INTRODUCTION
Homoeopathy is now a system of medicine with growing
acceptance all over the world. Homoeopathy is a specialised
system of therapeutics based on the law of healing - Similia
Similibus Curentur which means ‘let likes be treated by likes’.
The beginning of this new idea was blossomed in the mind of Dr.
Samuel Hahnemann and cherished in the minds of Dr. Herring, Dr.
Kent,
Dr. Boeninghausen, Dr. Farrington and many others to attain the
present status.
Homoeopathy signifies a system of treatment based on
the similarity between symptoms of the patient and those
obtained during proving of drugs on healthy human beings. The
basic concept of disease is that, all natural diseases are due
to derangement of the vital force of an individual resulting in
abnormal sensations and functions manifested as signs and
symptoms both in mental and physical plains. This image of the
disease which we call as totality of symptoms is the sole guide
for the physician to select the similimum - the curative remedy.
Thus Homoeopathy is a system of medicine giving more importance
to the diseased individual than the disease itself.
Dysmenorrhoea is one of the most common gynaecologic
complaints in women who present to clinicians.
Dysmenorrhoea is the general term for painful menstruation.
Painful menstruation is when menstrual periods are accompanied
by either sharp, intermittent pain or dull, aching pain, usually
in the pelvis or lower abdomen. Primary dysmenorrhoea refers to
menstrual pain that occurs in otherwise healthy women and is not
related to any specific problems with the uterus or other pelvic
organs. It
is predominantly confined to adolescent girls.
Secondary dysmenorrhoea is defined as
menstrual pain resulting from anatomic and/or macroscopic pelvic
pathology and so the treatment may require surgical intervention
at times. On the other hand primary dysmenorrhoea is
purely functional and homoeopathic medicines both constitutional
anti miasmatic and specific medicines are highly effective in
its treatment.
This is a humble effort made by me to show the
homoeopathic fraternity and the whole suffering humanity, the
efficacy and significance of homoeopathic medicines in the
management of primary dysmenorrhoea.
We are here to add what we can to,Not to get what we can from,
LIFE.-
Sir William Osler
AIMS AND OBJECTIVES
*
To determine the efficacy and significance of homoeopathic
medicines in the management of primary dysmenorrhoea.
*
To determine the medicines and the corresponding potencies
frequently indicated in the management of primary dysmenorrhoea
REVIEW OF LITERATURE
PART I Dysmenorrhoea
3.1 Anatomy
3.2 Physiology
3.3 Definition
3.4 Classification
3.5 Primary
Dysmenorrhoea
3.6 Epidemiology
3.7 Pathophysiology
3.8 Clinical features
3.9 Physical examination
3.10 Lab studies
3.11 Differential diagnosis
3.12 Complications
3.13 Prognosis
3.14 Patient education
3.15 Secondary Dysmenorrhoea
PART II 3.16 Medicinal management
PART III 3.17 Miasmatic back ground
PART IV 3.18 Repertorial analysis
PART I
DYSMENORRHOEA
Dysmenorrhoea is one of the most common
gynaecologic complaints in women who present to clinicians.
Dysmenorrhoea is pelvic pain during a menstrual period.
Painful menstruation is when menstrual periods are accompanied
by either sharp, intermittent pain or dull, aching pain, usually
in the pelvis or lower abdomen.
Painful menstruation affects many women. For
a small number of women, such discomfort makes it next
impossible to perform normal household, job, or school-related
activities for a few days during each menstrual cycle. It is the
leading cause of lost time from school and work among women in
their teens and 20's.
The pain may begin several days before or
just at the start of the period. It generally subsides as
menstrual bleeding tapers off. Although some pain during
menstruation is normal, excessive pain is not. Dysmenorrhoea
refers to menstrual pain severe enough to limit normal
activities or require medication.
There are commonly two general types of dysmenorrhoea :
-
Primary dysmenorrhoea refers to menstrual pain that occurs in
otherwise healthy women. This type of pain is not related to
any specific problems with the uterus or other pelvic organs.
-
Secondary dysmenorrhoea is menstrual pain that is attributed
to some underlying disease process or structural abnormality
either within or outside the uterus.
3.1 ANATOMY
THE UTERUS
(Womb)
The uterus is a hollow, thick-walled, muscular organ
situated deeply in the pelvic cavity between the bladder and
rectum. Into its upper part the uterine (fallopian) tubes open,
one on either side, while below, its cavity communicates with
that of the vagina. When the ova are discharged from the ovaries
they are carried to the uterine cavity through the uterine
tubes. If an ovum be fertilized it imbeds itself in the uterine
wall and is normally retained in the uterus until prenatal
development is completed, the uterus undergoing changes in size
and structure to accommodate itself to the needs of the growing
embryo. After parturition the uterus returns almost to its
former condition, but certain traces of its enlargement remains.65
In the virgin state
the uterus is flattened antero-posteriorly and is pyriform in
shape, with the apex directed downward and backward. It lies
between the bladder in front and the pelvic or sigmoid colon and
rectum behind, and is completely within the pelvis, so that its
base is below the level of the superior pelvic aperture. Its
upper part is suspended by the broad and the round ligaments,
while its lower portion is imbedded in the fibrous tissue of the
pelvis.
The uterus measures about 7.5 cm. in length, 5 cm. in breadth,
at its upper part, and nearly 2.5 cm. in thickness; it weighs
from 30 to 40 gm. It is divisible into two portions. On the
surface, about midway between the apex and base, is a slight
constriction, known as the isthmus, and corresponding to
this in the interior is a narrowing of the uterine cavity, the
internal orifice of the uterus. The portion above the isthmus is
termed the body, and that below, the cervix. The
part of the body which lies above a plane passing through the
points of entrance of the uterine tubes is known as the fundus.
The Body (corpus uteri)
gradually narrows from the fundus to the isthmus. The vesical or
anterior surface (facies vesicalis) is flattened and
covered by peritoneum, which is reflected on to the bladder to
form the vesicouterine excavation.The intestinal or posterior
surface (facies intestinalis) is convex transversely and
is covered by peritoneum, which is continued down on to the
cervix and vagina. It is in relation with sigmoid colon, from
which it is separated by coils of small intestine.
The fundus (fundus uteri) is convex in all
directions, and covered by peritoneum continuous with that on
the vesical and intestinal surfaces.The lateral margins (margo
lateralis) are slightly convex. At the upper end of each,
the uterine tube pierces the uterine wall. Below and in front of
this point the round ligament of the uterus is fixed, while
behind it is the attachment of the ligament of the ovary. These
three structures lie within a fold of peritoneum, the broad
ligament which is reflected from the margin of uterus to the
wall of the pelvis.
The Cervix (cervix uteri; neck) is the lower
constricted segment of the uterus. It is somewhat conical in
shape, with its truncated apex directed downward and backward,
but is slightly wider in the middle than either above or below.
Owing to its relationships, it is less freely movable than the
body, so that the latter may bend on it. The cervix projects
through the anterior wall of the vagina, which divides it into
an upper, supra vaginal portion, and a lower, vaginal
portion.The supravaginal portion (portio
supravaginalis [cervicis]) is separated in front
from the bladder by fibrous tissue (parametrium).The uterine
arteries reach the margins of the cervix in this fibrous tissue,
while on either side the ureter runs downward and forward.
Posteriorly, the supravaginal cervix is covered by
peritoneum. It is in relation with the rectum, from which it may
be separated by coils of small intestine. The vaginal
portion (portio vaginalis [cervicis]) of the
cervix projects free into the anterior wall of the vagina
between the anterior and posterior fornices. On its rounded
extremity is a small, depressed, somewhat circular aperture, the
external orifice of the uterus, through which the cavity
of the cervix communicates with that of the vagina.
Interior of the Uterus—The
cavity of the uterus is small in comparison with the size of the
organ.
The Cavity of the Body (cavum uteri) is
a mere slit, flattened antero-posteriorly. It is triangular in
shape, the base being formed by the internal surface of the
fundus between the orifices of the uterine tubes, the apex by
the internal orifice of the uterus through which the cavity of
the body communicates with the canal of the cervix
The Canal of the Cervix (canalis cervicis
uteri) is somewhat fusiform, flattened from before backward,
and broader at the middle than at either extremity. It
communicates above through the internal orifice with the cavity
of the body, and below through the external orifice with the
vaginal cavity. The wall of the canal presents an anterior and a
posterior longitudinal ridge, from each of which proceed a
number of small oblique columns, the palmate folds,
giving the appearance of branches from the stem of a tree; to
this arrangement the name arbor vitæ uterina is applied.
The total length of the uterine cavity from the external orifice
to the fundus is about 6.25 cm.
Ligaments.—The
ligaments of the uterus are eight in number: one anterior; one
posterior; two lateral or broad; two uterosacral; and two round
ligaments.
The anterior ligament consists of the
vesicouterine fold of peritoneum, which is reflected on to the
bladder.
The posterior ligament consists of the
rectovaginal fold of peritoneum, which is reflected from the
back of the posterior fornix of the vagina on to the front of
the rectum. It forms the bottom of a deep pouch called the
rectouterine excavation, which is bounded laterally by
two crescentic folds of peritoneum which pass backward from the
cervix uteri on either side of the rectum to the posterior wall
of the pelvis. These folds are named the sacrogenital or
rectouterine folds. They contain a considerable amount of
fibrous tissue and non-striped muscular fibers which are
attached to the front of the sacrum and constitute the
uterosacral ligaments.
The two lateral or broad ligaments (ligamentum
latum uteri) pass from the sides of the uterus to the
lateral walls of the pelvis. Together with the uterus they form
a septum across the female pelvis, dividing that cavity into two
portions. In the anterior part is contained the bladder; in the
posterior part the rectum, and in certain conditions some coils
of the small intestine and a part of the sigmoid colon. Between
the two layers of each broad ligament are contained: the uterine
tube superiorly; the round ligament of the uterus; the ovary and
its ligament; the epoöphoron and paroöphoron; connective tissue;
unstriped muscular fibers; and bloodvessels and nerves. The
portion of the broad ligament which stretches from the uterine
tube to the level of the ovary is known by the name of the
mesosalpinx. Between the fimbriated extremity of the tube
and the lower attachment of the broad ligament is a concave
rounded margin, called the infundibulo pelvic ligament.
The round ligaments (ligamentum teres uteri)
are two flattened bands situated between the layers of the broad
ligament in front of and below the uterine tubes. Commencing on
either side at the lateral angle of the uterus, this ligament is
directed forward, upward, and lateralward over the external
iliac vessels. It then passes through the abdominal inguinal
ring and along the inguinal canal to the labium majus, in which
it becomes lost. The round ligaments consists principally of
muscular tissue, prolonged from the uterus; also of some fibrous
and areolar tissue, besides bloodvessels, lymphatics; and
nerves, enclosed in a duplicature of peritoneum, which, in the
fetus, is prolonged in the form of a tubular process for a short
distance into the inguinal canal. This process is called the
canal of Nuck. It is generally obliterated in the adult, but
sometimes remains pervious even in advanced life. In
addition to the ligaments just described, there is a band named
the ligamentum transversalis colli (Mackenrodt) on either
side of the cervix uteri. It is attached to the side of the
cervix uteri and to the vault and lateral fornix of the vagina,
and is continuous externally with the fibrous tissue which
surrounds the pelvic blood vessels.
The form, size, and situation of the uterus vary at
different periods of life and under different circumstances.
*In
the fetus
the uterus is contained in the abdominal cavity, projecting
beyond the superior aperture of the pelvis The cervix is
considerably larger than the body.
*At
puberty
the uterus is pyriform in shape, and weighs from 14 to 17 gm. It
has descended into the pelvis, the fundus being just below the
level of the superior aperture of this cavity.
*The
position of the uterus in the adult is liable to
considerable variation, depending chiefly on the condition of
the bladder and rectum. When the bladder is empty the entire
uterus is directed forward, and is at the same time bent on
itself at the junction of the body and cervix, so that the body
lies upon the bladder. As the latter fills, the uterus gradually
becomes more and more erect, until with a fully distended
bladder the fundus may be directed backward toward the sacrum
*During
menstruation
the organ is enlarged, more vascular, and its surfaces rounder;
the external orifice is rounded, its labia swollen, and the
lining membrane of the body thickened, softer, and of a darker
color.
At each recurrence of menstruation, a molecular disintegration
of the mucous membrane takes place, which leads to its complete
removal, only the bases of the glands imbedded in the muscle
being left. At the cessation of menstruation, a fresh mucous
membrane is formed by a proliferation of the remaining
structures.
*During
pregnancy
the uterus becomes enormously enlarged, and in the eighth month
reaches the epigastric region. The increase in size is partly
due to growth of pre ëxisting muscle, and partly to development
of new fibers.
*After
parturition
the uterus nearly regains its usual size, weighing about 42 gm.;
but its cavity is larger than in the virgin state, its vessels
are tortuous, and its muscular layers are more defined; the
external orifice is more marked, and its edges present one or
more fissures.
*In
old age
the uterus becomes atrophied, and paler and denser in texture; a
more distinct constriction separates the body and cervix. The
internal orifice is frequently, and the external orifice
occasionally, obliterated, while the lips almost entirely
disappear.
Structure.—The
uterus is composed of three coats: an external or serous, a
middle or muscular, and an internal or mucous.
The serous coat (tunica serosa) is
derived from the peritoneum; it invests the fundus and the whole
of the intestinal surface of the uterus; but covers the vesical
surface only as far as the junction of the body and cervix.
The muscular coat (tunica muscularis)
forms the chief bulk of the substance of the uterus. In the
virgin it is dense, firm, of a grayish color, and cuts almost
like cartilage. It is thick opposite the middle of the body and
fundus, and thin at the orifices of the uterine tubes. It
consists of bundles of unstriped muscular fibers, disposed in
layers, intermixed with areolar tissue, bloodvessels, lymphatic
vessels, and nerves. The layers are three in number: external,
middle, and internal. The external and middle layers constitute
the muscular coat proper, while the inner layer is a greatly
hypertrophied muscularis mucosæ. During pregnancy the muscular
tissue becomes more prominently developed, the fibers being
greatly enlarged.
The mucous membrane (tunica mucosa) is
smooth, and closely adherent to the subjacent tissue. It is
continuous through the fimbriated extremity of the uterine
tubes, with the peritoneum; and, through the external uterine
orifice, with the lining of the vagina.
In the body of the uterus the mucous membrane is
smooth, soft, of a pale red color, lined by columnar ciliated
epithelium. In it are the tube-like uterine glands, they
are of small size in the unimpregnated uterus, but shortly after
impregnation become enlarged and elongated, presenting a
contorted or waved appearance. In the cervix the mucous
membrane is thrown into numerous oblique ridges, which diverge
from an anterior and posterior longitudinal raphé. Extending
through the whole length of the canal is a variable number of
little cysts, presumably follicles which have become occluded
and distended with retained secretion, called the ovula
nabothi. On the vaginal surface of the cervix the epithelium
is similar to that lining the vagina, viz., stratified squamous.
Vessels and Nerves.—The
arteries of the uterus are the uterine, from the
hypogastric; and the ovarian, from the abdominal aorta
. They are remarkable for their tortuous course in the
substance of the organ, and for their frequent anastomoses. The
termination of the ovarian artery meets that of the uterine
artery, and forms an anastomotic trunk from which branches are
given off to supply the uterus, their disposition being
circular. The veins are of large size, and correspond
with the arteries. They end in the uterine plexuses. In the
impregnated uterus the arteries carry the blood to, and the
veins convey it away from, the intervillous space of the
placenta.The nerves are derived from the hypogastric and
ovarian plexuses, and from the third and fourth sacral nerves.65
3.2 PHYSIOLOGY
OVULATION
Ovulation is the process by which an ovum, in the form
of a secondary oocyte, is discharged from the ovary to become a
gamete.62
The ovary is covered by a germinal epithelium which
consists of a specialized stroma embedded in which are the
primordial follicles. The primordial follicles develop into
fully formed graafian follicles with the onset of puberty. This
process of maturation is essentially controlled by the ovarian
hormones, Oestrogen and Progesterone regulated by the Pituitary
gonadotrophic hormones, Follicle stimulating hormone (FSH) and
Luteinising hormone (LH), which in turn is regulated by the
Hypothalamic releasing hormones. Under gonadotrophic
stimulation, a number of follicles develop in the ovary in each
cycle, but the majority of these become atretic and degenerate,
only one of them maturing in to a graafian follicle.
The adult ovary goes through a cycle of activity which
occupies approximately 28 days. The cycle commences on the first
day of menstruation and has two phases: the ripening of an ovum
which occupies the first 14 days – the follicular phase;
and the formation, function and early degeneration of the corpus
luteum which occupies the second 14 days – the luteal phase.
These two phases are separated by ovulation. The duration
of luteal phase is more constant than that of the follicular
phase and is generally reckoned as 14±2 days.
Follicular phase
The primordial follicle consists of a primary oocyte
surrounded by a single layer of flattened cells, the pre
granulose, derived from the cells of sex cord. The pre granulose
cells become cuboidal and proliferate. At this stage a hyaline
membrane is formed around the ovum, zona pellucida. Fluid spaces
appear between the granulose cells, they coalesce to form a
cavity, the antrum, pushing the ovum to one side. The granulose
cells are now termed as corona radiata and the whole mass of
cells is termed the cumulus. The surrounding parenchymal cells
arrange themselves concentrically around the follicle which
constitutes the theca interna and the follicle is now called as
the graafian follicle and continues to grow to a size more than
1 cm.
Ovulation
It implies the rupture of the graafian follicle
resulting in the discharge of ovum from it. It occurs as a
result of thinning and degeneration of the cyst wall. As the
time for ovulation approaches, the outer end of fallopian tube
moves towards the ovary so that the fimbriae tend to embrace it
and are ready to catch the ovum. Unless fertilized, the ovum
survives only 12-24 hours and then disintegrates in the tube
without leaving any trace.
Luteal phase
Immediately the ovum is discharged, the cyst collapses
and the lining cells undergo luteinization, a process in which
they enlarge by imbibing fluid. The cells also proliferate and
the total effect is to enlarge the original follicle until the
new structure – the corpus luteum is 1-2 cm in diameter and
projects from the surface of the ovary. The development of the
corpus luteum is completed in 5 days. Its activity is at a
maximum during the following 3 or 4 days, but there after wanes
as degenerative changes commence 4-6 days before the next
menstrual period.62
MENSTRUATION
It is defined as a periodic physiologic discharge of
blood, mucus and other cellular debris from the uterine mucosa
which occurs at more or less regular intervals, except during
pregnancy and lactation, from the time of puberty to menopause.47
Menstruation represents the breaking down and casting off of an
endometrium prepared for a pregnancy which does not materialize,
and so is sometimes described as ‘the weeping of a
disappointed uterus’.69
The average age at which menstruation begins is
between the twelfth & fourteenth year but in a minority it may
start as early as the tenth or as late as the seventeenth year.
The term menarche indicates the onset of first menses and
menopause its final cessation.47
The Menstrual Cycle (Endometrial cycle)
The periodicity of the menstrual cycle is variable. Generally,
it occurs at an interval of 28 days, most women have cycles with
an interval that lasts from 21 to 35 days, but there is a great
variation among women in general. The duration of the flow is
also variable, the usual being 3-6 days and estimated blood loss
is 20-80 ml. The first 4 days of the cycle are occupied with
menstruation, during the remaining 24 days the histological
cycle consists basically of a proliferative phase and a
secretory phase.26
Proliferative phase
The graafian follicle under the influence of FSH secretes
Oestrogen which produces proliferative changes in the
endometrium, the stage extending from the 5th or 6th
to the 14th day of the cycle. The glands become
tubular, the epithelium becomes columnar and continuous. The
stromal cells become spindle shaped with evidences of mitosis.
The spiral vessels form loose capillary network. The thickness
of the endometrium measures about 3-4 mm.
Secretory phase
After ovulation the ruptured graafian follicle
develops into corpus luteum, which secretes progesterone.
Progesterone stimulates the endometrium to undergo secretory
hypertrophy. It begines on the 15th day and ceases
5-6 days prior to menstruation. The glands increase in size,
become corkscrew shaped. The stromal cells become swollen,
large, polyhedral. The blood vessels undergo marked spiraling.
The thickness of endometrium reaches its highest, about 5-6 mm.
Menstrual phase
In the absence of pregnancy, the corpus luteum
degenerates, both oestrogen and progesterone levels decline and
this fall brings about menstruation. The endometrial growth
ceases 5-6 days prior to menstruation, the contraction and
constriction of coiled arteries results in ischaemia causing
necrosis. The regressive changes in the endometrium are
pronounced 24-48 hours prior to menstruation. Menstrual bleeding
occurs when the open arteries damaged by necrosis relax and
discharge blood in to the uterine cavity. Some degree of venous
haemorrhage also occurs. The menstrual flow stops as a result of
combined effect of prolonged vasoconstriction, myometrial
contraction and local aggregation of platelets.26
A fall in the level of oestrogen and progesterone also
starts off a fresh positive feedback mechanism and triggers the
hypothalamus to release gonadotrophins. This is how a menstrual
cycle is regulated.
Correlation of endometrial and ovarian cycles
By the end of a menstrual period, a new follicle is
beginning to ripen in the ovary. Endometrial proliferation
therefore occurs during the follicular phase in the ovary.
Ovulation marks the change over from the proliferative to the
secretory phase in the endometrium. Secretory activity and
decidual reaction are manifestations of the luteal phase in the
ovary.32
Hormonal control of ovulation
There is an inverse relation between ovarian and
pituitary hormones and this indicates a feed back system of
control. At the beginning of the cycle the blood oestrogen level
is low and this stimulates FSH secretion. As a result follicles
mature and large quantities of oestrogen are secreted. These
progressively inhibit FSH secretion and initiate LH secretion,
producing ovulation and corpus luteum formation. Progesterone
and oestrogen are both produced by the luteal cells. If
fertilization of ovum does not occur, the corpus luteum
regresses, oestrogen and progesterone production diminishes,
menstruation occurs and FSH secretion is stimulated. The
secretion of FSH & LH in turn is under the influence of a centre
in the Hypothalamus, thought to be near the median eminence.
Thus the Hypothalamic – Pituitary axis mediates the effects of
ovarian hormones and through FSH & LH controls the menstrual
cycle.32
DYSMENORRHOEA
3.3 Definition
Dysmenorrhoea is defined as difficult menstrual flow
or painful menstruation. It
refers to menstrual pain severe enough to limit normal
activities or require medication.67
The term dysmenorrhoea is derived from the Greek words
dys, meaning difficult/painful/abnormal, meno,
meaning month, and rrhea, meaning flow.67
3.4 Classification
Dysmenorrhoea is classified as 1. Primary (spasmodic)
2. Secondary (congestive )
3.
Membranous
4. Ovarian
*
Primary dysmenorrhoea is defined as menstrual pain not
associated with macroscopic pelvic pathology. It occurs in the
first few years after menarche and affects up to 50% of post
pubescent females.
*
Secondary dysmenorrhoea is defined as menstrual pain resulting
from anatomic and/or macroscopic pelvic pathology. This
condition is most often observed in women aged 30-45 years.
*
Membranous dysmenorrhoea is regarded as an extreme form of the
spasmodic variety. It is usually rare, the pain is accompanied
by the passage of membranes which may take the form of casts of
the uterine cavity.52
*
In ovarian dysmenorrhoea 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.52
3.5 PRIMARY DYSMENORRHOEA
Primary
dysmenorrhoea is the commonest among the four types of
dysmenorrhoea.9 It is usually defined as cramping
pain in the lower abdomen occurring at the onset of menstruation
in the absence of any identifiable pelvic disease.68
Synonyms
Spasmodic, Intrinsic, Essential, Functional dysmenorrhoeas
24
3.6 Epidemiology
Primary dysmenorrhea is by far the most common
gynaecologic problem in young menstruating women. It is so
common that many women fail to report it in medical interviews,
even when their daily activities are restricted. Reported
prevalence rates are as high as 90 percent.72
Frequency
The peak incidence of primary dysmenorrhoea occurs in
late adolescence and the early 20s. It is more common amongst
girls from affluent society. The incidence of dysmenorrhoea in
adolescents is reportedly as high as 92%. The incidence falls
with increasing age and with increasing parity. The prevalence
and severity of in parous women were significantly lower. In an
epidemiologic study of an adolescent population (aged 12-17 y),
Klein and Litt reported a prevalence of dysmenorrhoea of 59.7%.
Of patients reporting pain, 12% described it as severe; 37%, as
moderate; and 49%, as mild. Dysmenorrhoea caused 14% of patients
to miss school frequently.70
Age:
Primary dysmenorrhoea is predominantly confined to adolescent
girls. The most severe cases are seen between the age of 15 &
19. It is rare to encounter in women over the age of 35.8
Race:
No data suggest that race affects the incidence of dysmenorrhoea.
Mortality/Morbidity:
While primary dysmenorrhea is not life threatening, it
is the most common reason, why women miss work. It is a leading
cause of absenteeism for women younger than 30 years,
can disrupt personal life and is a significant public health
problem associated with substantial economic loss related to
work absences. Ten percent of women with the condition have
severe pain that can be incapacitating.71
3.7 Pathophysiology:
The etiology and pathophysiology of spasmodic
dysmenorrhoea have not been fully elucidated. Nonetheless, the
following may be involved 67 -
♣ Spasmodic dysmenorrhoea has some connection with the hormonal
stimulus to the uterus. If the uterus has not been exposed to
Progesterone, as in the cases of all anovulatory bleeding, pain
is never experienced. Indeed, dysmenorrhoea only occurs in
ovulatory cycles.
♣
Growing evidence suggests that the pathogenesis of primary
dysmenorrhoea is due to prostaglandin F2alpha (PGF2alpha), a
potent myometrial stimulant and vasoconstrictor synthesised in
the secretory endometrium, under the action of progesterone.
This results in increased rhythmic
uterine contractions from vasoconstriction of the small vessels
in the uterine wall. Increased prostaglandins synthesis also may
be responsible for the distressing gastrointestinal symptoms
occasionally present. The response to prostaglandin
inhibitors in patients with dysmenorrhoea supports the assertion
that it is prostaglandin mediated.
♣ Substantial evidence attributes dysmenorrhoea to prolonged
uterine contractions, increased myometrial tone and decreased
blood flow to the myometrium leading to muscle ischaemia. So
dysmenorrhoea may be comparable to Angina Pectoris in so far as
the pain mechanism is considered.
♣ Leukotrienes have been postulated to heighten the sensitivity
of pain fibers in the uterus. Significant amounts of
leukotrienes have been demonstrated in the endometrium of women
with primary dysmenorrhea that does not respond to treatment
with prostaglandin antagonists
♣ The posterior pituitary hormone vasopressin may be involved in
myometrial hypersensitivity, reduced uterine blood flow, and
pain in primary dysmenorrhoea Vasopressin's role in the
endometrium may be related to prostaglandin synthesis and
release.
♣ A neuronal hypothesis has also been advocated for the
pathogenesis of primary dysmenorrhoea. Type C pain neurons are
stimulated by the anaerobic metabolites generated by an ischemic
endometrium.
♣ Primary dysmenorrhoea has also been attributed to behavioral
and psychological factors. The incidence is higher amongst
affluent introspective and neurotic women. Those having a low
threshold for pain and predisposed to undue fears and anxiety
are most susceptible. Although these factors have not been
convincingly demonstrated to be causative, they should be
considered if medical treatment fails.
♣ It depends upon the presence of a neurotic constitution, the
nervous system in general and the uterine nerves in particular,
being in a morbid sensibility, so that the causes which might in
others produce neuralgia of the head or other parts, here
concentrate their force upon the uterine nerves, giving rise to
hyperaesthesia which under the influence of the menstrual
congestion, causes pain.22
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