Dysmenorrhea – Menstrual Cramps (Tong Jing 痛经)

Painful Menstruation
In this article, I will present a simple explanation of what dysmenorrhea is, and its cause and treatment from a Western medicine point of view. In future writings I will offer the Chinese medicine mechanism, diagnosis and treatment, both with acupuncture and herbal medicine.

Dysmenorrhea is an acute condition characterized by pain or severe discomfort that occurs in about 50 to 60% of menstruting women before, during, or after the period, or shedding of the endometrial lining. The pain usually occurs in the lower abdomen, but can also affect areas of the low back, hips, and upper legs. Some women experience the pain as sharp, intermittent pain or dull, aching pain.

Dysmenorrhea is generally classified into primary and secondary dysmenorrhea.

Primary Dysmenorrhea (PD)

Primary dysmenorrhea is the most common type and is defined as menstrual pain that has no underlying gynecological disorder. The pain is often the result of excessive muscular contraction within the uterus and starts within a few hours before or after menstruation begins. The uterine contractions are triggered by a combination of low blood levels of hormones and by the release of substances known as prostaglandins. It is thought that some women release higher levels of these hormones which lead to stronger contractions. These contractions help to release the vascular lining and tissue that had formed in the uterus in preparation for possible conception. High levels of prostaglandins has been found to lead to other symptoms concurrent to uterine cramps such as diarrhea, headaches and nausea in around 60% of women with PD.. The symptoms usually subside as menstruation tapers off after 2 or 3 days of phase one of the cycle.

Primary dysmenorrhea generally starts around 3 years from the initial arrival of menarche and is very common with young women in high school and well into college years. It is considered one of the most common reasons for absenteeism from school or work.

Treatment of Primary Dysmenorrhea

The first choice in Western medicine for treating primary dysmenorrhea is through the use of nonsteroidal anti-inflammatory drugs, or as they are commonly called, NSAIDs. Their mode of action is to inhibit the production and release of the prostaglandin hormones we spoke of above. These are the same hormones that cause the uterus to contract and are also responsible for associated symptoms such as headaches, nausea, and diarrhea. Most women respond well to NSAID treatment, and is the first option for those seeking relief.

When NSAID treatment fails to relieve primary dysmenorrhea, or in cases where birth control is desired, contraceptives may be prescribed. Unlike NSAIDs which may take an hour to relief the pain, contraceptives may take a few menstrual cycles to show their effect. Some women use the NSAIDs during this time to cope with the symptoms of primary dysmenorrhea.

There are several forms of prescribing contraceptives in the treatment of PD, including combined oral contraceptives, extended cycle oral contraceptives, injectable DMPA (often used in severe cases),and an intrauterine device such as LNG-UID. Unlike the NSAIDs, which inhibit prostaglandin activity, contraceptives work by altering the hormonal processes of menstruation. This topic will be covered in more detail when we discuss contraceptives prior to IVF treatment.

Secondary Dysmenorrhea (SD)

Secondary dysmenorrhea is defined as menstrual cramps that originate from some form of disorder of the woman’s reproductive organs. The pain starts earlier in the cycle in contrast to primary dysmenorrhea where the pain start shortly before or on the start of the cycle. The pain and cramps also last longer in secondary dysmenorrhea than in primary.

Secondary dysmenorrhea can be caused by one or several reasons:

  • Endometriosis – when tissue that is the type that lines the endometrium is found in other pelvic organs.
  • PID (pelvic inflammatory disease), which is primarily an infection of the fallopian tubes, but can also affect the ovaries, uterus, and cervix
  • Ovarian cyst or tumor
  • Fibroids – benign tumors that develop within the uterine wall or are attached to it
  • STI (sexually transmitted infection)
  • Adenomyosis – the tissue that lines the uterus (called the endometrium) begins to grow within its muscular walls
  • IUD (intrauterine device (IUD)

Treatment of Secondary Dysmenorrhea

Treatment of secondary dysmenorrhea is based on the underlying etiology or root of the symptoms. As noted above, abnormal conditions in the reproductive system is considered to be primary factor for secondary dysmenorrhea. A thorough examination which may include biopsies may be necessary for a definite diagnosis, and treatment may range from antibiotics, such as in STIs to surgery for removal of fibroids to a hysterectomy.