Dysmenorrhea, pain associated with menses, is either Primary (Functional) or
Secondary (Acquired). It is most common during adolescence and tends to decrease
over time and after pregnancy. Pain results from myometrial uterine contractions
stimulated by increased prostaglandin production in secretory endometrium.
Treatment involves suppressing prostaglandin secretion and/or ovulation and
addressing underlying disorders.
Primary dysmenorrhea is cyclical pain associated with menses during ovulatory
cycles without demonstrable lesions affecting the reproductive structures.
Secondary dysmenorrhea is pain with menses that is caused by demonstrable
pathology. Dysmenorrhea causes more absenteeism from school and work than any
other single factor. Up to 40% of female adults have some degree of menstrual
- Contractions due to increased prostaglandin secretion
- Uterine ischemia
- Anxiety and stress
- Narrow cervical os
- Tissue expulsion through narrow cervix
- Displaced uterus
- Narrow cervical os, cervical stemosis, other anatomic
- Tissue expulsion through narrow cervix
- Extrauterine pregnancy
- Congenital abnormalities
- Endometrial polyp/submucosal fibroid expulsion
- Uterine infections
- Chronic/acute pelvic inflammatory disease (PID)
- Intrauterine device (IUD)
- Ovulatory cycles
- Stressful events
- Pelvic infection
- Abdominal surgery/ectopic pregnancy
- Sexually transmitted
|Signs and Symptoms|
Symptoms and degree of pain vary from person to person.
- Low abdominal cramping/dull ache
- Ache radiating to lower back, groin, legs
- Pain may begin before or at start of menses, usually peaks after 24
hours, and decreases after 48 hours
- Heavy menstrual flow
- Constipation or diarrhea
- Frequent urination
- Vomiting (infrequently)
- Premenstrual syndrome
- Often vague, often continuous low abdominal pain/cramping
- Increased pain with menses
- Associated gastrointestinal upset, thigh
- PMS Syndrome
- Gastrointestinal disorders
- Irritable bowel syndrome
- Sexually transmitted disease
- Chronic tubal inflammation
- Adhesions from previous abdominal surgery/ectopic
- Enlarged uterus
- Urinary tract infection
- Abdominal exam: Rule out any palpable mass; check for abnormal bowel
sounds and tender or distended bladder.
- Pelvic exam: Uterine or ovarian pressure may result in extreme
tenderness—suggestive of pelvic inflammatory
To exclude infection:
- White blood cell count/differential
- Elevated erythrocyte sedimentation rate (ESR)
- Cervical/vaginal cultures to rule out localized
- Enlarged uterus
- Fibrous/ovarian tumors
- Abdominal surgery/ectopic pregnancy adhesions
- Uterine displacement/
- Pelvic ultrasound; pelvic CT may be
- Pain occurrence in relation to menstrual cycle (pain two to three
days prior to and/or lasting two to three days following commencement of blood
flow may indicate pathology, or relationship to bowel movements or
- Presence and/or condition of intrauterine devices
- Psychological assessment (major life events, level of
physical/emotional functioning, history of physical abuse)
- Laparoscopy, cervical mucus/endometrium
Prior to invasive diagnosis, trial therapeutic medical management is
recommended. Exercise/relaxation can also be done. Studies indicate relief in
25% to 85% of patients without pathological disorders.
- Antiprostaglandins, anti-inflammatory (ibuprofen 800 mg to start; 400
to 600 mg every six hours) for primary disorder without pathological
- Gonadotropin-releasing hormone (GnRH) analogs/oral contraceptives to
suppress ovarian function (consider age/risk factors)
- Antibiotics for PID
- Estrogen/oral progestins for endometriosis (e.g., norethindrone for
12 months). Prognosis: 80% relief, 50% return of fertility.
- Diuretics, if edema present
|Complementary and Alternative
Dysmenorrhea may be effectively treated with alternative therapies and
mind-body techniques such as meditation, yoga, tai chi, and gentle exercise.
Begin with nutritional support, magnesium, B6, vitamin E, and red raspberry. A
minimum of three months may be required to accurately assess the effects of
Increase intake of essential fatty acids. These are anti-inflammatory and
needed for hormone synthesis. Essential fatty acids are found in cold-water
fish, nuts, and seeds. Reduce intake of saturated fats (meat products and dairy
products) which are pro-inflammatory. Eliminate refined foods, sugar, dairy
products, and methylxanthines (coffee and chocolate) which are pro-inflammatory
and deplete the body of essential nutrients. Increase fresh fruits and
vegetables, proteins, and whole grains.
- Magnesium (400 mg/day) with B6 (100 mg/day) throughout cycle to
promote hormone production and induce relaxation. Can be used at higher doses
during menses (magnesium up to 600 mg/day, and B6 up to 300 mg/day) for acute
- Vitamin E (400 to 800 IU/day) to improve blood supply to muscles and
promote oxygen utilization
- B-complex (50 to 100 mg/day) for reducing the effects of
- Flaxseed, evening primrose, or borage oil (1,000 to 1,500 mg one to
two times/day), to reduce inflammation and support hormone production
- Niacinamide (50 mg bid) to reduce pain and inflammation. Begin seven
days before menses and continue until the end of flow. Adding rutin (60 mg/day)
and vitamin C (300 mg/day) will potentiate
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
- Chaste tree (Vitex agnus-cactus) and black cohosh
(Cimicifuga racemosa), 30 drops each, bid, influence the pituitary to
balance the estrogen:progesterone ratio and reduce dysmenorrhea.
- Red raspberry (Rubus idaeus) tea has tonifying properties and
strengthens uterine tissue.
- Tea of chamomile (Matricaria recutita) and ginger root
(Zingiber officinale) can help reduce ovarian cyst pain.
- Tinctures of cramp bark (Viburnum opulus), black cohosh,
Jamaica dogwood (Piscidia piscipula), and wild yam (Dioscorea
villosa) can be used together in equal parts to relieve pain and cramping.
Use 20 drops every half hour for four doses, then as needed up to eight
doses/day for seven days.
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and
The following methods help to increase circulation and relieve pelvic
congestion. Do one or both for maximum therapeutic effects.
- Castor oil pack: Used externally, castor oil is a powerful
anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth
(e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or
heating pad) over the pack and let sit for 30 to 60 minutes. For best results
use three consecutive days in one week.
- Contrast sitz baths: Use two basins that can be comfortably sat in.
Fill one with hot water, and one with cold water. Sit in hot water for three
minutes, then in cold for one minute. Repeat this three times to complete one
set. Do one to two sets per day three to four days per
Dysmenorrhea may respond to acupuncture treatment, for pain relief and
resolving deficiencies/excesses that may contribute to
Therapeutic massage is helpful in reducing the effects of the stress which
may exacerbate dysmenorrhea.
- Regular evaluation to determine effectiveness of
- Patient to report additional symptoms/complaints or if treatment
offers no relief
- Patient's desire for pregnancy when determining treatment
- Allergies/adverse interactions to traditional/nontraditional
- Avoid stress and caffeine, alcohol, and sugar prior to onset of
- Regular exercise increases blood circulation.
- Relaxation reduces stress.
- Reduce risk of acquiring sexually transmitted
Infection from underlying pathology
- Most women experience dysmenorrhea at some time in their
- Pregnancy often relieves primary dysmenorrhea.
- Prognosis is good when underlying causes are accurately diagnosed and
- Certain drugs/underlying pathologies may interfere with
Batchelder HJ, Scalzo R. Allopathic specific condition review:
dysmenorrhea. Protocol J Botan Med. 1995;1(1).
Berkow R, ed. The Merck Manual of Diagnosis and Therapy. 16th ed.
Rahway, NJ: Merck Research Laboratories; 1992.
Branch WT Jr. Office Practice of Medicine. 3rd ed. Philadelphia, Pa:
WB Saunders Co; 1994.
Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual
cycle symptoms. Am J Obstet Gynecol. 1993;168:1417-1423.
Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing Inc; 1987.
Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
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instructions for individual patients. The publisher does not accept any
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