ysmenorrhea is typically described as cramping pain in the lower abdomen beginning at the onset of menstrual flow and lasting eight to 72 hours. It is often accompanied by nausea, vomiting, diarrhoea, headaches, muscle cramps, lower back pain, fatigue, and, in more severe cases, sleep disturbance. It occurs in 50 to 90 percent of adolescent girls and women of reproductive age and is a leading cause of female absenteeism from school or the workplace. Dysmenorrhea leads to decreased quality of life and increased risk of depression and anxiety.

Causes

An excess or imbalance of prostaglandins and leukotrienes in the menstrual fluid is believed to be the cause. This, in turn, produces vasoconstriction in the uterine vessels, causing the uterine contractions responsible for pain.

The condition is categorised as primary and secondary. Primary dysmenorrhea is physiological and occurs in the absence of pelvic disease. PD begins an average of six to twelve months following menarche.

Secondary dysmenorrhea is a recognised medical condition and accounts for about ten percent of cases of dysmenorrhea. The underlying pathology includes endometriosis, fibroids, pelvic inflammatory disease, etc. It is more likely to occur years after onset of menstruation. The pain can precede the start of the period by several days and may last throughout the period. Symptoms more consistent with secondary dysmenorrhea include changes in or progressive worsening of pelvic pain, abnormal uterine bleeding, vaginal discharge and dyspareunia. In such a case, one must see a family physician or a gynecologist for further investigations and management. There might also be a need of surgical intervention to cure secondary dysmenorrhea.

Risk factors

Longer duration of menses, early menarche, smoking, alcohol and obesity are all risk factors associated with dysmenorrhea. Childbirth reduces dysmenorrhoea, and its severity diminishes with age.

Management

Primary dysmenorrhea (absence of pelvic disease) can be managed with lifestyle modification and pain killers as per need. Smoking is directly associated with dysmenorrhea; hence, it should be stopped. Hot fomentation helps relieve pain, and can be done with hot water packs and bottles. Lying in supine position with back/ abdominal massage may also be helpful for some women. Regular, chamomile or mint tea may also be beneficial.

Pain killers are advisable to manage cramps. Mefenamic acid and ibuprofen are good choices. Weak opioid analgesics are not recommended. Other options for severe pain are hormone contraceptive pills, but only if advised by a physician.

There is low-quality evidence that exercise, performed for about 45 to 60 minutes each time, three times per week or more, regardless of intensity, may provide a clinically significant reduction in menstrual pain intensity. Transcutaneous electrical nerve stimulation physiotherapy has some role.

There is some role of complementary diet but there is insufficient supportive evidence. They include calcium, magnesium, thiamine, ginger, fish oil supplements and toki-shakuyaku-san (TSS - a Japanese herbal remedy). Some remedies may have adverse effects and may interact with medication.

Self-acupressure, a safe and low-risk intervention, can significantly reduce average menstrual pain intensity, number of days with pain and use of analgesics over a three-month period. Manual acupuncture and electro-acupuncture are effective at reducing menstrual pain compared with no treatment.

Pain killers are advisable to manage cramps. Mefenamic acid and ibuprofen are good choices. Weak opioid analgesics are not recommended. Other options for severe pain are hormone contraceptive pills, but only if advised by a physician.

Premenstrual syndrome

PMS is the name given to the various symptoms you may experience in weeks before your period. PMS symptoms typically begin in the week before your period and last until five or so days after the start of your period. The cause is unknown. However, the release of an egg from an ovary each month (ovulation) appears to trigger symptoms.

A woman may experience symptoms like abdominal bloating, breast tenderness, headache, acne, constipation or mood changes. Psychological symptoms that might bother include tiredness, irritability, feelings of anger, anxiety. Apart from emotional changes one might experience changes in sleep and appetite.

Symptom management

Regular exercise helps reduce these symptoms. Reducing the amount of sugar, sugary drinks and refined carbohydrates within a balanced diet before a period is also helpful. Carbohydrates with a lower glycemic index give a slower, steadier release of sugar and may be a better choice for some women with PMS (e.g., granary/ wholemeal bread rather than white bread). Smaller, more frequent meals may suit better than infrequent large meals. There is weak evidence for the role of magnesium, vitamin B6 (pyridoxine), and calcium.

Evening primrose oil or simple painkillers such as ibuprofen or paracetamol may help with breast tenderness.

Cognitive behaviour therapy is a talking treatment (psychological treatment) which avoids the need for medicines for coping with premenstrual symptoms. For this, one can consult a clinical psychologist.

If symptoms are severe or quality of life is affected, one must consult a family physician or a gynaecologist for pharmacological management with anti-depressants and hormone pills.

The writer is a family physician