DYSMENORRHEA

DEFINITION- 

Dysmenorrhea, defined as throbbing painful cramps that occur just before and during their menstrual periods.  It is the most common gynecological problem among the women, one of the most common causes of pelvic pain. Pain starts from the lower abdomen and radiates to lower back and thighs.

CLASSIFICATION-

Dysmenorrhea can be broadly classified into:

Primary Dysmenorrhea–

 It is a lower abdominal pain happening during the menstrual cycle, which is not associated with other diseases or pelvic pathology. Prostaglandin (PGF) is the main contributor to the cause of dysmenorrheas. 

Secondary Dysmenorrhea-

It is usually associated with other pathology inside or outside the uterus. There are many common causes of secondary dysmenorrhea, which include uterine fibroids,overian cyst, endometrial polyps, pelvic inflammatory disease (PID) and the use of an intrauterine contraceptive device (IUD).

SIGN AND SYMPTOMS-

For some women, the discomfort is just annoying. For others, menstrual cramps can be severe enough to interfere with everyday activities for a few days every month. The clinical features of Dysmenorrhea are as follow-

• Prostaglandins induce abdominal contractions that can cause ache and gastrointestinal symptoms.
• Dysmenorrhea is associated with increased pain sensitivity and heavy menstrual bleeding.
• Throbbing or cramping pain in the lower belly that can be intense Pain that starts 1 to 3 days before your period.
• Symptoms  peaks 24 hours after the onset of your period  and subsides in 2 to 3 days
• Dull and continuous ache
• Abdominal Pain that radiates to lower back and thighs
• Niggling response to NSAIDS or oral contraceptives
• Painful sexual intercourse (Dyspareunia) 
• Abnormal vaginal discharge
• Some women also have nausea,vomiting, loose stools, fatigue and headache etc. 

CAUSES-

There are many causes of dysmenorrhea. Menstrual cramps can be caused by:

• Longer, heavier or irregular menstrual periods.
• Endometriosis- fragments of the endometrium are found on other pelvic organs, most commonly on ovaries, fallopian tubes, or the tissue lining your pelvis.
• Retroverted uterus-It is a condition where the uterus tilts backwards instead of forward.
• Uterine fibroids-These noncancerous growths in the wall of the uterus can cause pain and crams during periods.
• Psychological or social stress
• Adenomyosis-The tissue that lines your uterus begins to grow into the myometrium (muscular walls of the uterus).
• Menarche before age of twelve 
• Pelvic inflammatory disease (PID) – PID infection of the female reproductive organs is commonly caused by sexually transmitted bacteria.
• Cervical stenosis- In some women, the opening of the cervix is small enough to impede menstrual flow, causing a painful increase of pressure within the uterus.

DIAGNOSIS

• A proper medical history about the onset, duration and severity of the pain is taken 
• Pelvic examination
• Ultrasonography of the lower abdomen 
• Laparoscopy

RISK FACTORS-

• Genetic factors
• Stress 
• Depression/anxiety
• Early age at menarche
• Long and heavy menstrual periods
• Nulliparity
• Smoking
• Family history of dysmenorrhea
• Higher BMI (Body Mass Index)

PREVENTION –

Dysmenorrhea (kashtaarthava) can be prevented by modifying the lifestyle and diet.

 Lifestyle changes

• Regular Exercise  
• Retraction of tobacco smoking 
• Avoid stressful situation while approaching periods.
• Get proper sleep at least for 7 to 8 hours

Dietary changes

• Take good Dietary supplements such as vitamin E, omega 3 fatty acids and magnesium etc.
• Take Low fat diet 
• Reduce caffeine intake
• Decrease alcohol intake

Management-

In modern science-

Treating the cause is key to reducing the pain.Treatment of Primary Dysmenorrhea is directed providing relief from cramping pelvic pain and associated symptoms.

 NSAIDS and the combination of oral contraceptives are the most commonly used treatment modalities. 

NSAIDS reduce pain by lowering prostaglandin hormone levels thereby decreasing intrauterine contractions.

• Diclofenac
• Ibuprofen 
• Ketoprofem 
• Meclofenamate
• Mefanamic acid 
• Naproxen

 Oral contraceptives are the ideal option to those who do not want to conceive. Some of them are: 

• Estradiol valerate plus dienogest
• Ethinyl estradiol levonorgestrel
• Medroxyprogestrone
• Levonorgestrel 

Releasing intrauterine device Treatment of secondary dysmenorrhea involves correction of underlying organic cause. Specific measures such as medical or surgical may be required to treat pelvic pathological condition

IN AYURVEDA-

CHIKITSA SUTRA OF KASHTAARTHAVA-

 As vata dosha is the main cause for all yonivyapad, the treatment should be directed towards the vitiated vata and eradication of the cause.

 The principles of treatment can be subdivided into:-

SHODANA (PURIFICATION THERAPY) 

• Snehana (Oleation)- Bahya snehana- External oil massage with vata pacifying oil like Bala taila, Dhanwanthara tailam, sesame oil etc.  Abyantara Snehana- intake of traivrita sneha
• Swedana (fomentation)- with ksheera (milk)
• Virechana (purgation)- Mild purgation is good for all type yonivyapad Trivrit Lehyam is the best because it has vataanulomana properties (downward passage of vata) and sukha rechaka (mild purgation)
• Vamana (emesis)
• Basti (enema)- After proper snehana and swedana procedure decoction enema and medicated oil enema is given. It is most effective treatment to normalize the Apana vata localized in the abdomen by entering the srotas (channels) by removing the spasm.

SHAMANA (PALLIATIVE TREATMENT)

ABHYANTARA CHIKITSA (INTERNAL THERAPY)-

• Kashayam– Nyagrodhadhi kashayam, Maharasnadi kashayam, Sapthasaram Kashayam, Dashamoolakatutrayam kashayam, Dhanwantharam Kashayam, Vizhalveradi Kashayam, Kurunthotti kashayam
• Arishtam- Dashamoolarishtam, Jeerakaarishtam, Ashokaarishtam
• Gritham (medicated ghee)-Phala sarpi, Brhat shatavari gritam, Triphaldi gritam 
• Choornam (powder)- Hinguwashtaka Choornam, Pushyanaga Choornam
• Vati (tablets)- Rajapravaartini vati, Nashtapushpantaka rasa, Soubhaagyadi vati, Dhanwantharam gulika, Chandraprabha vati, Kanchanara guggulu

STHANIKA CHIKITSA (LOCALISED TREATMENT)-

• It is done using the drugs predominant for the vitiated doshas Kalka, pichu (tampon), yoni prakshalana (douching), abhyanga (massage) Pichu is done by soaking the tampon with oils like tila taila, Dhanwanthara tailam and inserted inside the vagina for specific time.
• Yoni prakshalana (douching) is done using with triphala Kwatha.
• Abhyanga over the abdomen with warm tila taila few days before menstruation is found to be very effective.

HOME REMEDIES-

• Take 2-3 garlic cloves in the early morning 
• Boil 5 g of Carom seeds/cumin seeds/fenugreek seeds/fennel during the menstruation 
• Boil around 1 tsp. of sesame seeds in 60 ml of water and drink every morning few days prior to menstruation
• Intake 5 ml of castor oil in warm milk provides immediate relief from menstrual cramps.
• Prepare a dessert with sesame seeds, cumin seeds mixed with jaggery and ghee and make small balls out of it. Consume it frequently.
• Intake 1 glass of parsley juice twice every day
• Drink cinnamon tea with honey during menstruation ¬ Intake of dark chocolate after meals proven to relief from menstrual cramps. 
• Massage the lower abdomen, thigh with war sesame oil/castor oil and apply hot bag fomentation 
• Avoid vata increasing factors such as travelling, stress, drinking caffeine etc. few days prior to menstruation. 
• Drink 6-8 glass of warm water daily 
• Always consume food which is warm and easy to digest.
•  Sip 2 cups per day of chamomile tea few days prior to menstruation