What are primary and secondary dysmenorrhoea?

Primary dysmenorrhoea is pain starting about the time that the monthly bleeding begins.

Secondary dysmenorrhoea begins a few days before the onset of the period. It tends to be associated with disease processes including:

Typically, primary dysmenorrhoea starts within a few months of the menarche (first period) whereas secondary dysmenorrhoea starts later after the disease process has developed.

What is retrograde menstruation?

Most of the blood shed with the endometrial lining during a period is passed out through the cervix and then the vagina.

During a period, if the internal pelvic organs are inspected by a gynaecologist (e.g. laparoscopy) there is almost invariably a little blood that has tracked up through the Fallopian tubes. This blood may irritate the peritoneum (Q 2.4) resulting in pain (peritonism).

How can painful periods be treated?

Most teenage girls experience some painful periods. It may be distressing for a teenager to discover that womanhood may involve physical pain as well as emotional upheaval. Usually mild analgesics (pain-killers), such as paracetamol, are all that are required. If this proves inadequate, early medical assessment is advisable. Uncomfortable pelvic examination of young teenagers by the doctor can usually be avoided; an ultrasound picture (pelvic ultrasound) to check that the womb and ovaries appear healthy can provide reassurance to all concerned.

Stronger analgesics (Q 24.17D) or mild hormone treatment should be considered. The hormone treatments include progestogens (e.g. Duphaston or Provera –Q24.17B) or perhaps one of the combined oral contraceptive pills (Table 16.1). There is evidence that the combined oral contraceptive pill can be used to effectively and safely treat dysmenorrhea associated with endometriosis.0804

A positive attitude, encouragement that there are a variety of treatment options for painful periods and reassurance that the girl can continue with a full and active life, should be emphasised.

Patient Story - Dysmenorrhoea:

A sixteen-year old girl was referred because of debilitating primary dysmenorrhoea and slightly heavy periods. Through the first two consultations, her mother in the presence of her daughter, emphasised her anxieties about endometriosis. The mother had suffered with endometriosis for many years eventually requiring hysterectomy (hysterectomy) although not even this provided relief from her pain. Investigation, including ultrasound but not laparoscopy, showed no obvious abnormality. Initially, the mother was reluctant to agree to medical treatment without the laparoscopy as We may be missing something?. Eventually, she accepted that the majority of women have some degree of endometriosis and that the combined contraceptive pill may prove effective for minimal endometriosis, retrograde menstruation or unexplained primary dysmenorrhoea. The girl was not in favour of laparoscopy particularly when we explained that the procedure carries a one in a thousand chance of damage necessitating laparotomy. The pill was prescribed and three months later the girl came to the clinic by herself. The pain had vanished with the medication and she was very happy.

The treatment of secondary dysmenorrhoea will depend on the underlying cause (5).

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