Definition
Dysmenorrhea literally means painful menstruation. Many women get some discomfort during menstruation. It is known as dysmenorrhea if the pain is severe and the woman has to take bed–rest and analgesic.

Types of Dysmenorrhea

• Primary (spasmodic)
• Secondary

Primary (Spasmodic)
This is the commonest type of dysmenorrhea. In primary dysmenorrhea there is no certain pelvic pathology involved.
Age
Primary dysmenorrhea is predominantly confined to adolescent girls, 15–18 years of age. It usually appears within 2 years of menarche. There may be a family history of dysmenorrhea in the mother or sister.
Clinical Features of Dysmenorrhea

• The pain begins a few hours before or just about with the onset of menstruation. The severity of pain usually lasts for few hours, it may extent to 24 hours but can persist beyond 48 hours.
• The pain is spasmodic and confined to the lower abdomen, it may radiate to the back and medial aspect of thighs.
• Systemic discomforts like nausea, vomiting, fatigue, diarrhea and headache may be associated.
• It may be accompanied by symptomatic changes causing pallor, cold sweats and occasional fainting.
• Rarely, fainting and collapse in severe cases may be associated.
• Abdominal or pelvic examination does not reveal any abnormal findings.

Causes of Pain

• The exact cause of spasmodic dysmenorrhea is unknown.
• The possible cause is that the uterine muscles get into a spasm and this in turn produces ischemia of the muscle. The pain is the result of this ischemia.
• The pain is related to dysrhythmic uterine contraction and uterine hypoxia (lack of oxygen).
• Psychosomatic factor due to tension and anxiety during adolescents or lower pain threshold is often attributed as an aggravating factor in pain perception. This may explain in part, the disappearance of pain with advancing age.

Treatment of Dysmenorrhea
Measures include improvement of general health and simple psychotherapy in terms of explanation and assurance. It should be explained to young girls that menstruation is a physiological phenomenon and not a disease. The girl should be taught the hygiene of menstruation. The patient should be reassured that the pain is short lived.

She may use a hot water bottle for fomentation of the lower abdomen. Usual activities including sports are to be continued. During period, bowel should be kept empty and mild analgesics and antispasmodics may be prescribed. With these simple measures, the pain is relieved in majority.
In severe cases

• Drugs.
• Surgery.

Drugs
The drugs used are

• Prostaglandin synthesize inhibitors.
• Oral contraceptives (The pill should be used for 3–6 cycles).

The suitable candidates for oral contraception are patients

• Wanting contraceptive precaution.
• With heavy periods.
• Unresponsive or contraindications to anti–prostaglandin drugs.

Surgery

• Dilatation of the cervical canal
  It is done under general anesthesia. Dilatation should be slow and gradual. If the pain recurs after being cured for few months, repeat dilatation is indicated. Sufficient dilatation is done with Hegar’s dilators upto 8–10 mm. Late sequels may be cervical incompetence. Cervical dilatation relieves pain by–i) stretching of the fibro muscular tissues at the level of internal os and ii) by causing injury to the sensory nerve endings cutting down the pain pathway. Curettage is unnecessary; may be of help if associated with menstrual abnormality or in membranous dysmenorrhea.
• Bilateral block of the pelvic plexus
  Paracervical block with alcohol may be carried out along with dilatation of the cervix to improve the result. It may be employed as a therapeutic test before a major operation like presacral neurectomy is undertaken.
• Presacral neurectomy –(Cotte’s operation)
  It can only be done in a hopeless case of a neurotic type of patient when all the other measures fail. The objective is to cut down the sensory pathway from the uterus.

Secondary (Congestive) Dysmenorrhea
Secondary dysmenorrhea is normally considered to be period–associated pain occurring in the presence of pelvic pathology.
Age
The patients are usually in thirties; more often parous (have had previous deliveries) and unrelated to any social status.
Clinical Features of Secondary Dysmenorrhea
The pain is dull, situated in the back and in front without any radiation. It usually appears 3–5 days prior to the period and relieves with the start of bleeding. The onset and duration of pain may vary. There is no systemic discomfort unlike primary dysmenorrhea. The patients may have got some discomfort even in between periods. There are symptoms of associated pelvic pathology. Abdominal and vaginal examinations usually reveal a lesion. At times, the lesion is revealed by laparotomy or laparoscopy.
Cause Of Pain
The pain may be related to increased vascularity in the pelvic organs. Common lesions are–chronic pelvic inflammatory disease, pelvic endometriosis, adenomyosis, uterine fibroid, endometrial polyp, IUCD etc.

Treatment of Secondary Dysmenorrhea
The type of treatment depends on the severity, age and parity of the patient. Analgesics provide temporary relief.