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Dx Menstrual Pain/ Dysmenorrhea Treatments:

Dysmenorrhea/ Menstrual Pain

The Merck Manual Home Edition
"Menstrual cramps (dysmenorrhea) are pains in the lowest part of the torso (pelvis) a few days before, during, or after a menstrual period. The pain tends to be most intense about 24 hours after periods begin and to subside after 2 to 3 days. The pain is usually crampy or sharp and comes and goes, but it may be a dull, constant ache. It sometimes extends to the lower back and legs[Editor: even for a week].

Many women also have a headache, nausea (sometimes with vomiting), and constipation or diarrhea. They may need to urinate frequently. Symptoms of premenstrual syndrome (such as irritability, nervousness, depression, fatigue, and abdominal bloating) may persist during part or all of the menstrual period. Sometimes menstrual blood contains clots. The clots, which may appear bright red or dark, may contain tissue and fluid from the lining of the uterus, as well as blood.

Symptoms tend to be more severe if:
*Menstrual periods started at an early age.
*Periods are long or heavy.
*Women smoke.
*Family members also have dysmenorrhea [Editor: or endometriosis].

Primary dysmenorrhea 50% of all women, sometime have dysmenorrhea
In about 5 to 15% of these women, cramps are severe enough to interfere with daily activities and may result in absence from school or work. Experts think that primary dysmenorrhea may be caused by release of substances called prostaglandins during menstruation. Prostaglandin levels are high in women with primary dysmenorrhea. [Editor; old theory] Prostaglandins may cause the uterus to contract (as occurs during labor), reducing blood flow to the uterus. These contractions can cause pain and discomfort. Prostaglandins also make nerve endings in the uterus more sensitive to pain. Lack of exercise and anxiousness about menstrual periods may also contribute to the pain.

Secondary dysmenorrhea is commonly caused by:
*Endometriosis: Tissue that normally occurs only in the lining of the uterus (endometrial tissue) appears outside the uterus. Endometriosis is the most common cause of secondary dysmenorrhea.
*Fibroids: These noncancerous tumors are composed of muscle and fibrous tissue and grow in the uterus.
*Adenomyosis: Endometrial tissue grows into the wall of the uterus, causing it to enlarge and swell during menstrual periods.
Less common causes:

*There are many less common causes of secondary dysmenorrhea. They include birth defects, cysts and tumors in the ovaries, pelvic inflammatory disease, and use of an intrauterine device (IUD) that releases copper or a progestin (a synthetic form of the female hormone progesterone. IUDS that release a progestin cause less cramping than those that release copper.

In a few women, pain occurs because the passageway through the cervix (cervical canal) is narrow. A narrow cervical canal (cervical stenosis) may develop after a procedure, as when a polyp in the uterus is removed or a precancerous condition (dysplasia) or cancer of the cervix is treated. A growth (polyp or fibrosis) can also narrow the cervical canal.

Doctors usually diagnosis dysmenorrhea when a woman reports that she regularly has bothersome pain during menstrual periods. They then determine whether dysmenorrhea is primary or secondary. Doctors must distinguish dysmenorrhea from two serious disorders that can also cause pelvic pain:

*An abnormally located (ectopic) pregnancy—that is, one not in its usual location in the uterus.[Editor:The pregnancy test is positive, there was sexual relations, and the menses is late].
*Pelvic inflammatory disease―infection of the uterus and/or fallopian tubes and sometimes the ovaries

Doctors can usually identify these disorders because the pain and the other symptoms they cause typically differ from those of dysmenorrhea.

In a href="">Pelvic inflammatory disease pelvic inflammatory disease, the pain may become severe and may be felt on one or both sides. Women may also have a foul-smelling, pus-like discharge from the vagina, vaginal bleeding, or both. Sometimes women have a fever, nausea or vomiting, or pain during sexual intercourse or urination. [Editor: dysmenorrhea occurs every month; P.I.D. occurs at non-recurring infrequently; usually once].

Warning signs:
In women with dysmenorrhea, certain symptoms are cause for concern:
*Severe pain that began suddenly
*A pus-like discharge from the vagina

When to see a doctor:
Women with any warning sign should see a doctor that day. If women without warning signs have more severe cramps than usual or have pain that lasts longer than usual, they should see a doctor within a few days. Other women who have menstrual cramps should call their doctor. The doctor can decide how quickly they need to be seen based on their other symptoms, age, and medical history.

What the doctor does: Doctors or other health care practitioners question the patient/family member about the pain and the medical history, including the menstrual history. Practitioners then do a physical examination. What they find during the history and physical examination may suggest a cause of the cramps and the tests that may need to be done.

For the menstrual history, practitioners collect information from the woman: what was the age of her first menses, are they regular, does this pain occur with each month, is it associated with heavy menses how long before the first day and afterwards does the pain last

Practitioners also note how old she was when symptoms began and what other symptoms she has. She is requested to describe the pain, including how severe it is, what relieves or worsens symptoms, and how symptoms interfere with her daily activities. Whether she has pelvic pain unrelated to periods is also important.

The woman is also questioned whether she has or has had disorders and other conditions that can cause cramps, including use of certain drugs (such as birth control pills) or an IUD.

A pelvic examination is done. Doctors check the vagina, vulva, cervix, uterus, and the area around the ovaries for abnormalities, including polyps and fibroids."

Medications Used in Treatment:
1. NSAIDs: non-steroidal anti-inflammatory drugs: aspirin, Advil® Alleve® ibuprofen,Anaprox® DS Naprosyn®/naproxen, Cataflam®/diclofenac, ketoprofen, mefenamic acid, melofenamate,Naprelanv, Motrin®IB
2. Oral Contraceptives: see list
3. Androgens: Danocrine®/danazol, testosterone, nandrolone, stanozolol
4. PDE5 inhibitors: Sildenafil

Suggested Links:
*N.H.S. Choices with Video

*[Editor] The Editor did research on the CAUSE of menstrual pain and was first to described the fact that the cervix develops separately from the uterus and each has its own nerve and blood supply. His uterine tracings were similar to Woodbury 1947, showing the uterus and cervix have separate contraction patterns. Dysmenorrhea, menstrual pain, occurs when the uterine contractions to expel menstrual debris are met by an unyielding, undilating cervix. The prostaglandins in the menstrual fluid are forced under high pressure into the veins of the uterus and into the body system. Blood debris also flows backwards through the fallopian tubes into the abdomen. The menstrual debris in the abdomen can cause endometriosis and more pain.

the Editor performed a double-blind study with a psychologist that confirms that transecting the uterosacral nerves that innervate the cervix will temporarily relieve pain. Injecting the cervix with lidocaine will relieve pain. Any procedure that relaxes the tight cervical circular muscles will relieve pain. That is why most women who deliver vaginally no longer have dysmenorrhea-- the cervix is stretched and torn so it cannot contract as before. That is why the trial with sildenafil (Viagra®) is so interesting. This medication is known to dilate blood vessels in the male penis and woman's labial tissue. What is not commonly recognized is that PG5 inhibitors are shown in laboratory studies to dilate smooth muscle; such as is present in the cervix/ around the cervical opening as well as the anal opening. The Editor has found that crushing three (3) to five (5) of the generic sildenafil (costing $1 each) and mixing it in half a teaspoon of K-Y® jelly can relieve the pain for up to 12-24 hours. Common therapies are over-the-counter ibuprofen (Advil® 200mg, Naprosyn® 200mg over-the-counter) in doses up to 400mg every 4 hours; Midol® and lastly, a combination oral contraceptive with very low dose estrogen (Yaz®, Seasonique®, Lo-Estrin 1/20®). Depo-Provera® may cause abnormal bleeding for a year.

*[Editor] For women who fail to respond to these simple, safe, over-the-counter and inexpensive treatments, gynecologists treat the young woman as if she might have endometriosis. Medical treatment with danazol 100-200mg twice daily has proven effective and the mild side effects are dissipated by the use of spirolactone 100mg twice daily. Should all fail, most gynecologists will resort to laparoscopy to confirm endometriosis and hysteroscopy to identify if there is a uterine anomaly causing pain. The Editor would do this for a woman desiring pregnancy; if not, his trial treatment of endometriosis with mixed anabolic steroids might very well prevent a surgical procedure.

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