Dysmenorrhea is a gynecological disorder marked by difficult menstrual flow or painful menstruations. It is one of the most common complaints in women

There are two form of dysmenorrheal

• Primary- this is marked by severe pain in the pelvic region which is not associated with macroscopic pelvic pathology i.e. there is no underlying disorder or disease causing the pain. This usually occurs in young girls, within first few years of getting the menstrual cycle. More than 50 % of young girls are affected by this pain.
• Secondary- this is marked by severe pelvic pain and cramps which occur as a result of macroscopic pelvic pathology i.e. there are underlying disorders such as endometriosis or chronic pelvic inflammatory disease. This occurs in older women, i.e women above the age of 30- 45 years.

Some of the risk factors involved in severe episodes of dysmenorrhea are:

1. Early onset of menstrual cycle, where the girls are less than 12 years when they have their first menstrual bleeding.
2. Long duration of menstrual cycle- this occurs in women who have more than 5 days of heavy bleeding
3. Heavy bleeding- heavy menstrual flow also marks severe episode of dysmenorrhea.
4. Smoking- women who are habitual smokers are more at a risk of this disorder.
5. Positive family history- some women have a history of dysmennorhea in the family and have high chances of suffering from it themselves.
6. Obesity- though thin girls also have severe pain in the pelvic region, obesity increases the chances of having painful menstrual cycle.
7. Alcohol consumption- studies have associated alcohol consumption with dysmennorhea.

Pathophysiology:

• Primary- one of the main reasons for development of primary dysmenorrheal is prostaglandin F2alpha (PGF2alpha). This is a strong myometrial stimulant and vasoconstrictor which is found in the secretory endometrium. Studies have shown that this disorder is prostaglandin mediated. It has also been linked to prolonged uterine contractions and lack of blood supply to the myometrium. This is because the endometrial fluid of dysmenorrhea patients have shown increased amount of prostaglandin.
• Secondary- As stated above, secondary dysmenorrhea occurs due to an underlying pathological disorders such
  1. Endometriosis
  2. Pelvic inflammatory disease
  3. Ovarian cysts and tumors
  4. Cervical stenosis or occlusion
  5. Adenomyosis
  6. Fibroids
  7. Uterine polyps
  8. Intrauterine adhesions
  9. Congenital malformations (eg, bicornate uterus, subseptate uterus)
  10. Intrauterine contraceptive device
  11. Transverse vaginal septum
  12. Pelvic congestion syndrome
  13. Allen-Masters syndrome

Clinical features:

The clinical features of primary and secondary dysmennorhea differ in the following ways.

• Primary- this occurs during the ovulatory cycle and usually occurs within a year of the first menstrual cycle. The pain and cramps start with the onset of menstruation and lasts for the first two days. The pain is spasmodic and occurs in the lower abdomen. It can also radiate to the back or anterior and medial thigh. The patient may also suffer from malaise, fatigue, nausea, vomiting, diarrhea, pain in the lower back and headache.  The pain is some patients are so severe that it appears to be labour like.
• Secondary- this form is not limited to onset of menses and the patient may experience abdominal bloating, pelvic heaviness and backache. It is observed that the pain increases during the luteal phase of the menstruation.

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