIDs are also available by prescription at a higher dose. These prescription medicines diclofenac, meclofenamate, mefenamic acid, and naproxen also have been approved by the FDA specifically for the treatment of dysmenorrhea. Prophylactic dosing with NSAIDs can be helpful, especially for the woman who has severe, incapacitating dysmenorrhea (e.g., misses 1 to 2 days of school or work per menstrual cycle). If a woman is using a contraceptive method that ensures regular cycling, NSAID dosing can begin 24 hours before the predicted menses. Individuals with premenstrual molimina (bloating, headaches, nausea, breast tenderness) can begin their NSAID dosing with the onset of these symptoms, which herald the onset of menstrual flow. Treatment may not be necessary for more than 2 to 3 days. If treatment is initiated with the onset of bleeding and/or associated symptoms, it can start with an initial loading dose followed by divided doses over 24 hours: Naproxen (Naprosyn, Aleve, Anaprox) dosing is 500 mg by mouth, to be followed by 250 mg by mouth every 6 to 8 hours. The dosage should not exceed 1.25 grams per day. Ibuprofen (Advil, Motrin, Nuprin) dosing is 400 mg by mouth every 4 to 6 hours, but should not exceed 3.2 grams per day. Ketoprofen (Orudis, Oruvail, Actron) dosing is 25 to 50 mg by mouth every 6 to 8 hours as needed, but should not exceed 300 mg per day.
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Scheduled dosing rather than as-needed dosing maintains consistent serum levels that may be helpful in preventing the waxing and waning of pain (i.e., the pain roller-coaster) that can occur with as-needed dosing. References: Akerlund M, Stromberg, P. Comparison of ketoprofen and naproxen in the treatment of dysmenorrhoea, with special regard to the time of onset of pain relief. Curr Med Res Opin. 1989;11:485-490. Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428-441. Calis KA. Dysmenorrhea. eMedicine [online]. Available at: http://www.emedicine.com/med/topic606.htm. Accessed February 27, 2007. Marjoribanks J, Proctor ML, Farquhar C. Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea. Cochrane Database Syst Rev. 2003;(4):CD001751.
How Oral Contraceptives Improve Primary Dysmenorrhea

By inhibiting ovulation, progesterone-
stimulated endometrial prostaglandin production is reduced

By reducing menstrual flow, which contains
prostaglandins
How Oral Contraceptives Improve Primary Dysmenorrhea Two mechanisms are probably involved in oral contraceptive-induced reduction or relief of dysmenorrhea. First, ovulation suppression prevents progesterone-stimulated endometrial production of prostaglandin F2. Second, reduced endometrial growth leads to decreases in menstrual fluid volume and the release of smaller amounts of prostaglandin F2.
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Oral Contraceptives Decrease Dysmenorrhea-Related Pain in Adolescents

18
Mean ( SD) MMDQ Pain Score
16 14 12 10 8 6 4 2 0
Placebo Oral Contraceptive

*P=0.004 vs. placebo
Baseline
3 Months
MMDQ = Moos Menstrual Distress Questionnaire; Oral Contraceptive = 20 g ethinyl estradiol/100 g levonorgestrel Reprinted from Davis AR, et al. Obstet Gynecol. 2005;106:97104, with permission from Lippincott Williams & Wilkins.
Oral Contraceptives Decrease Dysmenorrhea-Related Pain in Adolescents

Davis et al. randomized healthy adolescent girls ages 19 years and younger (N=76) who had moderate to severe dysmenorrhea to receive either a low-dose combination oral contraceptive (20 g ethinyl estradiol/100 g levonorgestrel) or placebo for 3 months. Efficacy was assessed by using scores on the pain subscale of the Moos Menstrual Distress Questionnaire (MMDQ). At the end of the treatment period, the MMDQ score was significantly less in girls who were treated with the oral contraceptive when compared with placebo (P=0.004). Participants in the active treatment group also reported decreased severity of pain and used less pain medication than those who received placebo. Reference: Davis AR, Westhoff C, O'Connell K, Gallagher N. Oral contraceptives for dysmenorrhea in adolescent girls: a randomized trial. Obstet Gynecol. 2005;106:97-104.
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Endometriosis-Related Dysmenorrhea Improved With Continuous Oral Contraceptive Use

Visual Analog Scale
100 90 80
Mean ( SD) Score
Verbal Rating Scale

3 *P<0.001 vs. baseline
*P<0.001 vs. baseline
70 60 50 40 30 20 10 0 Baseline 6 12 18 24
* *
* *
* *
*
1
Baseline
12
18
24
Months Since Baseline Reprinted from Vercellini P, et al. Fertil Steril. 2003;80:560-563, Copyright Elsevier 2003.
Months Since Baseline
Endometriosis-Related Dysmenorrhea Improved With Continuous Oral Contraceptive Use Participants in this study were women (n=50) who had undergone surgery for endometriosis in the previous year but continued to experience dysmenorrhea despite use of an oral contraceptive. Participants were advised to use a low-dose, monophasic oral contraceptive (20 g ethinyl estradiol/150 g desogestrel) continuously, suspending treatment for 1 week in the event of prolonged breakthrough bleeding. The presence and severity of dysmenorrhea-related pain were rated at 6-month intervals using a Verbal Rating Score (0 = absence of pain; 1 = some loss of work efficiency, mild pain; 2 = in bed part of 1 day, occasional loss of work, moderate pain; 3 = in bed for 1 day, incapacitation, severe pain) and a 100-mm visual analog scale. Mean visual analog scale and verbal rating scores were significantly decreased after 6 months of continuous use of the oral contraceptive. The severity and frequency of dysmenorrhea continued to be significantly decreased after 2 years of continuous use of the oral contraceptive. Reference: Vercellini P, Frontino G, De Giorgi O, Pietropaolo G, Pasin R, Crosignani PG. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril. 2003;80:560-563.
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Bleeding Patterns in Depot Medroxyprogesterone Acetate Users Over Time

100%
Percentage of patients
Bleeding / spotting days per 30-day month
80% 60% 40% 20% 0% 3 9 15 21 27 33 39 45 54 60 66 Month
11-30 8-10 1-7 0
Reprinted from Schwallie PC, Assenze JR. Fertil Steril. 1973;24:331-339, Copyright Elsevier 1973.
Bleeding Patterns in Depot Medroxyprogesterone Acetate Users Over Time Depot medroxyprogesterone acetate (DMPA) is an injectable progestin-only contraceptive that is a potent inhibitor of gonadotropins. Continued use of the drug results in endometrial suppression. The use of depot medroxyprogesterone acetate causes the bleeding of a normal menstrual cycle to become irregular and unpredictable and to be more often characterized as spotting or light bleeding rather than as heavy menstrual flow. This decrease in menstrual blood loss may result in decreased menstruationassociated pain. Bleeding data were collected by Schwallie and Assenze in a collaborative study that examined a regimen of 150 mg of MPA every 90 days. The study, conducted over a 6year period (19651971), enrolled 3,857 women and gathered 72,215 woman-months of experience. Data were analyzed for the percentage of women who experienced the following during a 30-day month irrespective of cycle length: amenorrhea (0 days bleeding and/or spotting); 17 days bleeding and/or spotting; 811 days bleeding and/or spotting; 1230 days bleeding and/or spotting. Bleeding/spotting days were not total days but rather were days when either bleeding or spotting had occurred. The above graph illustrates that the percentage of women who become amenorrheic increased with each subsequent injection period. An important concern about the use of DMPA is the possibility that bone mass may be decreased with long-term use. During adolescence, the accumulation of critical bone mass is dependent on adequate levels of estrogen. A progestin-only injection offsets the balance of estrogen in the body, effectively reducing the levels available to increase bone mass. The Society for Adolescent Medicine endorses the following guidelines for clinicians who prescribe DMPA for their adolescent patients:
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Continue prescribing DMPA to adolescent girls in need of contraception with adequate explanation of benefits and potential risks. Inform patients of the possible risk of bone loss. Understand the individual risk profile for osteopenia for patients on DMPA. It is up to the clinician in concert with the adolescent and potentially her guardian to consider the inclusion of bone density monitoring if DMPA is the desired method of contraception. Duration of use need not be restricted to 2 years. Recommend the following to all adolescents: daily intake of 1300 mg of calcium carbonate plus 400 IU of vitamin D and daily exercise. Consider giving estrogen replacement therapy to girls who have osteopenia or are considered to be at high risk for osteopenia (without having undergone dual energy X-ray absorptiometry if they are otherwise doing well on DMPA and have no contraindication to estrogen.
References: Schwallie PC, Assenze JR. Contraceptive use-efficacy study utilizing medroxyprogesterone acetate administered as an intramuscular injection once every 90 days. Fertil Steril. 1973;24:331-339. Greydanus DE, Patel DR, Rimsza ME. Contraception in the adolescent: an update. Pediatrics. 2001;107:562-573. Kaunitz AM. Current concepts regarding use of DMPA. J Reprod Med. 2002;47:785789. Jain J, Jakimiuk AJ, Bode FR, Ross D, Kaunitz AM. Contraceptive efficacy and safety of DMPA-SC. Contraception. 2004;70:269-275. Scholes D, LaCroix AZ, Ichikawa LE, Barlow WE, Ott SM. Change in bone mineral density among adolescent women using and discontinuing depot medroxyprogesterone acetate contraception. Arch Pediatr Adolesc Med. 2005;159:139-144. Cromer BA, Scholes D, Berenson A, Cundy T, Clark MK, Kaunitz AM, for the Society for Adolescent Medicine. Depot medroxyprogesterone acetate and bone mineral density in adolescentsthe black box warning: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;39:296-301.
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Levonorgestrel-Releasing Intrauterine System: Decreased Menstrual Bleeding and Pain

The levonorgestrel-releasing intrauterine
system (LNG-IUS) releases 20 g of levonorgestrel every 24 hours
Decreases amount of menstrual blood loss Used to treat heavy menstrual bleeding 3-year follow-up study 47% of users were amenorrheic Prevalence of menstrual pain decreased
from 60% to 29%
Baldaszti E, et al. Contraception. 2003;67:87-91.
Levonorgestrel-Releasing Intrauterine System: Decreased Menstrual Pain and Bleeding The levonorgestrel intrauterine system (LNG-IUS) has been available in the United States since 2000 and is marketed under the name Mirena by Berlex. The LNG-IUS provides highly effective contraception for up to 5 years. The LNG-IUS releases 20 g/24 hours of levonorgestrel from a polymer cylinder mounted on a T-shaped frame that is covered with a release rate-controlled membrane. Levonorgestrel, a highly potent progestin, is released in small, predictable doses directly into the uterine cavity, thereby suppressing endometrial growth. Because of its direct actions on the endometrium, the LNG-IUS decreases menstrual blood loss and results in amenorrhea in some women. In fact, the LNG-IUS effectively reduces heavy menstrual bleeding. In a 3-year follow up study of LNG-IUS users (n=165) conducted by Baldaszti et al., 47% of women were amenorrheic at 3 years. In addition, the prevalence of menstrual pain decreased from 60% before insertion of the LNG-IUS to 29% within 3 years after insertion. Reference: Baldaszti E, Wimmer-Puchinger B, Loschke K. Acceptability of the long-term contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year follow-up study. Contraception. 2003;67:87-91.
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Summary
Primary dysmenorrhea is lower pelvic pain that is
associated with menstruation and typically begins in adolescence due to genital tract pathology
Secondary dysmenorrhea is dysmenorrhea that is Over-the-counter nonsteroidal antiinflammatory
drugs provide pain relief from dysmenorrhea dysmenorrhea by suppressing ovulation and lowering prostaglandin levels, which lead to decreased menstrual blood loss
Hormonal contraceptives improve symptoms of
Summary
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Management of Dysmenorrhea

Paula J. Adams Hillard, MD

Slide Source: Contraception Online www.contraceptiononline.org

Dawood MY. Obstet Gynecol. 2006;108:428-441.

Slide Source: Contraception Online www.contraceptiononline.org

Diagnosis of Primary Dysmenorrhea

onset of menstrual bleeding

Dawood MY. Obstet Gynecol. 2006;108:428-441.

Slide Source: Contraception Online www.contraceptiononline.org

Characteristics of Secondary Dysmenorrhea

through the end of menstruation

May be noncyclic May be accompanied by pelvic tenderness or

French L. Am Fam Physician. 2005;71:285-291.

Slide Source: Contraception Online www.contraceptiononline.org

Incidence of Dysmenorrhea in Young Women

0 (none) 1 (mild) 2 (moderate) 3 (severe) Absenteeism*

9% 27% 41% 23% 26%

28% 35% 23% 15% 51%

33% 35% 22% 10% 34%

*Missed school or work.

Slide Source: Contraception Online www.contraceptiononline.org

Incidence of Dysmenorrhea Among Patients in Primary Care Settings

Treatment Approaches for Dysmenorrhea

Treatment Approaches for Dysmenorrhea: Nonsteroidal Antiinflammatory Drugs

medicines for dysmenorrhea

medications do not have proven efficacy

Slide Source: Contraception Online www.contraceptiononline.org

Using Over-the-Counter NSAIDs to Treat Dysmenorrhea: Patient Counseling

Slide Source: Contraception Online www.contraceptiononline.org

How Oral Contraceptives Improve Primary Dysmenorrhea

stimulated endometrial prostaglandin production is reduced

Slide Source: Contraception Online www.contraceptiononline.org

Oral Contraceptives Decrease Dysmenorrhea-Related Pain in Adolescents

Placebo Oral Contraceptive

Oral Contraceptives Decrease Dysmenorrhea-Related Pain in Adolescents

Endometriosis-Related Dysmenorrhea Improved With Continuous Oral Contraceptive Use

Verbal Rating Scale

*P<0.001 vs. baseline

Months Since Baseline

Slide Source: Contraception Online www.contraceptiononline.org

Bleeding Patterns in Depot Medroxyprogesterone Acetate Users Over Time

80% 60% 40% 20% 0% 3 9 15 21 27 33 39 45 54 60 66 Month

11-30 8-10 1-7 0

Slide Source: Contraception Online www.contraceptiononline.org

Levonorgestrel-Releasing Intrauterine System: Decreased Menstrual Bleeding and Pain

system (LNG-IUS) releases 20 g of levonorgestrel every 24 hours

from 60% to 29%

Baldaszti E, et al. Contraception. 2003;67:87-91.

Slide Source: Contraception Online www.contraceptiononline.org

Secondary dysmenorrhea is dysmenorrhea that is Over-the-counter nonsteroidal antiinflammatory

Hormonal contraceptives improve symptoms of

Slide Source: Contraception Online www.contraceptiononline.org

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