What is Algodismenorrhea (Dysmenorrhea)?
Algomenorrhea (dysmenorrhea) is a cyclically recurring pain syndrome that accompanies menstrual rejection of the endometrium. The frequency of algomenorrhea ranges from 8 to 80%. With algomenorrhea, disability and changes in psychosomatic status are possible, and therefore it is not only a medical, but also a social problem.
Pathogenesis during Algodysmenorrhea (Dysmenorrhea)
There are primary, or functional, algodimenorrhea, not associated with anatomical changes of the internal genital organs, and secondary, due to pathological processes in the pelvic organs.
Primary alyodismenorrhea appears in adolescence after 1–1.5 years after menarche, with the onset of ovulation, usually in girls of asthenic physique, excitable and emotionally labile. Prerequisites for primary algodysmenorrhea:
- luteal phase deficiency;
- insufficient levels of endogenous opiates (endorphins, enkephalins);
- functional failure of endometrial tissue proteolytic enzymes and impaired fragmentation of the falling uterine mucosa;
- excessive prostaglandins due to the inadequacy of lipid peroxidation.
The emergence of primary algodimenorrhea, most researchers attributed to a high level of prostaglandins E2 and F2 and / or an increase in their relative amounts in menstrual endometrium. Prostaglandins E2 and F2 are powerful stimulants of the contractile activity of the myometrium. During menstruation, disruption of the integrity of cell membranes and endometrial rejection contribute to the release of prostaglandins into the extracellular space, their content in the menstrual blood increases. Vasospasm and local ischemia lead to impaired pelvic hemodynamics: venous congestion promotes cell hypoxia, the accumulation of allogeneic substances, irritation of nerve endings and the occurrence of pain. The pain increases as a result of the accumulation of calcium salts in the tissues: the release of active calcium increases the intrauterine pressure, the amplitude and frequency of uterine contractions.
A significant role in the woman’s reaction to increased spastic contractions of the uterus during menstruation is played by pain sensitivity. Extensive pain receptor fields are located mainly in the thalamus. The pelvic and celiac nerves, which include afferent fibers from the cervix and body of the uterus, have representation in the thalamus. The intensity of the sensation of pain is due to neurotransmitters – endogenous opiates, and depends on the type of autonomic nervous activity, mental state, emotional background, etc. The pain threshold is largely determined by the synthesis of endogenous opiates. Strong motivation and willpower, switching attention to any activity can ease the pain or even suppress it.
Symptoms of Algomenorrhea (dysmenorrhea)
Cramping pain on menstruation days or a few days before it is localized in the lower abdomen, radiating to the lower back, less often in the region of the external genitalia, groin and thighs. The pains are paroxysmal and quite intense, accompanied by general weakness, nausea, vomiting, spastic headache, dizziness, fever to 37-38 ° C, dry mouth, bloating, fainting and other vegetative disorders. Sometimes a single symptom becomes the lead, it bothers more than pain. Severe pains deplete the nervous system, contribute to the development of asthenic condition, reduce the ability to work.
Diagnosis of Algodismenorrhea (dysmenorrhea)
Diagnosis of primary algodysmenorrhea is based on:
- characteristic constitutional features, young patients, the appearance of algomenorrhea 1.5-2 years after menarche;
- concomitant vegetovascular symptoms of algomenorrhea;
- the absence of anatomical changes during gynecological examination;
- asthenic physique, slimming tendencies.
Treatment of Algomenorrhea (dysmenorrhea)
Treatment of primary algomenorrhea should be comprehensive.
It includes:
- inhibitors of prostaglandin synthesis. It is necessary to take into account their effect on the gastric mucosa and platelet aggregation and to prescribe nonsteroidal anti-inflammatory drugs in suppositories. The most commonly used indomethacin is 25 mg 3 times a day, naprosin 250 mg 2-3 times a day, Brufen 200 mg 3 times a day, aspirin 200 mg 4 times a day. The feasibility of using these drugs within 48-72 hours after the onset of menstruation is determined by the fact that prostaglandins are secreted in maximum quantities in the first 48 hours from the onset of menstruation;
- antispasmodics, analgesics (as an antispasmodic therapy);
- combined estrogen-progestin drugs with a high content of gestagens or more active gestagens from the 5th to the 25th day of the menstrual cycle 1 tablet for at least 3 months (the mechanism of their action is not clear enough, perhaps, combined contraceptives, inhibiting the growth of the endometrium, help reduce the synthesis of prostaglandins in it);
- sedatives in accordance with the severity of neuro-vegetative disorders from herbal preparations to tranquilizers (valerian, Relanium, trioxazine);
- homeopathic remedies (remens, mastodinon, menalgin and others);
- non-pharmacological treatment – physiotherapy and acupuncture: electrophoresis of novocaine to the solar plexus area of 8-10 procedures every other day during the cycle, Shcherbak collar with bromine, ultrasound, DDT and SMT;
- vitamin therapy – vitamin E 300 mg per day for the first 3 days of painful menstruation;
- the correct mode of work and rest; playing sports that promote harmonious physical development (swimming, skating, skiing).
What is Algodismenorrhea secondary?
Secondary algomenorrhea is caused by organic changes in the pelvic organs and often develops in women after 30 years with childbirth, abortions, and gynecological inflammatory diseases in history.
Causes of Algodismenorrhea Secondary
One of the most common causes is endometriosis. However, pain in this pathology is possible throughout the entire menstrual cycle and may increase 2-3 days before the menstruation. They are often not cramping, but aching with irradiation to the rectal area. Pain is not accompanied by a “vegetative storm” (vomiting, nausea, sweating, diarrhea). Gynecological examination, depending on the location and distribution of endometrioid heterotopies, determines the thickening and tenderness of the sacro-uterine ligaments, the pain of uterine dislocation, the increase in uterine appendages, the change in uterus and ovaries before menstruation, and their decrease after its end.
If the common forms of endometriosis do not present any particular difficulties for the diagnosis, then the so-called small forms can be diagnosed only during laparoscopic examination. The frequency of algodysmenorrhea in small forms of endometriosis reaches 72%. This form of endometriosis has a very scanty clinical symptoms. Pain during menstruation is mild, and women often do not attach much importance to them. Especially often this form of endometriosis has been diagnosed in recent years when examining women suffering from infertility.
Algomenorrhea can occur in women using intrauterine contraceptives (IUD). In these women, the concentration of prostaglandins in the endometrium is significantly increased and clearly correlates with the content of macrophages in the endometrium when using IUD. When IUD containing progesterone (for example, progestasert), algomenorrhea is not observed. This is explained by a decrease in contractile activity of the uterus under the influence of the hormone of the corpus luteum.
Menstruation is accompanied by sharp cramping pains in submucous myoma of the uterus. Pain also occurs in the so-called nasal myomatous nodes, when the node reaches the internal pharynx and the uterine contractions is pushed through the cervical canal.
The cause of pain during menstruation can be tears in the back of the broad ligament of the uterus (Alain-Masters syndrome) and pelvic varicose veins. Tears of the posterior leaflet of the broad ligament occur during traumatic labor (large fetus, rapid delivery, imposition of obstetric forceps), with a rough expansion of the cervical canal during an articular abortion or diagnostic curettage of the mucous membrane of the uterus. Varicose veins of the pelvis may be the result of inflammatory and adhesive processes and pregnancy, disrupting blood circulation in the pelvic organs. A systemic process is possible, since women with dilated pelvic veins often have dilated hemorrhoidal veins and lower extremity veins.
Secondary algomenorrhea is observed in women with malformations of the genitalia that impede the flow of menstrual blood (additional closed uterine horn, additional closed vagina, etc.). In case of genital malformations, menstrual pain increases from the moment of menarche, patients are usually of a young age.
Chronic inflammatory processes in the small pelvis with the formation of adhesions between the peritoneal cover of the uterus and adjacent organs can be one of the causes of secondary algodimenorrhea. A vaginal examination of the pelvic organs can reveal tenderness, an increase in the uterus and its limited mobility.
Diagnosis of Algomenorrhea Secondary
The causes of painful menstruation are established with a carefully collected history taking into account the patient’s age and transferred gynecological diseases.
In the differential diagnosis of primary and secondary algodimenorrhea, ultrasound is important, allowing to diagnose various intrauterine pathology. Use of a contrast agent at transvaginal ultrasonography (hydrosonography) helps diagnostics of an intrauterine pathology. A more accurate diagnosis of uterine malformations that impede the flow of menstrual blood, provides an x-ray examination of the uterus with the introduction of a contrast agent – hysterosalpingography.
Hysteroscopy and laparoscopy are used not only for diagnostic purposes, but also for therapeutic purposes. Laparoscopy is often the only method for diagnosing small forms of external endometriosis, varicose veins of the pelvis, adhesions, rupture of leaves of broad ligaments.
Treatment of Algomenorrhea Secondary
Treatment of secondary algomenorrhea is determined by the organic pathology of the reproductive system, which has resulted in secondary algomenorrhea.
Organic diseases of the reproductive system, leading to secondary dysmenorrhea, often require surgical treatment.
Treatment of malformations of the uterus and vagina surgical. Early detection and treatment of malformations of the uterus and vagina prevent retrograde casting of menstrual blood into the abdominal cavity and the development of endometriosis. Endoscopy (hysteroscopy) allows surgical dissection of the intrauterine septum transcervical, through the endoscope operating channel or hysteroresectoscope.
With an unspecified diagnosis, prolonged use of analgesics and tranquilizers is unacceptable.