Primary Dysmenorrhoea

1. Primary Dysmenorrhoea Max Brinsmead PhD FRACOG July 2012

2. Primary Dysmenorrhoea – Definition • Pain with menstruation in the absence of any pelvic pathology • Secondary dysmenorrhoea is associated/secondary to pelvic pathology • Primary dysmenorrhoea is associated only with ovulatory cycles • Correlates with luteal Progesterone and intrauterine generation of Prostaglandins

3. Dysmenorrhoea – Differential Diagnosis • Endometriosis • Adenomyosis • PID • Fibroids • Uterine obstruction problems • Clot colic • Irritable bowel syndrome • Musculoskeletal problems

4. Clinical Clues • Pain that begins with or before menstruation and eases as the flow reduces is often PRIMARY • Pain that begins after the onset of menses or gets worse as the flow reduces is often SECONDARY • Endometriosis • PID • Primary dysmenorrhoea may get better after 1st pregnancy and childbirth • But not always • Ask about pre menstrual spotting (PMS) • “Do you go straight into a full flow or do your periods muck about for a few days” • PMS has a high likelihood of endometriosis • And luteal phase defects

5. Dysmenorrhoea – The Psychogenic Component The Problem is worse for: • Emotional/Vulnerable • Work dissatisfaction • School problems • Sexual dysfunction • Smokers • Drug dependent

6. 10 Dysmenorrhoea - Treatment • Rest, Relaxation, Local heat • Psychotherapy • Diet – weight reduction • Smoking cessation • NSAIDs – in the correct dose/mode • COC • Cyclical • Continuous • Depo Provera • Mirena • BUT there is still a 20 – 25% rate of incomplete control of symptoms using these treatments

7. NSAIDs – First-line Treatment • 73 RCTs unanimous. NSAID more effective than placebo (RR 4.50, OR CI 3.85-5.27) • And more effective than Paracetamol • But have more side effects • Mostly gastrointestinal • Studies thus far have not identified any particular NSAID to have either greater effectiveness or safety

8. Surgical Treatments • Laparoscopic uterine nerve ablation (LUNA) • Laparoscopic presacralneyrectomy (LPSN) • Both shown to be effective compared to no treatment or controls in RCT • LPSN more effective than LUNA in the longer term • Constipation is a side effect of LPSN • Hysterectomy is the ultimate cure for dysmenorrhoea

9. Cochrane on Diet & Herbal Remedies • Magnesium: 3 trials - some benefit • Vitamin B6: 1 trial showed benefit but Mg + B6 was no better than Mg alone • Vitamin B1: 1 large trial (100mg daily) showed benefit • Vitamin E: Does not appear to boost the analgesic effects of NSAID • Omega-3 fatty acids more effective than placebo in 1 small trial • Japanese Herbal Remedy more effective than placebo in 1 small trial • 14 RCTs of Chinese Herbal Medicine show benefit (RR=1.99, CI 1.52 -2.60)

10. Cochrane on Other Interventions • High frequency TENS more effective than placebo (7 RCTs, OR 7.2, CI 3.1-16.5) • Auricular acupuncture of some benefit in pain associated with pelvic endometriosis • No benefit from spinal manipulation • 4 trials of exercise but only one of high quality • Exercise reduces menstrual distress scores and has a residual effect for next 3 cycles • 5 trials of behaviour modification provides some support for relaxation training, or “pain management training”