Dysmenorrhoea (Periods Pain), Management & Treatment
It has been estimated that as many as one in two women suffer from dysmenorrhoea (period pains). Up to one in ten of those affected will have severe symptoms, which necessitate time off school or work. Many of these women will try self-medication, seeking advice from their doctor only if this treatment is unsuccessful. Pharmacists or Doctors should remain aware that discussing menstrual problems is potentially embarrassing for the patient and should therefore try to create an atmosphere of privacy.
WHAT YOU NEED TO KNOW?
Age
Previous history
Regularity and timing of cycle
Timing and nature of pains
Relationship with menstruation
Other symptoms
Headache, backache
Nausea, vomiting, constipation
Faintness, dizziness, fatigue
Premenstrual syndrome (PMS)
Medication
Significance of Questions And Answers
Age
The peak incidence of primary dysmenorrhoea occurs in women between the ages of 17 and 25. Primary dysmenorrhoea is defined as pain in the absence of pelvic disease, whereas secondary dysmenorrhoea refers to pain, which may be due to underlying disease. Secondary dysmenorrhoea is most common in women aged over 30 and is rare in women aged under 25. Common causes of secondary dysmenorrhoea Include endometriosis or pelvic inflammatory disease (PID). Primary dysmenorrhoea is uncommon after having children.
Previous history
Dysmenorrhoea is often not associated with the start of menstruation (menarche). This is because during the early months (and sometimes years) of menstruation, ovulation does not occur. These anovulatory cycles are usually, but not always, pain-free and therefore women sometimes describe period pain that begins after several months or years of pain-free menstruation. The pharmacist should establish whether the menstrual cycle is regular and the length of the cycle. Further questioning should then focus on the timing of pains in relation to menstruation.
Types, Timing and nature of pains
- Primary dysmenorrhoea
Primary dysmenorrhoea classically presents as a cramping lower abdominal pain that often begins during the day before bleeding starts. The pain gradually eases after the start of menstruation and is often gone by the end of the first day of bleeding.
Mittelschmerz; Mittelschmerz is ovulation pain which occurs midcycle, at the time of ovulation. The abdominal pain usually lasts for a few hours, but can last for several days and may be accompanied by some bleeding.
- Secondary dysmenorrhoea
The pain of secondary or acquired dysmenorrhoea may occur during other parts of the menstrual cycle and can be relieved or worsened by menstruation. Such pain is often described as a dull, aching pain rather than being spasmodic or cramping in nature. Often occurring up to 1 week before menstruation, the pain may get worse once bleeding starts. The pain may occur during sexual intercourse. Secondary dysmenorrhoea is more common in older women, especially in those who have had children. In pelvic infection, a vaginal discharge may be present in addition to pain. If, from questioning, the pharmacist suspects secondary dysmenorrhoea, the patient should be referred to her doctor for further investigation.
Endometriosis; Endometriosis mainly occurs in women aged between 30 and 45, but can occur in women in their twenties. The womb (uterus) has a unique inner lining surface (endometrium). In endometriosis, pieces of endometrium are also found in places outside the uterus. These isolated pieces of endometrium may lie on the outside of the uterus or ovaries, or elsewhere in the pelvis. Each section of endometrium is sensitive to hormonal changes occurring during the menstrual cycle and goes through the monthly changes of thickening, shedding and bleeding. This causes pain wherever the endometrial cells are found. The pain usually begins up to 1 week before menstruation and both lower abdominal and lower back pain may occur. The pain may also be non-cyclical and may occur with sexual intercourse (dyspareunia). Endometriosis may cause sub fertility.
Mittelschmerz; Mittelschmerz can be severe and the cycle can sometimes be shortened, so that ovulation pain may be closely followed by premenstrual and menstrual pain. Once the flow of blood is established, pain may be relieved.
Pelvic inflammatory disease; Pelvic infection can occur and may be acute or chronic in nature. It is important to know whether or not an intrauterine contraceptive device (coil) is used. The coil can cause increased discomfort and heavier periods, but also may predispose to infection. Acute pelvic infection occurs when a bacterial infection develops within the fallopian tubes. There is usually severe pain, fever and vaginal discharge. The pain is in the lower abdomen and may be unrelated to menstruation. It may be confused with appendicitis.
Chronic PID may follow on from an acute infection. The pain tends to be less severe, associated with periods and may be experienced during intercourse. It is thought that adhesions that develop around the tubes following an infection may be responsible for the symptoms in some women. In others, however, no abnormality can be found and pelvic congestion is assumed to be the cause. In this situation psychological factors are thought to be important.
Other symptoms
Women who experience dysmenorrhoea will often describe other associated symptoms. These include nausea, vomiting, general GI discomfort, constipation, headache, backache, fatigue, feeling faint and dizziness.
Premenstrual syndrome
The term PMS describes a collection of symptoms, both physical and mental, whose incidence is related to the menstrual cycle. Symptoms are experienced cyclically, usually from 2 to 14 days before the start of menstruation. Relief from symptoms generally occurs once menstrual bleeding begins. The cyclical nature, timing and reduction in symptoms are all important in identifying PMS. Some women experience such severe symptoms that their working and home lives are affected. Sufferers often complain of a bloated abdomen, increase in weight, swelling of ankles and fingers, breast tenderness and headaches.
Practical points
1 Exercise during menstruation is not harmful, as some ‘old wives tales’ would have people believe. In fact, exercise may well be beneficial, since it raises endorphin levels, reducing pain and promoting a feeling of well-being. There is some evidence that moderate aerobic exercise can improve symptoms of premenstrual syndrome.
2 There is some evidence that a low-fat, high-carbohydrate diet reduces breast pain and tenderness.
3 PRODIGY gives the following advice to women taking analgesics for dysmenorrhoea:
(i) Take the first dose as soon as your pain begins, or as soon as the bleeding starts, whichever comes first. Some doctors’ advice to start taking the tablets on the day before your period is due. This may prevent the pain from building up.
(ii) Take the tablets regularly, for 2–3 days each period, rather than ‘now and then’ when pain builds up.
(iii) Take a strong enough dose. If your pains are not eased, ask your doctor or pharmacist whether the dose that you are taking is the maximum allowed. An increase in dose may be all that you need.
(iv) Side-effects are uncommon if you take an anti-inflammatory for just a few days at a time, during each period. (But read the leaflet that comes with the tablets for a full list of possible side-effects.)
Medication
The pain of dysmenorrhoea is thought to be linked to increased prostaglandin activity, and raised prostaglandin levels have been found in the menstrual fluids and circulating blood of women who suffer from dysmenorrhoea. Therefore, the use of analgesics that inhibit the synthesis of prostaglandins is logical. It is important, however, for the pharmacist to make sure that the patient is not already taking an NSAID.
Women taking oral contraceptives usually find that the symptoms of dysmenorrhoea are reduced or eliminated altogether, and so any woman presenting with the symptoms of dysmenorrhoea and who is taking the pill is probably best referred to the doctor for further investigation.
When to
WHEN TO REFER?
Presence of abnormal vaginal discharge
Abnormal bleeding
Symptoms suggest secondary dysmenorrhoea
Severe intermenstrual pain (Mittelschmerz) and bleeding
Failure of medication
Pain with a late period (possibility of an ectopic pregnancy)
Presence of fever
Treatment timescale
If the pain of primary dysmenorrhoea is not improved after two cycles of treatment, referral to the doctor would be advisable.
Management
Simple explanation about why period pains occur, together with sympathy and reassurance, is important. Treatment with simple analgesics is often very effective in dysmenorrhoea.
Ibuprofen
Ibuprofen can be considered the treatment of choice for dysmenorrhoea; providing the drug is appropriate for the patient (i.e. the pharmacist has questioned the patient about previous use of aspirin, and history of GI problems and asthma). Ibuprofen inhibits the synthesis of prostaglandins and thus has a rationale for use. Most trials have studied the use of NSAIDs at the onset of pain. One small study compared treatment started premenstrually against treatment from onset of pain: both strategies were equally effective. For selfmedication, a maximum daily dose of 1200 mg per day is allowed, so women could be advised to try a dose of 200–400 mg three times daily. A variety of proprietary brands of ibuprofen is available, in tablet and capsule form, some of which are specifically marketed for period pains. Sustained-release formulations of ibuprofen are also available.
Contraindications; Care should be taken when recommending ibuprofen. The drug can cause GI irritation and should not be taken by anyone who has or has had a peptic ulcer. All patients should take ibuprofen with or after food to minimize GI problems. Ibuprofen should not be taken by anyone who is sensitive to aspirin and should be used with caution in anyone who is asthmatic, because such patients are more likely to be sensitive to ibuprofen. The pharmacist can check if a person with asthma has used ibuprofen before. If they have done so without problems, they can continue.
Aspirin
Aspirin also inhibits the synthesis of prostaglandins but is less effective in relieving the symptoms of dysmenorrhoea than ibuprofen. Aspirin can cause GI upsets and is more irritant to the stomach than ibuprofen. For those who experience symptoms of nausea and vomiting with dysmenorrhoea, aspirin is probably best avoided. Soluble forms of aspirin will work more quickly than traditional tablet formulations and are less likely to cause stomach problems. Patients should be advised to take aspirin with or after meals. The pharmacist should establish whether the patient has any history of aspirin sensitivity before recommending the drug.
Paracetamol
Paracetamol has little or no effect on the levels of prostaglandins involved in pain and inflammation and so it is theoretically less effective for the treatment of dysmenorrhoea than either ibuprofen or aspirin. However, Paracetamol is a useful treatment when the patient cannot take ibuprofen or aspirin because of stomach problems or potential sensitivity. Paracetamol is also useful when the patient is suffering with nausea and vomiting as well as pain, since it does not irritate the stomach. The pharmacist should remember to stress the maximum dose that can be taken.
Hyoscine
Hyoscine, a smooth muscle relaxant, is included in one proprietary product marketed for the treatment of dysmenorrhoea on the theoretical basis that the antispasmodic action will reduce cramping. In fact, the dose is so low (0.1 mg Hyoscine in some combination formulations) that such an effect is unlikely and the products might be considered to be successful due to its analgesic action and psychological effect. The anti-cholinergic effects of Hyoscine mean it is contraindicated in women with closed-angle glaucoma. Additive anti-cholinergic effects (dry mouth, constipation, blurred vision) means Hyoscine is best avoided if any other drug with anti-cholinergic effects (e.g. tricyclic antidepressants) is being taken.
Caffeine
There is some evidence (from a trial comparing combined ibuprofen and caffeine with ibuprofen alone and caffeine alone) that caffeine may enhance analgesic effect. OTC products contain 15–65mg of caffeine per tablet. A similar effect could be achieved through drinking tea, coffee or cola. A cup of instant coffee usually contains about 80 mg caffeine, a cup of freshly brewed coffee about 130 mg, a cup of tea 50 mg and a can of cola drink about 40–60 mg.
Non-drug treatments
High-frequency transcutaneous electrical nerve stimulation (TENS) may be of benefit. It seems to work by altering the body’s ability to receive or perceive pain signals. High-frequency TENS has pulses of 50–120 Hz at low intensity, and when compared with placebo in seven small RCTs was found to be effective for pain relief in primary dysmenorrhoea. Low-frequency TENS is also available and has pulses delivered of 1–4 Hz at high intensity. Although low-frequency TENS was better than placebo the evidence is less convincing than for high frequency.
Acupuncture may be helpful and was found in a small but well-designed study to be more effective than its placebo equivalent (sham acupuncture, where the needles are positioned away from the ‘real’ acupuncture sites). The treatments were given once a week for 3 weeks per month over a 3-month period. Women receiving ‘real’ acupuncture gained significant pain relief. While further research is needed to confirm this effect, some women may want to try it.
Locally applied low-level heat may also help pain relief. Results from one study showed that the time to noticeable pain relief was significantly reduced when ibuprofen was combined with locally applied heat, as compared with ibuprofen alone. Fish oil (omega-3 fatty acids) compared with placebo in one study showed the use of additional pain relief to be significantly lower in the treatment group. There were significantly more adverse effects in the women treated with fish oil, but these were not serious. Pyridoxine alone and combined with magnesium showed some benefit in reducing pain, compared with placebo.
