Dysmenorrhea

DYSMENORRHEA (from the Greek dys- prefix denoting qualitative disturbance and menorrhoea—monthly flow), a term broadly designating the most diverse disorders in the course of the menstrual function. Usually, however, dysmenorrhea is understood to mean menstruation accompanied by abnormally severe pain. The attempts of some authors to introduce a more precise name for this type of disorder (e.g., Seitz's menalgia) have not caught on. From the very definition of dysmenorrhea, it is evident that this is not an independent disease, but merely a certain symptom complex accompanying the physiological phenomenon of menstruation. This circumstance makes the classification of individual forms of dysmenorrhea according to any definite feature extremely difficult. In general, all cases of dysmenorrhea can be divided into 1) cases in which local changes in the genital sphere can be demonstrated, and 2) cases in which, despite sometimes markedly pronounced symptoms of dysmenorrhea, no deviations from the norm can be established in the genital organs. Therefore, of all the proposed classifications, the most rational is to adopt the simplest one, which accepts these two main forms of dysmenorrhea—symptomatic and essential. Marion Sims (1866) long ago advanced the proposition—nulla dysmenorrhoea, nisi obstructiva, arguing that the main etiological factor of dysmenorrhea is a mechanical obstruction to the outflow of menstrual blood (e.g., narrowing of the uterine cervix in acute anteflexion of the uterus). The modern view on the significance of this factor has, however, changed significantly; purely mechanical obstacles to the outflow of blood from the uterus are now attributed only secondary importance. True stenosis of the cervix is extremely rare; it is the result of ulcerative processes, the consequence of traumatic injuries during childbirth or surgical intervention (excessive energetic curettage during the production of an artificial abortion should be especially emphasized). Myomatous nodes and polypoid formations closing (like a valve) the internal os of the uterus can indeed serve as a cause of mechanical dysmenorrhea. Finally, as a special form of mechanical dysmenorrhea, one can point to the so-called Dysmenorrhoea membranacea (see below). Much greater importance in the occurrence of dysmenorrhea is held by other factors, among which inflammation occupies a prominent place. Inflammatory altered tissues, especially the peritoneum, are generally extremely sensitive to swelling under the influence of premenstrual blood engorgement. On the other hand, pain sensitivity can also be explained here by the displacements to which the inflamed organs and tissues are subjected under the influence of uterine contractions in the process of expelling the menstrual contents of the uterus. In addition to these etiological factors, even greater importance is currently attached to factors that disrupt the general balance of the organism—in the sense of functional disorders of the endocrine glands and the autonomic nervous system, which precisely explain the majority of cases of so-called essential dysmenorrhea. These disorders, in turn, can be primary (constitutional) or secondary. Dysmenorrhea, which is frequently encountered in infantile-hypoplastic individuals, can be explained by ovarian hypoplasia, due to which the organs that should participate directly in the menstrual process prove to be inadequate; therefore, such physiological processes as premenstrual hyperemia and swelling cause pain. The normal state of the autonomic nervous system is essential for the correct execution of the menstrual function; therefore, disorders in this area easily lead to dysmenorrhea. Ovarian hypoplasia in infantiles causes an increase in vasomotor excitability, disrupts the regularity of blood filling in the premenstrual stage, and can be the cause of an abnormal reaction in the form of precisely dysmenorrhea. The easy excitability of the autonomic nervous system in hysteroneurasthenics is the reason why physiological menstrual contractions of the uterus are perceived very painfully. Theilhaber at one time explained essential dysmenorrhea by spastic cramp of the circular musculature of the internal os. At present, the presence of a special sphincter in the region of the internal os is denied, but the possibility of spastic dysmenorrhea is nevertheless admitted. As a special neuropathic form, the so-called Dysmenorrhoea nasalis can also be indicated, in which the neuro-reflex irritation originates from the region of the nasal conchae and nasal septum. It should be pointed out that psychogenic reflexes can also play an important role in the etiology of dysmenorrhea. In secondarily developed ovarian hypoplasia, the main etiological factors are all those factors that lead to general weakening of the organism. Severe living conditions, the lack of adequate nutrition, and the oppression of the organism (especially during its growth period) by heavy mental and physical labor should be especially emphasized. The question of whether any professions have a particularly harmful effect on the female genital sphere is still under development, but it can already be said that women engaged in labor associated with constant neuropsychic tension (schoolteachers, governesses, typists, clerks, telephone operators, etc.) often suffer from dysmenorrhea as an occupational disease. In the clinical picture of a dysmenorrheic attack, local and general disorders can be distinguished. Local pains usually appear in two forms: either they occur periodically and have a spasmodic character, spreading from the sacrum to the lower abdomen and radiating to the legs, or they have a constant character, sometimes concentrating in certain points of the abdominal cavity. Both the intensity and the time of onset of the pains vary. They can begin either with the onset of menstruation or after it (most often, however, they appear before the onset of menstruation and often subside with the appearance of blood). Sometimes pains analogous to dysmenorrheic ones occur regularly approximately in the middle of the interval between two menstruations. These so-called middle pains (Mittelschmerz of German authors) are apparently connected with the moment of rupture of the Graafian follicle in the ovary. Some women indicate a dependence of pain on the state of the psyche. Frequently, an attack of dysmenorrhea is accompanied by general disorders in the form of increased irritability of the entire nervous system, neuralgia, headaches sometimes taking the character of migraine, cardiovascular system disorders, nausea, vomiting, impaired intestinal function, etc. In constitutional anomalies, dysmenorrhea appears with the appearance of the very first periods. Dysmenorrhea acquired due to other causes may occur at any time. Dysmenorrhea based on a constantly operating cause usually recurs with every menstruation. Conversely, dysmenorrhea of psychogenic origin does not differ by such constancy and depends on the state of the patient's psyche at the given time. Regarding the influence of sexual life and childbirth processes on dysmenorrhea, some forms of dysmenorrhea (especially in infantile-hypoplastic women) often disappear with the onset of sexual life or after childbirth. The diversity of etiological factors shows that the true cause of dysmenorrhea in each individual case can be established only on the basis of a thorough gynecological and general examination of the patient. Examination of the autonomic nervous system is very important, and in some cases also a thorough psychoanalysis. It is further necessary to take into account the features of the constitution, as well as to study the influence of the entire environment, everyday life, and labor conditions of the given woman. The diversity of etiological factors explains the difficulty of accurate prognosis. In inflammatory dysmenorrhea, the outcome depends, of course, on the prevalence and nature of the underlying process. It is more difficult to decide the question when it comes to deeper constitutional disorders. In the prophylaxis of dysmenorrhea, the elimination of all hazards for the growing female body is of great importance, which is achieved by sensible hygienic measures that should begin at an early age. It is especially important to care for proper development during puberty. Good living conditions, proper nutrition, and sensible physical culture can yield the best results. A question of utmost importance is also the protection of this age from heavy physical as well as excessive mental labor. The prophylaxis of inflammatory forms of dysmenorrhea is carried out by appropriate measures of anti-inflammatory treatment, especially of gonorrheal and postpartum infections. The treatment of dysmenorrhea pursues two goals: symptomatic treatment of the attack itself and rational, i.e., as far as possible etiological therapy of the underlying condition. With the extreme diversity of causes causing pain, there naturally cannot be any schematic treatment for them. Recommending the individualization of the treatment of the attack, Schröder advises, in inflammatory and spastic forms of dysmenorrhea, first of all, bed rest. Conversely, in hypoplastics, in whom the attack is caused by excessive hyperemia of tissues poorly capable of swelling, movements are useful, followed by measures diverting to the intestine, hydrotherapeutic measures, and local bloodletting from the vaginal portion of the uterus.

In the spastic form in asthenic women, the use of atropine in pills or drops is useful (for example, according to the prescription of Jaschke - Atropini sulfur. 0.003, Papaverini hydrochlor., Codeini phosphor., aa 0.3, Aq. destil. ad 20.0 - 20 drops 2 times a day). Belladonna in suppositories can also be prescribed. In all forms of dysmenorrhea, phenacetin, antipyrine, pyramidon, valerian and bromine preparations, as well as narcotics (except morphine) may prove useful. Vogt recommends the slow intravenous infusion of 0.2-0.5 novoprotin to relieve the attack. In nasal dysmenorrhea, the attack is often stopped under the influence of lubricating the nasal conchae with a 10% cocaine solution. As for causal therapy, proceeding from the modern view of dysmenorrhea as a disorder of a general nature, general therapeutic methods must be placed at the basis of treatment. First of all, of course, it is necessary to put the patient in the best possible hygienic conditions of work and life. Then general strengthening treatment should be prescribed, in which physical agents and climatic conditions (sunlight, air, hydrotherapy, light sports) can be of great service. As a method that increases the body's resistance and reduces the irritability of the nervous system, calcium therapy can be recommended (for example, Calcii carbonici praecip. 10.0 + Calcii phosph. 5.0 two to three times a day on the tip of a knife). In endocrine disorders, special treatment with preparations of the corresponding glands, in particular ovarian preparations (such as folliculin), can be carried out. Jaschke recommends trying the administration of luteoglandol 10-12 days before the expected menstruation. In ovarian hypofunction, some authors also use small, so-called irritating doses of X-rays, but this kind of therapy, in view of its poor study, must be treated with great caution. As for local therapy, in some cases it is definitely indicated (e.g., in stenoses, polyps, myomatous nodes) and should consist in appropriate surgical intervention. If inflammatory changes are at the root of dysmenorrhea, local treatment is also of course necessary, which is carried out according to generally accepted principles, and here physical therapy procedures (heat, light, mud therapy, diathermy, and according to some authors, intrauterine electrification) turn out to be quite appropriate. Surgical methods of treatment of dysmenorrhea, so widespread in earlier times, are now assigned a relatively very limited scope of application. The most suitable cases for such therapy are cases of constriction of the cervical canal and acute-angle flexion of the uterus in infantile-hypoplastic individuals. The simplest type of intervention here consists in dilating the cervical canal with Hegar dilators. In modern times, for a more permanent dilation of the cervix, as well as in order to eliminate the increased tendency of the uterus to spastic contractions, the methods of Fehling and Menge have been proposed. Fehling's method consists in the fact that after maximum dilation of the cervix, curettage of the uterus is performed, and then a curved glass tube 5 cm long is inserted into it, which remains lying there for 10 days; every 3 days the tube is changed, and the uterine cavity is thoroughly washed with a 1% formalin solution. Menge produces a significant dilation of the uterine cavity, bringing Hegar bougies to the very bottom of it. After preliminary dissection of the cervix from the inside with a metrotome, the dilation is brought to Hegar dilator No. 16. After this, the uterine cavity is tightly packed with antiseptic gauze moistened with oil. The tampon remains lying for up to 10 days under the control of temperature and the general condition of the patient. Menge notes 80% complete recoveries. Other methods designed for permanent dilation of the cervix usually consist in the fact that with them the cervix is either only dissected or a wedge-shaped area is cut out from the thickness of its walls. In its simplest form, the operation was proposed by M. Sims (in the form of dissection of the posterior wall of the cervical canal). The huge disadvantage of all these operations is that, destroying the cervical canal of the uterus as such, they significantly disrupt physiological relations and often lead to the occurrence of subsequent inflammatory conditions of the mucous membrane of the uterus with all their consequences.

A. Timofeev. D. membranacea, membranous dysmenorrhea—an anomaly of menstruation in which the patient, along with blood, excretes (usually on the 2nd or 3rd day of menstruation) accompanied by severe pain, a membranous cast of the uterine cavity. In individual cases, such a cast has the appearance of a sac in which the mouths of the tubes and the internal os of the uterus can be clearly distinguished; more often, however, the sac ruptures, and only pieces (films) remain, rough on the outside and smooth as velvet on the inside. At one time, membranous dysmenorrhea was considered (without sufficient grounds) to be a manifestation of a special form of endometritis (endometritis exfoliativa, s. membranacea). At present, it has been clarified that what was previously considered phenomena of endometritis is in reality nothing more than the functional layer of the uterine mucosa, corresponding in structure to the first and last days of the menstrual cycle (pregravid mucosa, decidua menstrualis). The pathogenesis of the disease is unclear. Most view membranous dysmenorrhea as a symptom-neurosis (similar to colitis membranacea). It is possible that local constitutional factors play a role here. Schroeder (as a hypothesis) expresses the thought that the basis of the disease is the absence in the premenstrual mucosa of the necessary amount of tryptic enzymes, due to which under normal conditions the breakdown of the menstrual mucosa occurs. With an unclear pathogenesis, therapy for membranous dysmenorrhea has little chance of success.