- The causes of dysmenorrhea
- Clinical forms
- Primary dysmenorrhea
- Secondary dysmenorrhea
- Diagnosis and basic principles of treatment
More than half of women of reproductive age all over the world 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 the culprits of poor health and loss of efficiency in this period.
According to the generally accepted international classification, the previously used term "algodismenorrhea", denoting 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 the term "dysmenorrhea" is more appropriate to denote a pathological condition associated with psychophysiological and neuroendocrine disorders during menstruation, since in translation it means "violation of a monthly hemorrhage" and explains the entire spectrum of abnormalities of the menstrual cycle.
Pain with dysmenorrhea usually begin 2 to 12 hours before the onset of menstruation and gradually fade within a few days. The nature of pelvic pain is predominantly cramping, pulling, aching, pressing, stitching, with irradiation into the lumbar and sacral region, kidneys, rectum and bladder. Pain syndrome can have varying degrees of intensity, exhausts the patient and contributes to the development of asthenia. In addition, a painful condition is accompanied by vegetative disorders in the form of dizziness, fainting, nausea, vomiting, diarrhea, chills, fever, sensation of heat, sweating, frequent urination, bloating. There may be disorders of the psychoemotional sphere with a violation of perception of smell and taste, increased irritability, insomnia, apathy, lack of appetite.
The causes of dysmenorrhea
Such a condition, typical 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 results in a temporary loss of ability to work in 80-85% of the female population, beginning with the school bench. Among adolescents, severe pain syndrome during menstruation occurs in 40-75% of cases and grows every year. Practically every second woman at a young age has manifestations of dysmenorrhea, which gradually decrease with age or completely disappear after childbirth. In adulthood, menstrual pain is most often associated with acquired pathology of the genital organs.
The severity of manifestations of the disease directly depends on living and working conditions. Women who do not receive adequate nutrition and are engaged in heavy physical labor, including athletes, are much more likely to suffer from menstrual pain than others. Adverse external factors can also lead to the development of a pathological process. Often, hypothermia, infectious diseases, traumas, stressful situations, operative interventions on the genital organs contribute to the onset of the disease. Harmful habits, especially nicotine addiction, several times increase the risk of developing dysmenorrhea at a young age.
There is a hereditary predisposition to the development of violations of the menstrual cycle, about 30% of women with dysmenorrhea of the daughter suffer from the same disease. An emotional component plays an important role in the onset of menstrual pain. 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 normal 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 pain, three forms of the disease are distinguished:
- Light menstrual pains bother the woman only in the first day from the beginning of menstruation, are not accompanied by vegetative 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 easy current, with no proper attention to one's health, it can become worse with time.
- Moderate menstrual pains occur within a few days of the onset of menstruation and are accompanied by systemic disorders (headaches, fainting, convulsions , nausea, vomiting, diarrhea, frequent urination, bloating, nervousness, insomnia). The working capacity is significantly reduced and usually the medication is required to maintain a full activity.
- Severe menstrual pain develops from the onset of menstruation and lasts up to 5-7 days, have a pronounced debilitating character, are accompanied by a full range of systemic disorders. Efficiency is usually lost completely even when taking painkillers.
In clinical practice, primary (spastic) and secondary (organic) dysmenorrhea, distinguished by the mechanism of development, are distinguished. With primary dysmenorrhea, organic gynecological pathology, as a rule, is absent. The cause of pelvic pain in secondary dysmenorrhea are inflammatory or tumor diseases of the genital organs: endometriosis, ovarian cysts, chronic salpingitis, oophoritis, adnexitis , adenomyosis , polyposis, cervical stenosis, malformation of the genital organs, bacterial, viral and fungal infections. It is also quite often provokes menstrual pain intrauterine contraception.
The first manifestations of primary dysmenorrhea, as a rule, are found 1-2 years after the menarche with the appearance of ovulatory cycles. In the first few years the pain can be quite tolerable, short-lived and easily eliminated with the help of conventional analgesics. The accompanying manifestations are not expressed clearly and do not interfere with the daily life of the girl. Over time, the course of the disease can be significantly aggravated, the peak intensity occurs approximately 5 years after the appearance of the first symptoms.
Pain sensations in primary dysmenorrhea are not associated with structural changes in the genital organs, the dysfunction of the contractile activity of the myometrium under the influence of biologically active substances, the increase in intrauterine pressure and the violation of blood flow in the uterine vessels are at the forefront.
In patients with dysmenorrhea, the uterus has increased contractile activity, the force of uterine contractions in patients with this pathology is 5 times higher than that in healthy women. Dysfunction of the uterus musculature leads to a violation of the permeability of endometrial cell membranes with excessive release of leukotrienes and prostaglandins into the uterine cavity. In addition to the fact that these substances are powerful stimulants of the contractile activity of the smooth muscles of the uterus, they increase the sensitivity of the pain receptors in its wall and lead to disorders of hemodynamics. Increased activity of myometrium in combination with spasm or prolonged dilatation of uterine vessels leads to hypoxia of the pelvic organs and the occurrence of pain of central origin. At the same time mechanical compression of veins and arteries of the uterine wall leads again to an increased release of prostaglandins, which increases spasm and aggravates hypoxia. Thus there is a "vicious circle", leading to the accumulation of chemicals in the blood, irritating the nerve endings and causing severe pelvic pain. Strengthening pain is also promoted by the ions of potassium and calcium, thromboxinins emerging from the collapsing endometrium. In addition to the pain syndrome, 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.
At the basis of a violation of the synthesis of prostaglandins lies the failure of hormonal activity. The level of prostaglandin secretion directly depends on the content and ratio of estradiol and progesterone. Progesterone insufficiency has a significant effect on the conversion of fatty acids to arachidonic acid in endometrial cells, which is the precursor of prostaglandins and leukotrienes, and active and excessive accumulation in the inner lining of the uterus takes place during the second phase of the cycle.
An important etiological factor in the development of menstrual pain is the disproportion of hormones in the posterior lobe of the pituitary - oxytocin and vasopressin. An increase in the level of vasopressin in the blood approximately a day before the onset of menstruation contributes to the development of hypoxic phenomena in the pelvic organs. In some cases, severe pelvic pain associated with dysmenorrhea is associated with a decreased level of intracellular magnesium in the connective tissue of the uterus body.
In the development of pain syndrome, 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 sensitive neurons of the spinal cord leads to decompensation and a reduction in the pain threshold. Also, increased sensitivity to pain can be caused genetically. In addition, there may be an individual susceptibility to pain, based on one's own feelings, emotions, behavior and attitudes toward disturbances in well-being.
Patients with dysmenorrhea have complex complex disorders of the psychovegetative sphere associated with dysfunction of the sympathoadrenal system or serotonin regulation. Sympathetic type of response is due to hypersecretion or accumulation in norepinephrine tissues. In this case, patients are concerned about severe migraine headaches, nausea, chills or fever, fever, redness of the neck and chest, pain in the heart, arrhythmia, frequent urination, sweating. The skin is pale and cold, cyanosis of the nail plates is noted, the pupils are dilated. Sympatoadrenal crises can develop. In an emotional state, anxious and compulsive states prevail, down to depressive disorders.
Parasympathetic disorders due to elevated serotonin levels in the blood and CSF are characterized by lowering of arterial pressure, dizziness, fainting, vomiting, a feeling of lack of air, marked pallor and hypothermia. Women during menstruation become lethargic and apathetic, edematous, allergic diseases can be exacerbated.
The most common causes of secondary dysmenorrhea are genital endometriosis and chronic inflammatory diseases of the sexual system (adnexitis, salpingo-oophoritis). The mechanism of the onset of pain in secondary dysmenorrhea differs little from that of the primary dysmenorrhea. The main difference is the aggravation of the course of the disease under the influence of morpho-functional disorders of the genital system.
In inflammatory diseases, inflammatory mediators are released, which additionally affect the nerve endings during the menstrual cycle. When involved in the pathological process of nearby organs, adhesions are formed, fibrosing of tissues, which causes soreness in their displacement and tension. With tumor processes and cystic changes, the surrounding tissues are compressed by growing formations. The formation of obstacles in the way of menstrual blood contributes to its accumulation in the uterus and there is a reverse current through the uterine tubes with outflow into the abdominal cavity. Feeling of bursting, burning in the lower abdomen and in the area of the external genitalia, increasing pain when changing the position of the body, irradiation in the lower back, kidneys, bladder, epigastrium may accompany the period of menstrual bleeding and even continue for several days after it. Monthly usually abundant, with a large number of clots, prolonged. Pain is often acyclic in nature and is disturbed throughout the cycle, intensifying 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 pathological discharge from the genital tract, largely exhaust the woman and help reduce the pain threshold. One of the manifestations of secondary dysmenorrhea may be dyspareunia (pain during sexual contact), which negatively affects not only the physical, but also the mental health of women.
In the case of chronic recurrent inflammation, the pain syndrome can multiply repeatedly in the premenstrual period and subside with the onset of menstruation. In addition to pain, the patient may be disturbed by an increase in body temperature and intoxication phenomena associated with exacerbation of the inflammatory process.
In women in adulthood, suffering from dysmenorrhea, the accompanying symptoms depend on their physical condition and most often concern the cardiovascular and nervous systems. In addition, such women are more prone to depressive disorders and have a pronounced unstable psycho-emotional mood.
Diagnosis and basic principles of treatment
Diagnostic measures for dysmenorrhea include conducting 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 assigned a blood test with determination of the hormone levels at different phases of the cycle, ultrasound of the pelvic organs, hysteroscopy (according to indications), laparoscopy (according to indications). If necessary, the cardiovascular, digestive, nervous and urinary systems are examined.
Treatment of painful menstruation is mainly pharmacological and is aimed at correcting hormonal disorders. 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 blocks the synthesis of prostaglandins during a month's bleeding. The use of oral contraceptives has a positive effect on various disorders of the menstrual-ovarian cycle, promote its normalization, reduce the strength and frequency of uterine contractions, reduce intrauterine pressure, against which the blood supply of the pelvic organs improves, and the phenomena of dysmenorrhea disappear or become less pronounced. However, when prescribing treatment for young women should take into account 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 interruption of the main link of the pain syndrome - blockade of the formation of prostaglandins and pro-inflammatory cytokines. The effectiveness of the drugs in this series reaches 80%. In addition, they are well proven themselves as a comprehensive therapy for chronic inflammatory diseases. Recently, selective blockers of cyclooxygenase (nimesulide) have been favored in comparison with nonselective ones. Dosage and duration of the drug depends on the severity of the disease and the severity of symptoms, prescribed treatment for prevention (several days before the start of menstruation) or withdrawal symptoms (with the appearance of pain).
To reduce the contractile activity of the myometrium, antispasmodics (no-shpa), calcium channel blockers (verapamil), and magnesium preparations (magnesium B6) are used. 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 a reduction in the concomitant symptoms of dysmenorrhea and a positive polysystemic effect. B vitamins positively affect the nervous system, increasing resistance to pain stimuli.
Sufficiently effective methods of psychotherapy and psychocorrection, affecting the emotional sphere and eliminating the psychological factor of the occurrence of pain. Physiotherapy methods are also very popular.
In the treatment of secondary dysmenorrhea, in addition to all the above methods, it is necessary to conduct therapeutic measures for the underlying disease.
For the prevention of dysmenorrhoea should be properly organized sleep and rest, avoid heavy physical exertion in the second half of the menstrual cycle, abandon bad habits, do 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.