The term dysmenorrhoea refers to painful menstruation incapacitating the woman. It is one of the most frequent of all gynaecological complaints. It can be classified in to 4 types –
1) CONGESTIVE DYSMENORRHOEA
2) SPASMODIC DYSMENORRHOEA
3) MEMBRANOUS DYSMENORRHOEA
4) OVARIAN DYSMENORRHOEA

CONGESTIVE DYSMENORRHOEA
(secondary, extrinsic or organic )
This variety is characterized by premenstrual pain situated either in the back or lower abdomen, occurring between three and five days or sometimes even longer before the onset of menstruation. It is always relieved by the menstrual flow. Patient is elderly beyond 30 years. The pain is always related to pelvic lesions.

AETIOLOGY
 Usually associated with pelvic inflammatory diseases – Salpingo oophoritis, Parametritis, Pelvic adhesions.
 Associated with chocolate cysts of ovaries, adenomyomas, endometriosis and acquired retroversion of uterus.
 Premenstrual congestion or tension syndrome.
 Intra uterine contraceptive devices

CLINICAL FEATURES
The pain or discomfort is referred to one or other iliac fossa, usually the left. Usually accompanied by an alteration in bowel habit mostly constipation, with some flatulent distention of upper colon. The pain is associated with irritability, malaise, headache, feeling of fullness and pain in breasts etc. Other menstrual irregularities like menorrhagia, metrorrhagia & leucorrhoea are frequently associated with the condition.

SPASMODIC DYSMENORRHOEA
( primary, intrinsic, essential, functional )
The majority of cases of dysmenorrhoea fall in to this group. In the true spasmodic variety, the condition does not become established until two or three years after the menarche though there may be a degree of discomfort associated with earlier periods. Probably the most severe cases are seen in patients between the age of 19 & 21. It is rare to encounter in women over the age of 30.

AETIOLOGY
The pain is due to muscular spasm which is sufficiently intense to cause ischemia. The pain is of uterine origin & no obvious pelvic lesion is found. The following factors have been implicated in its causation –
 CERVICAL OBSTRUCTION – due to organic stricture of cervix, pinpoint os, narrow cervical canal etc.
 UTERINE ABNORMALITIES – unicornuate & bicornuate uterus.
 ENDOCRINE FACTORS – dysmenorrhoea is invariably associated with ovulatory cycles. Women on oral contraceptive pills are rendered anovulatory and thus relieved from pain. Progesteron stimulates myometrial contraction of the smooth muscles of the cervix causing narrowing of cervical canal ; also stimulates production of prostaglandin F2alpha which in turn accentuates pain.
 NERVE PATHWAYS – it has been suggested that muscle spasm of the uterus may be a result of an imbalance in the autonomic nerve supply of the uterus.
 UTERINE HYPOPLASIA – Inadequate uterine muscles need vigorous contractions to expel the menstrual discharge & as such set up painful contractions.
 PSYCHOGENIC CAUSES – The incidence of dysmenorrhoea is higher amongst affluent, introspective & neurotic women. Women having a low threshold for pain and those predisposed to undue fears & anxiety are most susceptible.

CLINICAL FEATURES
The pain develops on the first day of the menstrual period, when excruciating lower abdominal pain is experienced which lasts for a relatively short time, perhaps for half an hour to an hour. This very severe pain is intermittent, colicky, cramp like and spasmodic and may cause faintness, collapse, vomiting and nausea. A mild degree of shock may follow a very severe attack. The severe attack of pain is followed by a similar but less pronounced type of pain, felt in the lower abdomen and pelvis and often down the anteromedial area of the thighs. Such pain persists usually for not more than 12 hours. The severe pain may be relieved by the passage of a clot. Other associated menstrual irregularities are rare. The spasmodic variety is often cured by marriage and pregnancy.

MEMBRANOUS DYSMENORRHOEA
It is regarded as an extreme form of spasmodic dysmenorrhoea. It is usually rare, runs in families and recur after pregnancy. The pain is usually accompanied by the passage of membranes which may take the form of casts of the uterine cavity. Microscopically the casts have the structure of endometrium during menstruation, except that the disintegrative processes are ill defined. The tryptic ferment secreted by the endometrium in normal menses is deficient. The exact cause is unknown.

OVARIAN DYSMENORRHOEA
Dr. O’DONEL BROWNE drew attention to the possible part played by the ovary in menstrual pain and he concluded that in over half the cases of dysmenorrhoea the ovary was at fault. The pain is felt for 2 or 3 days before menses in one or both lower quadrants in the areas innervated by the tenth thoracic to the first lumbar segments.

INVESTIGATIONS
The need for investigations depend upon the severity of symptoms, incapacitation and expectation of pelvic pathology.
Ultrasound of abdomen may reveal organic pelvic lesions. Hysterosalpingography, Laproscopy & Hysteroscopic investigations may be resorted to in cases of congestive dysmenorrhoea.
Vaginal examination is a useful procedure for assessment of pelvic organs in case of any abnormality, it is advisable provided she is not a teenaged girl.

GENERAL MANAGEMENT
Explanation of menstrual process, sex education and reassurance to the patient are important aspects of management.
Avoidance of stress and strain, intake of nourishing diet, correction of constipation, mild physical exercise and adequate rest and proper personal hygiene are necessary adjuvants.
When medical treatment fails, dilatation & curettage is advisable in married women.

HOMOEOPATHIC MANAGEMENT
PULSATILLA
Menses painful, too late, scanty, changeable in character. Irregular, intermittent flow, with chilliness. Pains rapidly shifting, appear suddenly, leaves gradually. Flows more during the day. Never well since puberty. Delayed first menses. Menses suppressed from getting the feet wet. Leucorrhea thick, acrid, excoriating.
Women fair, good looking, slow, indecisive, mild, gentle, easily weeping., consolation >. Dryness of mouth without thirst. Gastric derangements from eating rich food, fat, pastry.< warm room, evening, on beginning to move. > open air, cold application, lying on painful side.

ACTEA RACEMOSA
During menses, sharp lancinating, electric like pains in uterine region and various parts, dart from side to side., with chorea, hysteria or mania, increase of mental symptoms during menses. The more profuse the flow, the greater the suffering. Menses irregular, exhausting, delayed or suppressed by mental emotions. Severe left sided inframamary pains. Rheumatic dysmenorrhoea. Excessive muscular soreness, rheumatic pains in bellies of muscles. Sensation as if a heavy black cloud had settled over her so that all is in darkness.

CAULOPHYLLUM
Pains intermittent, paroxysmal, spasmodic, across lower abdomen extending to groins; erratic pains changing place every few minutes. Chorea, hysteria or epilepsy at puberty, during establishment of menstrual function. Leucorrhea acrid, exhausting, in little girls, preventing pregnancy. Habitual abortion from uterine debility. Rheumatism of small joints, fingers, toes, wrists.

SEPIA
Dysmenorrhoea with violent stitches upward in the vagina, lancinating pains from uterus to umbilicus. Pain extends from other parts to back. Menstrual irregularities- early or late, scanty or profuse, menorrhagia or metrorrhagia. Bearing down sensation as if every thing would protrude through the vagina, must sit with crossed legs. Sensation of a ball in inner parts during menses. Great sadness & weeping, dread of men, of being alone. Indifferent to those whom she loved best. Headache at menstrual nisus with scanty flow. Tongue foul, clears at each menstrual nisus. <cold weather, laundry work, at rest. > warmth, violent exercise.

NUX VOMICA
Menses : too early, profuse, lasts too long; or keeping on several days longer, with complaints at onset and remaining after. Menses every two weeks, irregular never at right time, stopping & starting again. Violent spasmodic pains in sacrum. Labour like pains, causing urging to stool or to urinate. Backache, lumbago, must sit up or turn over in bed. Hypochondriac, literary, studious women. Irritable, quarrelsome, impatient, oversensitive to all external impressions. Bad effects of highly spiced food, alcohol, coffee, tobacco, overeating, sedentary habits, mental overexertion. >while at rest, lying down, damp weather.

CALCAREA CARB
Menses too early, too profuse, long lasting. Dysmenorrhoea with headache, chilliness, toothache & vertigo. Feet habitually cold & damp, as if they had cold stockings on. Breasts swollen & tender during menses. The least mental excitement causes profuse return of menstrual flow. Profuse perspiration. Leucophlegmatic, blond, fair, tendency to obesity in youth. Takes cold easily. Great longing for eggs, aversion to milk & meat. Feels better in every way when constipated. >lying on painful side, dry weather.

SABINA
Menses too early, profuse, protracted, partly fluid, partly clotted, in persons who menstruated very early in life; with colic & labour like pains. Drawing pains in small of back, extending from sacrum to pubes. Discharge of blood between periods, with sexual excitement. Chronic ailments of women; arthritic pains, tendency to miscarriages, especially at third month. Menorrhagia at climacteric. Music is unbearable. < from least motion, warm room. > walking, cool open air.

NATRUM MUR
Headache, nausea & vomiting before, during & after menses. Menses irregular, profuse or scanty. Left sided clavus. Anaemic & cachectic women, great emaciation, losing flesh while eating well. Weeping disposition, consolation <. Bad effects of grief, vexation, anger, excessive use of salt. Aversion to bread. Tongue mapped with red insular patches. <at 10 or 11 am, at sea shore, heat of sun. > open air, lying on right side, cold bathing, perspiration.

KALI CARB
Feels badly week before menses. Backache before & during menses. Wants the back to be pressed. Back gives way, with great debility & sweating. While walking feels as if she must give up & lie down. Pains stitching < during rest, lying on affected side. Cannot bear to be touched. Persons inclined to obesity, takes cold easily. Aversion to being alone.

CYCLAMEN
Membranous & congestive dysmenorrhoea. Menses too early, too profuse, black & clotted, accompanied by vertigo, headache, dim vision. Pains pressive, drawing or tearing of parts where bones lie near the surface. Better during flow. <sitting & lying at night. > by walking. Leucophlegmatic persons with anaemic or chlorotic conditions, easily fatigued. Ailments from suppressed grief & terrors of conscience. Great sadness & peevishness, irritable, morose, inclined to weep, desire for solitude, aversion to open air.

AMMONIUM CARB
Menses preceded by gripping colic, too early, profuse, acrid makes the thighs sore, copious at night & while sitting. With toothache, sadness, fatigue, yawning & chilliness. Cholera like symptoms at the commencement of menses. Stout fleshy women leading a sedentary life. Readily catch cold in winter, dislikes washing. Haemorrhagic diathesis. < during menses. > lying on abdomen, on painful side.

LACHESIS
Congestive dysmenorrhoea. Pains all relieved by the flow. Always better during menses. Menses at regular time, too short, scanty. Complaints at climacteric. Thin emaciated persons, hot flushes, hot perspiration. Pains go from left to right, worse after sleep. Great sensitiveness to touch, intolerance of tight clothings. Great loquacity, suspicious, jealous. <warmth, heat of sun, hot drinks.

BORAX
Membranous dysmenorrhoea. Menses too soon, profuse, with gripping colic, nausea & pain in stomach extending to small of back. Leucorrrhoea albuminous, starchy, sensation as if warm water were flowing. Dread of downward motion, excessively nervous, easily frightened by the slightest noise.

BOVISTA
Menses flow only at night, not in day time. Diarrhoea before & during menses; occasional show every few days between periods, every two weeks, dark & clotted with painful bearing down. Great weakness of joints & weariness of hands & feet. Awkwardness. Sweat in axilla smells like onions.

KREOSOTE
Menses too early, profuse, protracted, pain during but < after it. Flow < on lying down, ceases on sitting. Flow intermits, cold drinks > menstrual pains. Severe headache before & during menses. Leucorrhoea acrid, offensive, odour of green corn. Women who are over grown, very tall for her age, old looking, wrinkled., post climacteric ailments.

CACTUS
Pulsating pains in uterus & ovaries. Menstrual flow ceases when lying down. Whole body feels as if caged, each wire being twisted tighter & tighter. Constriction of chest, uterus, vagina, as if clasped by an iron band. Congestive, periodic, right sided, neuralgic, throbbing pains.

MAG CARB
Menses with labour like pains, cutting colic, backache, weakness, chilliness, flows only at night or when lying down, acrid, dark pitch like, difficult to wash out. Menses preceded by sorethroat. Sour smell of the whole body. Craves meat.

MAG MUR
Menses with great excitement at every period, flow black, clotted, spasms & pains in back when walking, extends to thighs. < at night in bed. Leucorrhoea after exercise, two weeks after menses. Pain in liver region < lying on right side. Constipation stool hard dry crumbling at the verge of anus.

MAG PHOS
Menstrual colic, membranous dysmenorrhoea. Flow dark, stringy, pains < before, > when flow begins. Congestive dysmenorrhoea. Pains shooting, lightning like, coming & going suddenly, rapidly changing place < right side. > heat, bending double, pressure. Thin emaciated persons. Great dread of cold air, of uncovering, of touching.

COLOCYNTH
Dysmenorrhoea, agonizing pain in abdomen, compelling the patient to bend double, with restlessness. Twists & turns to obtain relief. > by hard pressure. Menses suppressed by anger, indignation, chagrin. Pains like lightning shocks, crampy pain in hips. Extremely irritable, impatient throws things out of hands.

DIOSCOREA
Menstrual colic, pains < by bending forwards & while lying down. > by standing erect or bending backwards. Violent twisting colic, occurring in regular paroxysms, as if intestines were grasped & twisted by a powerful hand. Pains suddenly shift to different parts, appear in remote localities as fingers & toes.

LAC CANINUM
Menses too early, profuse, flow in gushes, bright red viscid & stringy. Breasts swollen, painful before & during menses. Erratic pains flying from one part to another, side to side. Sorethroat & cough begin & end with menses. Pains begin on left & goes to right. Very forgetful, absent minded, thinks her disease uncurable.

VERATRUM ALBUM
Dysmenorrhoea with vomiting & purging, is so weak can scarcely stand for two days at each menstrual nisus. Cholera like symptoms at the commencement of menses. Rapid sinking of vital forces, complete prostration, collapse. Cold perspiration on forehead. Face, pale, Hippocratic, sunken. Thirst for large quantities of cold water, craves acids. Mania with desire to cut & tear, laschivious talks.

ACONITE
Pains are intolerable, drives her crazy, becomes very restless, must change position often. Great fear & anxiety of mind with great nervous excitability. Afraid to go out, to go in to a crowd, fear of death. Young girls of a full plethoric habit who lead a sedentary life. Amenorrhoea after fright, exposure to cold. Music is unbearable. <warm room, evening & night, lying on affected side, dry cold air. > open air.

BELLADONNA
Pains usually in short attacks, comes suddenly & ceases suddenly. Menses too early, profuse, bright red & hot, with bearing down sensation. Breasts feel heavy & painful. Women with light hair & blue eyes, plethoric, lymphatic constitutions. Congested red face with throbbing of brain & carotids. Head hot & painful, pulse full & bounding like buck shots. Violent delirium. <touch, noise, sun, least jar.> rest, standing & sitting erect, pressure.

CHAMOMILLA
Profuse discharge of dark clotted blood with labour like pains. Pains seems unendurable, drives to despair, with heat, thirst, fainting with numbness, eructations <. Pains drive her out of bed at night, compels to walk about. Peevish, irritable, oversensitive to pain & touch. Complaints from anger. Milk runs out in nursing women, nipples inflamed, tender. Toothache during menses if anything warm is taken. Cannot endure anyone near her, cross, averse to talking.

COFFEA
Pains felt intensely, almost insupportable, driving to despair, tossing about in anguish. Large clots of black blood, hypersensitive vagina. Tall lean stooping persons, dark complexion. Bad effects of sudden emotions, pleasurable surprises. Unusual activity of mind & body, full of ideas. Sleepless, wide awake at night. Oversensitiveness.

CALCAREA PHOS
Menses too early, excessive, bright red, if late, it is dark. Sometimes first bright then dark with violent backache. Girls at puberty, tall growing rapidly, anaemic, dark complexioned, emaciated. Ailments from grief, disappointed love. Complaints < when thinking about them. At puberty, acne & headache in school girls.

COCCULUS
During the effort to menstruate, she is so weak, scarcely able to stand from weakness of lower limbs. Leucorrhoea in place of menses, like washings of meat. Women & children who suffer severely during menses. Sensitive romantic girls, unmarried childless women. Bad effects of loss of sleep, night watching. Time passes too quickly.

CROCCUS SATIVUS
Dysmenorrhoea, blood black, viscid, clotted forming in to long black strings. Nervous or menstrual headaches, before, during & after flow. Chorea, hysteria, spasms of single set of muscles. Sensation as if something alive in abdomen. Frequent & extreme changes in emotions, sudden from the greatest hilarity to the deepest despondency.

IGNATIA
Women of a sensitive, nervous temperament, mentally & physically exhausted by long continued grief. Mental conditions rapidly change from joy to sorrow. Involuntary sighing, desires to be alone. Bad effects of anger, grief, disappointed love. Oversensitive to pain, pain in small spots. Hysterical pains.

ZINCUM MET
Congestive dysmenorrhoea, pains better by appearance of menses. Menses too late, suppressed, flow more at night. Breasts painful. Violent fidgety feeling in feet. Burning whole length of spine, backache < sitting. Defective vitality, nervous exhaustion, too weak to menstruate.

SECALE COR
Menses irregular, copious, dark fluid with labour like pains in abdomen. Continuous discharge of watery blood until next period. Habitual abortion. Skin feels cold to touch, yet patient cannot tolerate coverings. Women of thin, cachectic, scrawny appearance. Face, pale, ashy, sunken, Hippocratic. Craves acids, lemonades. Burning in all parts.

MEDORRHINUM
Intense menstrual colic with drawing up of knees, labour like pains, must press feet against support. Menses profuse, dark, clotted, stains difficult to wash off. Breasts & nipples sore & sensitive to touch. Breasts icy cold, rest of body warm. Chronic ovaritis, salpingitis, fibroids, cysts, carcinomas. Maltreated & suppressed gonorrhea. Craves liquor, acids, salt, sweets, ice. Burning of hands & feet. Weakness of memory. < thinking of complaints, sunset to sunrise, warmth. > at seashore, lying on abdomen.

TUBERCULINUM
Frightful dysmenorrhoea in women with a tubercular history. Menses early, profuse, long lasting, tardy in starting. Tall slim, blonde, narrow chested, takes cold easily. Emaciation, losing flesh while eating well. Symptoms ever changing.

VIBURNUM OPULUS
Menses too late, scanty, lasting a few hours with crampy pains, cramps extend down the anterior muscles of thighs. Spasmodic & membranous dysmenorrhoea. Aching in sacrum & pubes. Pain from back to loins & womb. Frequent miscarriage. Severe bearing down pains before menses. < lying down > movements.

XANTHOXYLUM
Neuralgic dysmenorrhoea with pain in back & down the legs. Menses too early, thick, almost black, in strings. Pain in loins & lower abdomen, worse left side extending down the thigh, along the genito crural nerves. Desire to take deep breath during pain. Wants to sit or lie down. Ovarian neuralgia. Thin emaciated chlorotic women with oedema of face & legs.

ERIGERON
Dysmenorrhoea with violent irritation of bladder & rectum. Bright red blood. Nose bleed instead of menses. Pain in left ovary & hip. Persistent haemorrhages.

TRILLIUM PENDULUM
Dysmenorrhoea with sensation as if hips & back were falling to pieces, better by tight bandaging. < least movement. Flooding with fainting, menorrhagia. Uterine fibroids. Gushing of bright red blood.

THLASPI
Menses too early, profuse, protracted, tardy in starting, first day merely a show, second day colic & vomiting. Profuse, dark, clotted blood with violent cramps, scarcely recovers from one period before another begins.

USTILAGO
Menses too scanty with ovarian irritation or too profuse & too early. Extreme pain during the period, flow profuse & do not cease until next period, most of the time confined to bed. Between periods, constant suffering under left breast at margin of ribs. Oozing of dark, highly coagulated blood, long black strings.

SENECIO AUREUS
Anaemic dysmenorrhoea. Before menses, inflammation of throat, chest & bladder which improve after menses. Functional amenorrhoea in young girls with backache. Great heat & constant urge for urination. Scanty bloody urine with much mucus & tenesmus.

EUPION
Congestive dysmenorrhoea. Pains > by appearance of menses. Nose bleed when flow intermits. Abdominal pain > by bending backwards. During menses irritable & disinclined to talk. Menses too early, copious. Uterine displacements.

PISCIDIA
Neuralgic & spasmodic dysmenorrhoea. Irregular menses. Insomnia due to worry, nervous excitement. A nerve sedative.

FRAXINUS AMERICANUS
Dysmenorrhoea from uterine tumours, fibroids, uterine enlargements. Cramps in feet with bearing down sensation.

ALETRIS FARINOSA
Dysmenorrhoea with labour like pains. Menses scanty, retarded. Prolapse of uterus. Anaemic, chlorotic girls with great debility. Tired all the time. Sensation of weight in uterus. China of uterine system.

JONOSIA ASOKA
Delayed or irregular menses. Headache due to suppressed menses. Menses scanty, pale, foul smelling, blackish, with, pain, palpitation, hysteria & loss of appetite.

MERCURIALIS PERENNIS
Dysmenorrhoea with scanty menses, pain & swelling of breasts. Amenorrhoea. Great dryness of mouth & throat. Burning of tongue & lips.

ZINCUM VALERIANICUM
Neuralgic dysmenorrhoea, ovaralgia, pains shoot down the limbs, even to the foot. Becomes almost insane with pain, sleeplessness from pain. Hysterical women.

ROSMARINUS
Violent pains followed by uterine haemorrhage, menses too early. Head heavy, drowsy. Chilly with icy coldness of lower extremities without thirst, followed by heat.