- Causes of dysmenorrhea
- Clinical forms
- Primary dysmenorrhea
- Secondary dysmenorrhea
- Diagnosis and treatment guidelines
More than half of women of reproductive age worldwide suffer from periodic pain during menstruation. Painful menstrual bleeding or dysmenorrhea, accompanied by a whole symptom complex of various health disorders, in most cases are responsible for poor health and loss of efficiency during this period.
According to the generally accepted international classification, the previously used term “algodysmenorrhea”, which refers to a pathological process, manifested by cyclic pain in the lower abdomen in the absence of gynecological pathology, is not used in practice because of its incorrect interpretation. It is believed that to refer to the pathological condition associated with psycho-physiological and neuroendocrine disorders during menstruation, the term "dysmenorrhea" is more expedient, since in translation it means "violation of monthly hemorrhage" and explains the whole range of deviations of the menstrual cycle.
Pain with dysmenorrhea usually begins 2-12 hours before the onset of menstruation and gradually subsides within a few days. The nature of pelvic pain is predominantly cramping, pulling, aching, pressing, stabbing, radiating to the lumbar and sacral regions, kidneys, rectum and bladder. Pain syndrome can have a different degree of intensity, it exhausts the patient and contributes to the development of asthenia. In addition, the painful condition is accompanied by vegetative disorders in the form of dizziness, fainting, nausea, vomiting, diarrhea, chills, fever, heat sensation, sweating, increased urination, abdominal distention. Disorders of the psycho-emotional sphere with impaired perception of smell and taste, increased irritability, insomnia, apathy, and lack of appetite may occur.
Causes of dysmenorrhea
Such a normal condition for an adult woman as menstruation can become not only an unpleasant medical problem, but also have social significance. The deterioration in the quality of life associated with dysmenorrhea leads to temporary disability in 80-85% of the female population, starting at school. Among adolescents pronounced pain syndrome during menstruation occurs in 40-75% of cases and grows every year. Almost every second woman at a young age has manifestations of dysmenorrhea, which gradually decrease with age or disappear completely after childbirth. In adulthood, menstrual pain is most often associated with acquired genital pathology.
The severity of the manifestations of the disease depends on the living and working conditions. Women who do not receive adequate nutrition and are engaged in heavy physical labor, including sportswomen, suffer from menstrual pain much more often than others. Adverse external factors can also lead to the development of a pathological process. Often, hypothermia, infectious diseases, injuries, stressful situations, surgery on the genitals contribute to the occurrence of the disease. Harmful habits, especially nicotine addiction, increase the risk of dysmenorrhea at a young age several times.
There is a genetic predisposition to the development of menstrual disorders, in about 30% of women with dysmenorrhea, the daughter suffers from the same disease. An important role in the occurrence of menstrual pain plays an emotional component. Girls and women prone to severe depression are more likely to suffer from dysmenorrhea and premenstrual syndrome.
Very often, menstrual bleeding completely changes the rhythm of everyday life. Sometimes “critical” days are so critical that they force a woman to spend several days in bed, suffering from pain. Depending on the intensity of the pain, there are three forms of the disease:
- Light menstrual pains disturb a woman only on the first day from the onset of menstruation, are not accompanied by autonomic disorders and do not lead to disruption of vital activity. This form of the disease is most common among the female population and, despite a fairly mild course, in the absence of proper attention to their health, it can worsen over time.
- Mild menstrual cramps are observed for several days from the onset of menstruation and are accompanied by systemic disorders (headaches, fainting, cramps , nausea, vomiting, diarrhea, frequent urination, bloating, nervousness, insomnia). The performance is significantly reduced and usually taking medication is required to maintain full activity.
- Severe menstrual pains develop from the beginning of menstruation and last up to 5-7 days, have a pronounced debilitating character, accompanied by a full range of systemic disorders. Efficiency is usually lost completely, even while taking painkillers.
In clinical practice, primary (spastic) and secondary (organic) dysmenorrhea, distinguished by a developmental mechanism, are distinguished. In primary dysmenorrhea, organic gynecological pathology is usually absent. The cause of pelvic pain in secondary dysmenorrhea is inflammatory or neoplastic diseases of the genital organs: endometriosis, ovarian cysts, chronic salpingitis, oophoritis, adnexitis , adenomyosis , polyposis, cervical stenosis, genital malformations, bacterial, viral and fungal infections. Also quite often provokes menstrual pain intrauterine contraception.
The first manifestations of primary dysmenorrhea, as a rule, are found 1-2 years after menarche with the advent of ovulatory cycles. In the first few years, the pain can be quite tolerable, short-lived and easily treatable with conventional analgesics. Concomitant manifestations of this are mild and do not interfere with the girl’s daily life. Over time, the course of the disease can be significantly aggravated, with a peak in intensity approximately 5 years after the onset of the first symptoms.
Pain in primary dysmenorrhea is not associated with structural changes in the genitals, the dysfunction of the contractile activity of the myometrium under the action of biologically active substances, increased intrauterine pressure and impaired blood flow in the uterine vessels come to the fore.
In patients with dysmenorrhea, the uterus has an increased contractile activity, the strength of uterine contractions in patients with a similar pathology is 5 times higher than in healthy women. Violation of the permeability of the endometrial cell membranes with excessive secretion of leukotrienes and prostaglandins into the uterine cavity leads to dysfunction of the uterine muscles. In addition to the fact that these substances are powerful stimulants of contractile activity of the smooth muscles of the uterus, they increase the sensitivity of pain receptors in its wall and lead to hemodynamic disorders. The increased activity of the myometrium in combination with spasm or prolonged dilatation of the uterine vessels leads to hypoxia of the pelvic organs and the emergence of pain of central origin. In this case, mechanical compression of the veins and arteries of the uterine wall again leads to an increased release of prostaglandins, which intensifies the spasm and aggravates the effects of hypoxia. Thus, a “vicious circle” occurs, leading to the accumulation of chemicals in the blood, irritating the nerve endings and causing severe pelvic pain. The thrombokinins emerging from the disintegrating endometrium of the potassium and calcium ions also contribute to increased pain. In addition to pain, hypersecretion of prostaglandins, elevated levels of potassium and calcium, as well as a number of other biologically active substances cause systemic autonomic disorders: tachycardia, headaches, nausea, vomiting and diarrhea.
Disruption of prostaglandin synthesis is based on the failure of hormonal activity. The level of prostaglandin secretion directly depends on the content and ratio of estradiol and progesterone. Progesterone deficiency significantly affects the conversion of fatty acids to arachidonic acid in endometrial cells, which is a precursor of prostaglandins and leukotrienes, and in the second phase of the cycle, they are actively and excessively accumulated in the inner lining of the uterus.
An important etiological factor in the development of menstrual pain is the imbalance of the hormones of the posterior lobe of the pituitary - oxytocin and vasopressin. Increasing the level of vasopressin in the blood about a day before the onset of menstruation contributes to the development of hypoxic phenomena in the pelvic organs. In some cases, severe pelvic pain in dysmenorrhea is associated with a reduced level of intracellular magnesium in the connective tissue of the uterus.
In the development of pain, in addition to local irritation of pain receptors in the uterine wall, a significant place is given to the central component. The prolonged effect of pain impulses on the sensory neurons of the spinal cord leads to decompensation and reduction of the pain threshold. Also, hypersensitivity to pain may be genetically determined. In addition, there may be an individual susceptibility to pain, based on one's own feelings, emotions, behavior, and attitudes towards impairment of well-being.
In patients with dysmenorrhea, complex complex disorders of the psychovegetative sphere are observed, associated with dysfunction of the sympathoadrenal system or serotonin regulation. The sympathetic type of response is due to hypersecretion or accumulation of norepinephrine in the tissues. In this case, patients are worried about severe headaches like a migraine, nausea, chills or feeling hot, fever, redness of the skin of the neck and chest, heart pain, arrhythmia, frequent urination, sweating. The skin is pale and cold, cyanosis of the nail plates is noted, the pupils are dilated. Sympathoadrenal crises may develop. In an emotional state, anxiety and obsessive states prevail, including depressive disorders.
Parasympathetic disorders due to elevated serotonin in the blood and cerebrospinal fluid are characterized by a decrease in blood pressure, dizziness, fainting, vomiting, a feeling of lack of air, severe pallor and hypothermia. Women in the period of menstruation become lethargic and apathetic, edematous, possible exacerbations of allergic diseases.
The most common causes of secondary dysmenorrhea are genital endometriosis and chronic inflammatory diseases of the reproductive organs (adnexitis, salpingoophoritis). The mechanism of pain in secondary dysmenorrhea is not much different from that in the primary. The main difference is the aggravation of the course of the disease under the action of morpho-functional disorders of the organs of the reproductive system.
In inflammatory diseases, inflammatory mediators are released, which additionally affect the nerve endings during the menstrual cycle. With the involvement of the surrounding organs in the pathological process, adhesions form, tissue fibrosis occurs, which causes soreness during their displacement and tension. During tumor processes and cystic changes, the surrounding tissues are compressed by growing growths. The formation of obstacles in the path of menstrual blood contributes to its accumulation in the uterus and a reverse flow occurs through the fallopian tubes with effusion into the abdominal cavity. Feeling of bursting, burning in the lower abdomen and in the external genital organs, increased pain when changing body position, irradiation to the lower back, kidneys, bladder, epigastrium can accompany the period of menstrual bleeding and even continue for several days after it. Monthly usually abundant, with a large number of clots, long. Pains are more often acyclic in nature and worried throughout the cycle, increasing during ovulation and with the onset of menstruation. In the rest of the time, constant pulling pains in the lower back and lower abdomen, accompanied by abnormal secretions from the genital tract, to a great extent exhaust the woman and help reduce the pain threshold. One of the manifestations of secondary dysmenorrhea can be dyspareunia (pain during intercourse), which adversely affects not only the physical but also the mental health of a woman.
In the case of chronic recurrent inflammation, the pain syndrome may increase many times in the premenstrual period and subside with the onset of menstruation. In addition to pain, the patient may be concerned about the increase in body temperature and the effects of intoxication associated with exacerbation of the inflammatory process.
In women in adulthood suffering from dysmenorrhea, associated symptoms depend on her physical condition and most often relate to the cardiovascular and nervous systems. In addition, such women are more susceptible to depressive disorders and have a pronounced unstable psycho-emotional mood.
Diagnosis and treatment guidelines
Diagnostic measures for dysmenorrhea include a detailed laboratory and instrumental examination and gynecological examination. In order to identify the causes of this disease, the patient, in addition to general tests, is prescribed a blood test with determination of the level of hormones in different phases of the cycle, ultrasound of the pelvic organs, hysteroscopy (if indicated), laparoscopy (if indicated). If necessary, an examination of the cardiovascular, digestive, nervous and urinary systems.
The treatment of painful menstruation is mainly pharmacological and is aimed at correcting hormonal disturbances. Pain in dysmenorrhea is effectively eliminated by the use of inhibitors of the synthesis of prostaglandins and oral contraceptives. Combined hormonal drugs create the necessary elevated levels of progesterone, which block the synthesis of prostaglandins during menstrual bleeding. The use of oral contraceptives has a positive effect on various violations of the menstrual-ovarian cycle, contributes to its normalization, reduces the strength and frequency of uterine contractions, reduces intrauterine pressure, against the background of which improves blood flow to the pelvic organs, and dysmenorrhea disappears or becomes less pronounced. However, when prescribing treatment for young women, consider the desire to become pregnant in the near future.
Pathogenetic drugs for the treatment of dysmenorrhea are non-steroidal anti-inflammatory drugs. Their action is based on the interruption of the main link of the pain syndrome - the blockade of the formation of prostaglandins and pro-inflammatory cytokines. The effectiveness of the use of drugs in this series reaches 80%. In addition, they have proven themselves quite well as an integrated treatment of chronic inflammatory diseases. Recently, preference has been given to selective cyclooxygenase blockers (nimesulide) over non-selective ones. The dosage and duration of the drug depends on the severity of the disease and the severity of symptoms, treatment is prescribed to prevent (a few days before the onset of menstruation) or relieve symptoms (with the appearance of pain).
To reduce the contractile activity of the myometrium, antispasmodics (no-spa), calcium channel blockers (verapamil) and magnesium preparations (magnesium B6) are used. The relaxation of smooth muscles under the action of these drugs occurs not only in the uterus, but also in other organs, in particular the stomach and intestines, which leads to the weakening of the accompanying symptoms of dysmenorrhea and positive polysystemic action. B vitamins have a positive effect on the nervous system, increasing resistance to pain stimuli.
Methods of psychotherapy and psychocorrection are quite effective, affecting the emotional sphere and eliminating the psychological factor of pain. Physiotherapeutic methods are also very popular.
In the treatment of secondary dysmenorrhea, in addition to all the above mentioned methods, it is imperative that therapeutic measures be taken regarding the underlying disease.
For the prevention of dysmenorrhea, you should properly organize a sleep and rest regime, avoid heavy physical exertion in the second half of the menstrual cycle, give up bad habits, not overwork, avoid excessive physical and mental stress. Полноценное питание с преобладанием продуктов, содержащих витамины В1, В6 и Е, является одним из важных компонентов профилактики дисменореи. Во время месячных следует отказаться от употребления тонизирующих напитков, шоколада и тяжелой жирной и соленой пищи. За несколько дней до предполагаемой менструации можно заваривать травяные мочегонные и успокоительные чаи, хороший эффект имеет душица, мелисса, мята и ромашка. Занятия умеренными физическими нагрузками, например, йогой или танцами способствуют гармоничному физическому развитию, усиливают кровообращение в малом тазу и предупреждают развитие гипоксии.