012 Dysmenorrhea

Abstract

“Dysmenorrhea”, of which the literal meaning from Ancient Greek, is “difficult menstrual flow”, is characterized by 24–48 h lasting lower abdominal cramps requiring medication or limiting normal activities, starting with menses or within few hours before or after their onset, correlated with ovulatory cycles and with duration and amount of menstrual flow. Nausea, vomiting, headache, dizziness, fatigue and other associated symptoms are often present. By definition, primary dysmenorrhea (PD) occurs with no pelvic pathology affecting 90% adolescents with dysmenorrhea. Secondary dysmenorrhea (SD) is associated with pelvic diseases, is present in 10% cases, being caused mostly by endometriosis and obstructive genital anomalies but also by PID, STDs, early pregnancy complications, adenomyosis, pelvic adhesions, cervical stenosis and other clinical pictures. Typically, PD arises 2 – 3 years after menarche, with onset of ovulatory cycles and may be diagnosed by meaningful history, focused on menstruation, and negative physical exam. Laboratory testing, imaging (US and MRI), hysteroscopy, laparoscopy are needed when SD is suspected. Several treatments exist. Non-medicinal approach includes exercise, acupuncture, topic heat, herbal preparations, magnetic devices, with some effectiveness but further studies are needed. Complementary and alternative medicine (Vitamins, Magnesium, fish oil, Chinese food) may be useful but need stronger evidence. NSAIDs, administered from the onset of bleeding at proper dosage for no longer than 2 – 3 days are first line treatment. Combined EPs, with different preparations and ways of administration, are suggested in sexually active girls and if NSAIDs are ineffective. Levonorgestrel Intra Uterine System (LNG IUS) lowers menstrual pain, now being advisable also in teens. Subdermal Etonorgestrel implant is effective too. In teens Depot medoxyprogesteronacetate rises concerns about bone mass. Because of bone demineralization, GnRH analogues are not allowed in under 16; in later ages an add-back estrogen and progesterone treatment is suggested. If medical treatments fail, laparoscopy is mandatory and not to be postponed: to diagnose and treat endometriosis and to remove functioning non-communicating uterine horns. Obstructive septa of genital anomalies must be removed. Careful follow-up recommended.