Definition

Dysmenorrhoea is defined as cyclic lower abdominal pain that occurs with, or precedes, menstruation.¹ Depending on the aetiology of the condition, dysmenorrhoea may be classified as either primary or secondary. Primary dysmenorrhoea is a functional disorder that has no identifiable pathological aetiology and is typically associated with ovulation. Pain caused by a demonstrable pathology to the pelvic or reproductive structures, however, is referred to as secondary dysmenorrhoea.¹

Epidemiology

The prevalence of dysmenorrhoea varies across the globe, affecting between 16.8 and 81 per cent of women.² Of the two categories of menstrual pain, primary dysmenorrhoea is the most common, contributing to around ninety per cent of dysmenorrhoeic cases.³ Primary dysmenorrhoea usually begins during adolescence or the early twenties, generally after regular ovulation is established, and usually after the first three to six menstrual cycles.⁴ Unlike the prevalence of secondary dysmenorrhoea, which increases with advancing age, the prevalence of primary dysmenorrhoea diminishes with age and, in some cases, following pregnancy.⁴

Aetiology and pathophysiology

Primary dysmenorrhoea is caused by abnormal eicosanoid production, specifically, an abnormal increase in endometrium-derived prostaglandin (PG) F_2α and PGE₂. These proinflammatory compounds are formed under the influence of progesterone, but can also rise following endometrial shedding, endometrial cell necrosis,⁴ excess omega 6 fatty acid intake, low omega 3 fatty acid consumption and/or abnormal fatty acid metabolism.^3,5,6 The PGs implicated in the pathogenesis of dysmenorrhoea exhibit a wide range of effects. PGF_2α, for instance, affects the gastrointestinal (GI) tract, causing nausea, vomiting and diarrhoea.⁴ PGF_2α is also a potent smooth muscle stimulant and vasoconstrictor, which, in sufficient quantities, can cause uterine ischaemia, myometrial contractions and uterine pain.³ In contrast, PGE₂ is a potent vasodilator and a possible contributor to excessive menstrual bleeding.⁴ While the cytokine hypothesis of dysmenorrhoea is theoretically plausible, evidence from clinical studies is mixed.^7,8

As opposed to the proinflammatory state of primary dysmenorrhoea, the cause of secondary dysmenorrhoea is primarily pathological. Conditions usually associated with secondary dysmenorrhoea include endometriosis, uterine adenomycosis, leiomyomata or fibroids, pelvic adhesions, cervical stenosis, pelvic inflammatory disease, in situ intrauterine device and endometrial polyps.^1,4

Other factors that may increase the severity or duration of dysmenorrhoea are anxiety, low levels of exercise, low fish consumption and cigarette smoking.^1,3 Several studies also report a higher risk of dysmenorrhoea among women with high stress (i.e. occupational or perceived stress) compared to those with low stress.^9,10

Clinical manifestations

Dysmenorrhoea typically presents as recurrent, spasmodic lower abdominal or suprapubic pain that is sharp or dull in quality.⁴ In many cases, the pain radiates to the lower back or thighs. Some women also report symptomatic improvement following the application of heat to the abdomen or by assuming the fetal position.⁴ In primary dysmenorrhoea symptoms usually begin 1–3 days before menses, peak 24 hours after the onset of menstruation and subside 2–3 days later. In secondary dysmenorrhoea, menstrual pain may commence long before menses begins and continue well after menstruation has ceased.¹ It is not uncommon for women with either type of dysmenorrhoea to also experience concomitant nausea, vomiting, diarrhoea, constipation, headache, fatigue, irritability, nervousness, urinary frequency, dizziness, sleeplessness and depression.^1,3

Clinical case

23-year-old woman with primary dysmenorrhoea

Rapport

Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, as well as the accuracy and comprehensiveness of the clinical assessment.

Assessment

Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment.

Health history

History of presenting condition

A 23-year-old woman presents to the clinic complaining of dull, spasmodic menstrual pain. The pain is located over the suprapubic region primarily, but at times can radiate to the lower back and is often accompanied by mild nausea, bloating, fatigue and irritability. The pain and concomitant symptoms have been present for the past 7 years and typically follow the same pattern – begin 1 day before menstruation, peak on the first day of menses (pain score = 7/10) and subside 2 days later. The menstrual cycle is regular (cycling every 28–30 days), menstruation volume is moderate and menses duration is generally 4–5 days. There is no mid-cycle bleeding or pain, nor abnormal vaginal or urethral discharge, dyspareunia, altered libido or dysuria. Fatigue generally aggravates the symptoms; paracetamol and hot packs to the abdomen provide moderate relief of pain.

Medical history

Family history

Father has hypercholesterolaemia and gastro-oesophageal reflux disease, paternal grandfather has type 2 diabetes mellitus, maternal grandmother has lung cancer.

Allergies

Bee venom (anaphylaxis).

Medications

Fish oil 1 g daily, paracetamol 1 g 4-hourly as needed.

Medical conditions

Severe pneumonia (1989), dysmenorrhoea.

Surgical or investigational procedures

Tonsillectomy and adenoidectomy (1993).

Lifestyle history

Tobacco use

Nil.

Alcohol consumption

Light social drinker. Consumes 2–3 standard size white wines 3–5 times a year.

Illicit drug use

Nil.

Diet and fluid intake
Breakfast	White toast with butter, coffee.
Morning tea	Coffee, banana or carrot cake.
Lunch	Leftover dinner, sandwich with white bread, ham, tomato, lettuce and pickles.
Afternoon tea	Coffee.
Dinner	Chicken or beef and vegetable stirfry with white rice, penne carbonara with mushrooms, focaccia with grilled chicken or roast beef, eggplant, capsicum and lettuce.
Fluid intake	3–4 cups of instant coffee a day, 2–3 cups of water a day.
Food frequency
Fruit	0–1 serve daily
Vegetables	2–3 serves daily
Dairy	0–1 serve daily
Cereals	5–6 serves daily
Red meat	6–7 serves a week
Chicken	1–2 serves a week
Fish	0 serves a week
Takeaway/fast food	twice a week

Quality and duration of sleep

Difficulty falling asleep (sleep latency of approximately 1 hour). Continuous sleep; average duration is 6 hours.

Frequency and duration of exercise

Has little time for a dedicated exercise program. Drives to work. Engages in incidental exercise (i.e. work-related walking) less than 2 hours a day. Engages in sedentary activities (i.e. desk duties) more than 8 hours a day.

Socioeconomic background

The client and both parents were born in the US. Since completing her law degree 3 years ago, the client has been employed as a full-time lawyer in a busy law firm in the central business district (CBD), which the client states is very stressful and often requires overtime. The client and her supportive same-sex partner reside in a privately rented apartment in the CBD. This same-sex relationship has led to some hostility between the client and her parents and two siblings. The client has no religious or cultural affiliations.

Physical examination

Clinical examination of the reproductive system is outside the scope of practice for most CAM practitioners. Thus, the following five elements represent a summary of the clinical examination conducted by the client’s physician.

Inspection

Both breasts are symmetrical, with no visible masses, lesions or discharge. The abdomen is flat. The labia, clitoris, urethral meatus, vaginal orifice, perineum and cervix are unremarkable.

Olfaction

There are no abnormal odours present.

Palpation

Both breasts are non-tender, with no palpable masses. The abdomen is soft and non-tender, with no palpable masses. Labia, clitoris, urethral meatus, vagina, perineum and cervix are non-tender. Bimanual examination revealed that the uterus is of normal size, shape and contour, and is non-tender. Rectovaginal examination is unremarkable.

Percussion

Not applicable.

Auscultation

Bowel sounds are normoactive in all four quadrants.

Additional signs

Client is afebrile (36.7°C, per oral). Blood pressure is 118/64. Client is of normal weight (BMI is 24.1 kg/m², waist circumference is 71 cm).

Clinical assessment tools

The menstrual symptom questionnaire (MSQ) provided an overall score of 72/120, where a score of zero represents no menstrual symptoms and a score of 120 represents frequent and intense menstrual symptoms. The menstrual pain ‘often’ experienced before and during menses and the concomitant symptoms ‘sometimes’ experienced during menstruation corroborate the type, frequency and intensity of symptoms reported in the client’s history.

Diagnostics

CAM practitioners may request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations.

Pathology tests

Fatty acids

Plasma or red cell fatty acid analysis assesses the concentration of fatty acids within the plasma or erythrocyte, including omega 3, omega 6 and omega 9 polyunsaturated fatty acids, saturated fatty acids and trans fatty acids. Given that the fatty acid composition of plasma and erythrocytes is correlated with the dietary intake of fatty acids,¹¹ this test can help to determine whether excess omega 6 fatty acid intake and/or low omega 3 fatty acid consumption are contributing factors in dysmenorrhoea.^3,5

Hormones and eicosanoids

Several small studies have compared the plasma concentrations of oxytocin, follicle-stimulating hormone, 17β-estradiol, vasopressin, luteinising hormone, progesterone and PGF_2α in healthy controls to women with primary dysmenorrhoea.^7,12,13 However, findings from these studies have been inconsistent, rendering questionable the value of hormone testing in women with dysmenorrhoea.

Radiology tests

Medical imaging, such as CT, MRI, ultrasound and uterosalpingography, may be requested if secondary dysmenorrhoea is suspected, particularly if it is attributed to uterine fibroids, tumours, pelvic inflammatory disease, adhesions or the presence of foreign objects.

Functional tests

A female hormone profile measures salivary levels of oestradiol, progesterone, testosterone and dehydroepiandrosterone (DHEA) over a single 28-day menstrual cycle. While saliva is a valid and reliable sample source for hormone analysis,¹⁴ the value of hormone testing in women with dysmenorrhoea is questionable as female hormones appear to play little to no role in the pathogenesis of the condition.

Invasive tests

Invasive tests may be required if secondary dysmenorrhoea is suspected. Hysteroscopy, laparoscopy and, in few cases, Papanicolaou testing, can be useful in detecting conditions associated with secondary dysmenorrhoea, such as endometriosis, uterine fibroids, pelvic adhesions and pelvic inflammatory disease.

Miscellaneous tests

Not applicable.

Diagnosis

Clusters of data extracted from the health history, clinical examination and pertinent diagnostic test results point towards the following differential CAM diagnosis.

• Menstrual pain (actual), related to emotional stress (client works in a stressful occupation, and has reported unresolved family conflict), high omega 6:omega 3 fatty acid intake (dietary intake of foods containing omega 3 fatty acid is minimal and the intake of omega 6 fatty acids is relatively high), and sedentary lifestyle (client’s occupation is largely desk-bound and client engages in very little physical exercise).

Planning

The goals and expected outcomes that best serve the client’s needs, and are most relevant to the case (as determined by the clinical assessment and CAM diagnoses), are as follows.

Goal

1. Client will demonstrate an improvement in menstrual pain (client’s primary concern is menstrual pain).

Expected outcomes

Based on the degree of improvement reported in clinical studies that have used CAM interventions for the management of dysmenorrhoea,^15–18 the following are anticipated:

1. Client will demonstrate a fifty per cent reduction in baseline severity of menstrual pain in 7 weeks or by dd/mm/yyyy (measured by 0–10 visual analogue scale).

2. Client will report a thirty per cent decrease in baseline duration of menstrual pain in 8 weeks or by dd/mm/yyyy (measured by symptom diary).

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