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Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent

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 Primary Dysmenorrhea in Adolescents:
Prevalence, Impact and Recent
Knowledge
Vincenzo De Sanctis1, MD, Ashraf Soliman2, MD, Sergio Bernasconi3, MD, Luigi
Bianchin4, MD, Gianni Bona5, MD, Mauro Bozzola6, MD, Fabio Buzi7, MD, Carlo De
Sanctis8, MD, Giorgio Tonini9, MD, Franco Rigon10, MD, Egle Perissinotto11, ScD

1 2
Private Accredited Hospital Quisisana, Pediatric and Adolescent Outpatients Clinic, Ferrara, Italy, Department
3
of Pediatrics, Division of Endocrinology, Alexandria University Children’s Hospital, Alexandria, Egypt, University
4 5
"G.D'Annunzio" Chieti-Pescara Italy, Rehabilitation Centre, La Nostra Famiglia, Padua, Italy, Division of Pediatrics,
Department of Mother and Child Health, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy,
6
Internal Medicine and Therapeutics, Section of Childhood and Adolescence, University of Pavia, Foundation IRCCS
7 8
San Matteo, Pavia, Italy, Department of Pediatrics, "Carlo Poma" Hospital, Mantova, Italy, Department of Pediatric
9
Endocrinology, Ospedale Infantile Regina Margherita, Turin, Italy, Centre of Pediatric Diabetology, Burlo Garofolo
10 11
Hospital, Trieste, Italy, Department of Pediatrics, University of Padua, Padova, Italy, Department of Cardiac,
Thoracic and Vascular Sciences, Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Italy

Corresponding author: Vincenzo De Sanctis MD, Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital,
44100 Ferrara, Italy; Tel: 39 0532 770243; E-mail: vdesanctis@libero.it

Abstract long menstrual periods, heavy menstrual flow, smoking

B
ackground and Objectives: Dysmenorrhea is
commonly categorized into two types; primary and
secondary. Primary dysmenorrhea (PD) is the focus of
this review. PD is defined as painful menses with cramping
sensation in the lower abdomen that is often accompanied
by other symptoms, such as sweating, headaches, nausea,
vomiting, diarrhea, and tremulousness. All these symptoms
occur just before or during the menses in women with
normal pelvic anatomy.
In adolescents the prevalence of PD varies between 16%
and 93%, with severe pain perceived in 2% to 29% of the
studied girls. Several studies suggest that severe menstrual
pain is associated with absenteeism from school or work
and limitation of other daily activities. One-third to one-
half of females with PD are missing school or work at
least once per cycle, and more frequently in 5% to 14%
of them. The wide variation in the prevalence rates may
be attributed to the use of selected groups of subjects.
Many risk factors are associated with increased severity
of dysmenorrhea including earlier age at menarche,
and positive family history. Young women using oral
contraceptive pills (OCP) report less severe dysmenorrhea.
The considerably high prevalence of dysmenorrhea among
adolescents verified that this condition is a significant
public health problem that requires great attention.
Summary of Main Results: Many methodological problems
are encountered during quantifying and grading severity of
pain related to dysmenorrhea. Quantifying and assessment
tools depend on women’s self-reporting with potential
bias. There is a scarcity of longitudinal studies on the
natural history of dysmenorrhea as well as the possible
effects of many modifiable risk factors. In addition, the
duration of follow-up in the available studies is relatively
short. Therefore, several aspects are still open for
research.
Medical treatment for dysmenorrhea includes anti-
inflammatory drugs (NSAIDs), OCP or surgical intervention.
The efficacy of conventional treatments using NSAIDs and
OCP is high. However, failure rate may reach up to 20%

465 Pediatric Endocrinology Reviews (PER) n Volume 13 n No 2 n December 2015


to 25%, besides the occurrence of drug-associated adverse
effects. Only 6% of adolescents receive medical advice to
treat dysmenorrhea while 70% practice self-management.
Unfortunately, some girls even abuse these medications
(non-therapeutic high doses) for quick pain relief.
In adolescent girls, when dysmenorrhea persists despite
the use of OCP and/or NSAIDs drugs is a strong indicator
of an organic pelvic disease. This condition mandates
an appropriate referral to a gynecologist with proper
laparoscopic diagnosis of endometriosis and/or other pelvic
diseases.
Conclusions: Dysmenorrhea is an important health problem
for adolescents, school and occupational as well as
practitioners. public health problem that adversely affects
the daily activities and quality of life for adolescent
women. The accurate prevalence of dysmenorrhea is
difficult to establish due to the variety of diagnostic
criteria and the subjective nature of the symptoms. In
adolescents, moderate to severe dysmenorrhea that affects
lifestyle and does not respond to medical treatment
requires professional attention and proper diagnosis of
possible underlying pelvic disease. Therefore, adolescent
care providers should be more knowledgeable and actively
involved in the care of dysmenorrhea.
Ref: Ped. Endocrinol. Rev. 2015;13(2):000-000
Key words: Dysmenorrhea, Adolescents, Epidemiology,
Health problems
Introduction
Dysmenorrhea is commonly categorized into two types;
primary and secondary. Primary dysmenorrhea (PD) is the focus
of this review. PD is defined as painful menses with cramping
sensation in the lower abdomen that is often accompanied
by other symptoms, such as sweating, headaches, nausea,
vomiting, diarrhea, and tremulousness. These symptoms occur
just before or during the menses in women with normal pelvic
anatomy (1).
Dysmenorrhea is one of the most common complaints amongst
adolescents, It affects the quality of life of many women in
their reproductive years although it was not considered a
medical problem until the 1970’s (1-4). In a Swedish cross-
sectional study 72% of 600 women, aged 19 years, reported
dysmenorrhea. In 15% of them dysmenorrhea limited their
activities and was not responsive to analgesics. Fifty percent
of these girls and women were absent from school or work
on at least one occasion due to dysmenorrhea and 7.9% were
absent every menstruation for at least half a day (5).
Pediatric Endocrinology Reviews (PER) n Volume 13
Primary Dysmenorrhea in Adolescents
Characteristics of Primary (PD) and
Secondary Dysmenorrheal (SD)
PD begins a few hours before or just after the onset of
menstruation. The severity of cramps peaks on the first 2
days of menstruation. PD occurs almost invariably in ovulatory
cycles and appears within 6–12 months after the onset of
menarche. 88% of adolescents experience their first painful
menstruation within the first 2 years after menarche. (6)
Dysmenorrhea that occurs more than 2 years after menarche
is more likely to be secondary (SD), and the underlying cause
should be vigorously sought (7).
The frequency decreases with age and does not appear to be
related to the occupation or physical condition of the woman.
PD occurs more frequently in unmarried compared to married
women (61% vs. 51%) (6).
SD is caused by underlying pelvic conditions or pathology and is
more common in women older than 20 years (8,9). SD can be
caused by endometriosis, pelvic inflammatory disease, intra-
uterine devices, ovarian cysts, adenomyosis, uterine myomas
or polyps, intra-uterine adhesions or cervical stenosis (5,7).
Risk Factors affecting dysmenorrhea
(occurrence, duration and severity):
Many risk factors are significantly associated with more
severe episodes of dysmenorrhea. These include earlier age
at menarche, heavy menstrual flow, smoking, positive family
history, obesity and alcohol consumption (10-14). Young women
who use oral contraceptive pill (OCP) report less severe
dysmenorrheal (9,13). Atheist women have a lower prevalence
compared to religious women (14). There is a lack of data
about any association between PD and nutritional deficiency.
However, iron therapy cures or improves dysmenorrhea in
women with iron deficiency and dysmenorrhea (15).
Obstetric factors such as pregnancy, full-term delivery and
breastfeeding, and socioeconomic factors including education
and religion, are correlated with dysmenorrhea. Physical
activity and body mass index do not appear to be associated
with increased menstrual pain (13). Place of residence appears
to affect the prevalence of dysmenorrhea.
Epidemiology
Prevalence rates of dysmenorrhea vary widely in the literature
and appear to be considerably high. The wide variation in
prevalence rates can be also attributed to the use of selected
groups of subjects and the absence of a universally accepted
method for defining dysmenorrhea. The majority of studies do
n No 2 n December 2015 466
 Primary Dysmenorrhea in Adolescents
not grade the severity of pain or distinguish between the types
of dysmenorrhea (PD versus SD).
A systematic review on dysmenorrhea in the UK population,
more than 10 years ago, showed prevalence rates of 41–97%,
with considerable severity in 11–14% of women. However, the
studies used in that review were small and the populations
differed widely in age and baseline characteristics (16).
A systematic review conducted by the World Health
Organization assessed the worldwide prevalence of
dysmenorrhea in 124,259 non-pregnant women with or without
endometriosis. Dysmenorrhea prevalence varied from 8.8% in
hospitalized women (aged 19–41 years) to 94% in girls aged
10–20 years (16).
In 1,018 Japanese junior high school students aged between 12
and 15 years, Kazama et al. reported a prevalence of moderate-
severe dysmenorrhea in 46.8% and severe dysmenorrhea in
17.7%. Higher chronological and gynecological ages (years
after menarche) were associated with a higher prevalence of
dysmenorrhea regardless of severity (p for trend < 0.001). Short
sleeping hours (< 6h/day) were associated with moderate to
severe dysmenorrhea (OR = 3.05, 95%CI: 1.06-8.77). High sports
activity levels were associated with severe dysmenorrhea (p for
trend = 0.045) (18).
In 2,561 female adolescents living in Tbilisi (Georgia), the
prevalence of dysmenorrhea was 52%. About 70% reported
frequent school absenteeism due to significant pain severity.
The risk of dysmenorrhea in students who had a family history
of dysmenorrhea was 6 times higher than in students with no
prior history. Prevalence was higher among smokers compared
to non-smokers 3.99% vs. 0.68% (p=.0.05 OR:6.102). Women
who had high sugar intake reported a marked increase of
dysmenorrhea compared to women taking no daily sugar
(55.61% vs. 44.39%, p=.0023). Alcohol consumption, family
atmosphere and nationality showed no correlation with
dysmenorrhea. Meal skipping (59.7% vs. 27%) and receiving
less sleep (38.7% vs. 19.5%, OR: 2.598) were the two most
important risk factors of dysmenorrheal (19).
A survey performed in three cities in Southwest Finland between
2010 and 2011, on 15-19 year old girls reported a prevalence
of dysmenorrhea in 33% of them. In 14% of them dysmenorrhea
was severe enough to cause frequent school absenteeism or
stopping their hobbies. Five percent of all teenage girls had
poor response to conventional therapy for PD (20).
The lowest prevalence of dysmenorrhea (16%) was reported in
a random sample of Japanese women aged 17–51 years using
daily diary recording for 1 month (21). Whereas, the highest
prevalence (93%) was reported in a large Australian study
performed on senior high school girls (22).
467 Pediatric Endocrinology Reviews (PER) n Volume 13
Clinical Presentation of PD and
Premenstrual Syndrome
PD is characterized by a crampy suprapubic pain that begins
between several hours before and a few hours after the onset
of the menstrual bleeding. Symptoms peak with the maximum
blood flow and last less than one day. Pain may persist up to 2
to 3 days. Symptoms are more or less reproducible from one
menstrual period to another (23,24). The pain is colicky and
occurs in the midline of the lower abdomen. Sometimes it is
described as dull and may extend to both lower quadrants and
radiate to the back of the legs or the lower back. Associated
systemic symptoms such as nausea, vomiting, diarrhea,
fatigue, mild fever and headache are fairly common.
It is possible to differentiate dysmenorrhea from premenstrual
syndrome (PMS) based on patient history. In PMS symptoms
begin before the menstrual cycle and resolve shortly after
menstrual flow begins (25).
Clinical Presentation of SD
SD occurs after menarche and may arise for the first time
in women in their 30s or 40s. Early dysmenorrhea that takes
place soon after menarche or in a patient who is clearly
anovulatory should alert the physician to the possibility of an
obstructing malformation of the genital tract. Occasionally,
adolescents may experience menstrual pain with their first
periods without any demonstrable underlying cause, especially
when the bleeding is heavy and accompanied by clots (23,24).
Chronic pelvic pain (CPP) and/or lower abdominal pain
which begins 1–2 weeks before the onset of menstruation
and relieved after the onset of menstruation is associated
with an underlying organic pathology such as endometriosis.
Endometriosis is defined as endometrial tissue implanted
outside the uterus. It is estimated that it affects 10% to
15% of women in the reproductive-age and as high as 70%
of women with chronic pelvic pain. Although most women
with endometriosis report the onset of symptoms during
adolescence, diagnosis is often delayed (26).
A systematic literature search for articles published between
1980 and 2011 identified 15 studies in the databases PUBMED
and EMBASE, on ‘endometriosis’, ‘laparoscopy’, ‘adolescents’
and ‘chronic pelvic pain (CPP)’. This review reported an
overall prevalence of confirmed endometriosis in 75%
of girls with CPP resistant to treatment, 70% of girls with
dysmenorrhea and in 49% of girls with CPP that was not
necessarily resistant to treatment (27).
The American Society of Reproductive Medicine reported
moderate to severe endometriosis in 32% of all girls, 16%
of girls with CPP resistant to treatment, 29% of girls with
n No 2 n December 2015

dysmenorrhea and 57% of girls with CPP that was not
necessarily resistant to treatment. The Authors concluded that
about two-thirds of adolescent girls with CPP or dysmenorrhea
had laparoscopic evidence of endometriosis. About one-third
of those adolescents with endometriosis had moderate–severe
disease (27).
A clinical staging system is used to describe the extent of
endometriosis, adhesions, and endometrial cysts in the ovary.
A score of 1-15 indicates minimal or mild endometriosis and
a score of 16 or higher indicates moderate or severe disease.
Arruda et al, applied questionnaires to 200 patients after a
histological diagnosis of endometriosis. Among the patients
analyzed, 2.5% were younger than 20 years, 50% were between
30 and 39 years, and 20.5% were older than 40 years. The main
clinical manifestations were dysmenorrhea (67%), chronic
pelvic pain (12.5%), infertility (10%), dysparunia (5.5%) or
over one of these manifestations (88%). The mean interval
between the onset of symptoms and diagnosis of endometriosis
was seven years. The interval took longer time (9 years) when
the symptoms began in adolescence, and shorter time (3
years) when started after 30 years of age. Patients presenting
with CPP or infertility took on average six months and 1.7
years respectively to see a doctor. Although 44% of patients
develop symptoms before 20 years of age, only 3.5% received a
definitive diagnosis in this age group (28).
Another study tested the presenting complaints of 39 young
women (10–21 years) with laparoscopic and histological-proved
endometriosis. The average age at diagnosis was 18.6 years,
with three cases diagnosed before 15 years of age. None had
genital malformations to justify the early onset of the diseases.
The main complaints triggering the start of the investigation
were non-cyclic CPP or acute pelvic pain. Three patients were
investigated because of having adnexal masses (29).
The findings of these descriptive studies suggest a long
and difficult road to reach appropriate diagnosis and early
management. Therefore, timely referral to an experienced
gynecologist and laparoscopic diagnosis of pelvic diseases
in adolescents with CPP and/or dysmenorrhea resistant to
medical treatment is recommended (26).
Measurements of Menstrual Symptoms
Pain is defined by the International Association for the Study
of Pain as ‘an unpleasant sensory and emotional experience
associated with actual or potential tissue damage’ (30).
Understanding the impact of pain must, therefore, acknowledge
both the stimulation of sensory receptors by a harmful stimulus
and other factors acting centrally and contributing to pain
perception.
In PD, pain intensity can be mild (does not disturb daily
activities or require painkillers), moderate (slightly interferes
Pediatric Endocrinology Reviews (PER) n Volume 13
Primary Dysmenorrhea in Adolescents
with daily routines but can be managed with painkillers) or
severe (markedly prevents daily life activities) (23-26).
Pain is a subjective symptom very difficult to quantify.
Quantifying and grading the pain of dysmenorrhea is not simple
and is associated with many technical difficulties. Instruments
used for quantifying dysmenorrhea are based on women’s self-
reporting, which is subjective and not precise.
Two tools are commonly used to measure the severity of
dysmenorrhea. The first is a verbal multidimensional pain
scoring system that measures pain severity taking into account
the impacts of pain on daily activities, systemic symptoms
and analgesic requirements. The second system depends on
asking the patient to assess the severity of dysmenorrhea and
express it on a linear visual analogue scale (VAS). This scale
is a 10 cm line on a sheet of paper. It represents a continuum
of severity of pain beginning with the extreme of “no pain
at all’’ and ending with the extreme of “unbearable pain.”
The participants are asked to rate pain by making a mark on
the line. Scale value was got by measuring the distance from
zero to that mark (31,32). Due to its simplicity and reasonable
reliability, VAS is more frequently used for pain assessment.
However, it is only a uni-dimensional measure and is therefore
is insufficient for accurate assessment of severity.
Multi-dimensional scales such as the Menstrual Distress
Questionnaire and the Menstrual Symptom Questionnaire
have been developed. Both are criticized for being based on
unrepresentative samples and for problems with validity.
In summary, there is a shortage of instruments to measure
menstrual symptoms and lack of validation of these
instruments and tools to be truthfully used in adolescents.
Many symptoms related to menstruation are not well-defined
and many can be mis-classified as ‘menstrual’ when they are
not truly that (33). Great personal variability exists in the
perception and/or reaction to pain can markedly affect the
judgment of pain. Adolescents may not be skilled at recalling
the accurate time and intensity of their symptoms in relation
to the menstrual cycle (before versus during) because they still
learn about their cycles. Therefore, menstrual pain should be
regarded as a multidimensional phenomenon that should be
measured by a multidimensional scoring system (34).
Pathophysiology of PD
The pathophysiology of PD is not fully elucidated. Psychological
rather than patho-physiologic factors are more stressed in the
literature discussing the etiology and management of this entity.
Four studies addressing different psychosocial variables failed
to demonstrate any effect of these variables on PD. In another
study, personality factors and certain attitude variables did not
have any effect or relation to PD (35). Therefore, other factors
have been taken in consideration.
n No 2 n December 2015 468
 Primary Dysmenorrhea in Adolescents

Menstrual bleeding is triggered by progesterone withdrawal Brain imaging in dysmenorrhea

following the demise of the corpus luteum. This sequentially
stimulates inflammation and prostaglandins (PG) production
Studies on neural function and brain imaging have increasingly
in the endometrium through activation of the NF-κB pathway.
shown that chronic pain conditions are associated with
A similar mechanism is also triggered by the blockade of
significant, widespread and sometimes long-lasting changes
progesterone receptors, using the same pathway to induce
in the central nervous system. These changes include resting
the translation of target genes related to the inflammatory
state, anatomy, connectivity and chemistry (48–50). These
cascade, including cyclooxygenase (COX)-2.The subsequent
findings raised an obvious interest to study CNS changes in
increase in PG production facilitates endometrial breakdown
women with dysmenorrhea.
and positively influences the intensity of dysmenorrhea and
bleeding (36). Brain-imaging studies have shown significant changes in
cerebral metabolism (fluoro-deoxyglucose positron-emission
The pathophysiology of PD includes two main categories:
tomography), cerebral structure (voxel-based morphometry)
uterine contraction and vasoconstriction, inflammation and
and neural activity induced by noxious skin stimulation (fMRI) in
release of inflammatory mediators and stimulation of pain
dysmenorrheic compared to non-dysmenorrheic women (51-54).
fibers.
More recently, Li et al. studied the anatomical brain magnetic
The uterine contraction and vasoconstriction theory
resonance images (MRI) for incidental findings (normal variants
currently has the strongest scientific basis. The increase
and abnormalities) in 163 healthy women with PD and 167
in PG, derived from COX-2 activities, in the endometrium
healthy controls without PD. Women with PD demonstrated
following the fall in progesterone in the late luteal phase,
significantly higher prevalence of overall incidental brain MRI
results in increased myometrial tone and excessive uterine
findings (PD: n = 18, 11.0%; HCs: n = 6, 3.6%; p = 0.005) that
contraction. Prostaglandins start accumulating in the endo-
should be ascribed to a preponderance of normal variants
myometrium a few days before menstruation starts. The levels
(PD: n = 16, 9.8%; HCs: n = 3, 1.8%; p = 0.001), especially
of PG - F2 α, vasopressin and leukotrienes concentrations are
cavum septum pellucidum. No other brain abnormalities were
higher in women with severe menstrual pain compared to
detected in women with PD. The authors concluded that
women who experience no or little menstrual pain (37-39).
PD are associated with high prevalence of some MRI normal
Increased leukotrienes, vasopressin and decreased prostacyclin
variants changes but not brain abnormalities (55).
levels contribute to the pathophysiology of dysmenorrhea.
Leukotrienes increase myometrial stimulation and T1-weighted MRI obtained from 44 PD patients and 32 healthy
vasoconstriction. Women who fail to respond to prostaglandin controls (HCs) matched for age and handedness proved that
inhibitors have been shown to have elevated levels of PD patients had significantly increased cortical thickness
leukotrienes (40). in the orbito-frontal cortex (OFC), insula (IN), primary/
secondary sensory area (SI/SII), superior temporal cortex
In the secretory and regenerative phases, increased expression
(STC), precuneus (pCUN) and posterior cingulate cortex
of proinflammatory cytokines and decreased expression of
(PCC) compared to HCs. In addition, women with PD had
growth factors were also observed. These factors may be
significantly decreased sub-cortical volumes of the caudate,
involved in the regulation of decidualization, endometrium
thalamus and amygdale. Moreover, there were significant
breakdown and repair and indirectly exacerbate primary
positive correlations between the PD-related duration and the
dysmenorrheal (41).
thickness of OFC, SFC, STC and IN (56).
An increase in vasopressin levels, without an accompanying
These findings provide evidence for pathological grey matter
increase in oxytocin levels, can produce dysrhythmic uterine
changes in patients with PD and support relationships between
contractions that are more likely to produce uterine hypoxia
the structural abnormalities and symptomatology.
and ischemia (42). Using these observations, a preliminary
study indicates that a vasopressin antagonist is able to
inhibit abnormal uterine contractions and relieve PD (43-45). Development of Chronic Pain
Stimulation of pain fibers in the uterus causes activation of the
afferent pain pathways which is transmitted up to the central Adolescents and young women with dysmenorrhea always
nervous system. It has been suggested that leukotrienes can raise an important question” does dysmenorrhea at early
increase the sensitivity of pain fibers (46). age predisposes for the development of more severe pain or
At the present there is no satisfactory hypothesis that explains co-morbidity with other chronic painful conditions later in life?
fully the pathophysiology of PD and the role played by the There is a scarcity of longitudinal studies on the natural
various vascular, molecular, muscular and neural changes that history of dysmenorrhea as well as on the effects of a range
lead to the production and sensation of pain (47). of possible modifiable risk factors over time. In addition, the

469 Pediatric Endocrinology Reviews (PER) n Volume 13 n No 2 n December 2015


duration of follow-up in these studies was relatively short.
Several facts are still unknown and many aspects require
further studies.
A longitudinal study on young women between the ages of
19 and 24 showed that the severity of dysmenorrhea only
decreased in women who gave born to children during the
previous 5 years, but was unchanged in those who remained
nulliparous, or those who had miscarriage or abortion (57).
Another study reported a significant effect of age on the
severity of dysmenorrhea. After adjusting for parity, older
women were more likely to experience a decline in the severity
of dysmenorrhea, independent of childbearing (58). Vincent
et al. observed that the longer the duration of the reported
dysmenorrheic symptoms (from 2 to 28 years), the greater is
the suppression of the woman’s hypothalamic-pituitary-adrenal
axis, as manifested by a reduction in serum cortisol levels (54).
Medical Treatment of PD
Treatment of PD is predominantly based on the main
theories of etiology. Medical treatment for dysmenorrhea
usually comprises anti-inflammatory drugs, OCP or surgical
intervention.
Non-steroidal anti-inflammatory drugs (NSAIDs) are a
rational and effective treatment of primary dysmenorrhea
that act through inhibiting prostaglandin production in the
endometrium. There is no evidence that one specific NSAID is
better than others. A Cochrane review found that NSAIDs are
significantly more effective for pain relief than placebo (OR
7.91; 95% CI 5.65–11.09) but with a significant risk of adverse
effects, especially gastric reflux (59). Furthermore, recent
data suggest that chronic use of these drugs may increase
the risk for developing unstable angina, acute myocardial
infarction, and venous thrombo-embolism (60).
The efficacy of OCP and other forms of treatment for
dysmenorrhea has been analyzed in two systematic
reviews (61,62). One of these reviews concluded that it
was not possible to state whether OCP reduced the pain of
dysmenorrhea because the reviewed studies were small and
because of the great variability of OCPs used. Many of these
OCPs were abandoned and not longer available at the review
time (61).
A Cochrane review assessed the effectiveness of OCPs for
treating PD has concluded that although OCPs are widely
advocated as standard treatment, there was only scanty
rigorous evidence to support this practice. Similarly the results
of this review were restricted because of the variable quality of
the randomized controlled trials included in the analysis (62).
Nevertheless, a low-dose OCP (Ethinyl estradiol 20 microgram
and levonorgestrel 100 microgram) has been shown to relieve
Pediatric Endocrinology Reviews (PER) n Volume 13
Primary Dysmenorrhea in Adolescents
dysmenorrhea-associated pain more effectively than placebo
in a double-blind, placebo-controlled clinical trial performed
on 76 healthy adolescents, aged 19 years or younger with
moderate or severe dysmenorrheal (63).
In subjects with severe dysmenorrhea who fail to respond to
cyclic 21/7-day OCPs regimens, it was possible to reduce pain
by adding pycnogenol during the hormone-free interval (64).
The levonorgestrel-releasing intrauterine system (LNG-IUS) has
been reported to be associated with less painful menstruation,
although more long-term studies are necessary. In contrast, a
copper intrauterine device (Cu-IUD) has no influence on the
severity of dysmenorrheal (65).
In some women, pain relief may be inadequate and the side
effects of OCP or NSAIDs may not be tolerable. Therefore,
investigating other therapeutic alternatives is warranted.
Calcium channel blockers, glyceryl trinitrate, leukotrienes
(10 mg/day), thiamine (100 mg/ daily), vitamin E (200 Units/
daily), omega-3 polyunsaturated fatty acids (2 g daily), oral
zinc sulphate (50 mg/daily) and cholecalciferol are under
evaluation (66-69).
Complementary and Alternative
Medicine (CAM)
CAM is described as medical systems, practices, interventions,
applications and theories that are not part of the conventional
medical system (70). Between 50% and 70% of Americans use a
CAM to prevent or treat health-related problems (71). Women
are more likely to be the users of unconventional therapies (72).
Clinicians also prescribe CAM.
Women with dysmenorrhea use several CAM treatments. These
include: trans-cutaneous electrical nerve stimulation (TENS),
acupuncture, acupressure, spinal manipulation, osteopathic
treatment, physical exercise, behavioral interventions and
some herbal and dietary therapies (73-77).
Herbal medicines have long been used in Eastern countries.
Recently these therapies are used worldwide. The efficacy
of herbal medicines for the treatment of PD has been
recently reviewed. A variety of herbal medicines exhibited
beneficial effects on PD. The major action of herbal
medicines is inhibition of uterine contractions. This is
mediated through one or more of the following mechanisms:
reduction of PG secretion, suppression of cyclooxygenase-2
expression, activation of superoxide dismutase, stimulation of
somatostatin receptor, decreasing intracellular Ca2+ and /or
recovery of phospholipid metabolism.
Nevertheless, further studies on the composition and
effectiveness of herbal formula and deciding about their
doses, safety and long-term outcomes are required and
recommended (77).
n No 2 n December 2015 470
 Primary Dysmenorrhea in Adolescents
Adolescents, Self-Treatment and
Dysmenorrhea
50% to 58% of adolescent undergraduate students in Turkey and
Britain and 43.8% in China, 52% to 58% of high school students
in the USA and Australia, and 33%-38% of young Sweden women
use self-treatment for dysmenorrhea (57,78-82).
Hispanic adolescents with dysmenorrhea (n= 706) reported
using multiple treatments to relieve their symptoms. These
methods included rest (58%), medications (52%), heating
pad (26%), tea (20%), exercise (15%) and herbs (7%). Six
percent received medical advice while 70% practiced self-
management. Some girls even go to the extent of using
these medications in non-therapeutic doses for quick pain
relief (83). Higher pain scores and pain that prevents normal
physical activities were important predictive factors for self-
medication management.
A questionnaire survey investigated the different modes of
self-medication in adolescent students with dysmenorrhea
(n= 528) The most frequent treatments used were: ibuprofen
(53%), paracetamol (51%), OCP (40%), hot-water bottle (or hot
pad) (35%), food supplements or medicinal plants (23%). In 80%
of the questioned girls, the family not the physician was the
main source of information (84).
Adolescents receive their knowledge about menstruation
from different sources. Mothers are the major source (85,86)
while healthcare providers represent a minor source (2%) (83).
Therefore, it is recommended that health care providers should
be knowledgeable, well-trained and actively involved in the
care of adolescents with dysmenorrhea (83-85).
Summary and recommendations
PD is defined as painful menses with cramping sensation in the
lower abdomen that is often accompanied by other symptoms.
These symptoms occur just before or during the menses in girls
with normal pelvic anatomy. The prevalence of dysmenorrhea
varies between 20%-90% because of the variable methods of
data collection, different definitions of dysmenorrhea and
diverse study populations. Pain is an extremely subjective
symptom difficult to quantify. Additionally, adolescents
may not be skilled in recalling dysmenorrhea related
symptoms because they are still learning their menstrual
cycle. Therefore, menstrual pain should be regarded as a
multidimensional phenomenon and thus better be measured by
a multidimensional scoring system (86).
Dysmenorrhea is a substantial public health burden because of
its high prevalence, and because it one of the leading causes
of absenteeism from school and work. It is responsible for
a significant loss of earnings and diminished quality of life.
471 Pediatric Endocrinology Reviews (PER) n Volume 13
Severe episodes of dysmenorrhea appear to be associated
with earlier age of menarche, long menstrual periods, heavy
menstrual flow, smoking and positive family history. Young
women using OCP report less severe dysmenorrhea.
There is a scarcity of longitudinal studies on the natural
history of dysmenorrhea and the effect of possible modifiable
risk factors. So, studying the epidemiology and natural
progression of menstrual pain and the underlying patho-
physiologic mechanisms is essential to generate robust
evidence and support targeted preventive interventions.
In adolescent girls, the persistence of the dysmenorrhea
despite the use of OCP and/or NSAIDs is a strong pointer to the
diagnosis of organic pelvic disease and justifies a laparoscopic
exploration. In addition, moderate to severe dysmenorrhea
requires professional attention, especially when pain affects
lifestyle or fertility is impaired. A comprehensive school
education program on menarche and menstrual problems may
help girls to cope better with dysmenorrhea and appropriately
seek medical assistance.
Disclosure
None of the authors declare conflict of interest
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