1. Primary Dysmenorrhoea
Max Brinsmead MB BS PhD
May 2015

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
Combined Oral Contraceptive
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 )
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 presacral neyrectomy (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 )

10. Cochrane on Other Interventions
High frequency TENS more effective than placebo (7 RCTs, OR 7.2, CI )
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”

11. Any Questions or Comments?
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