Menstrual Cycle-Related Discomforts

W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD

Disclosures

US Pharmacist. 2005;30(9) 

Introduction

Menstrual-related problems may or may not be self-treatable. Some problems, such as endometriosis, must be referred to a physician for a full medical evaluation. On the other hand, pharmacists can provide assistance for the more common problems, e.g., premenstrual syndrome (PMS) and dysmenorrhea.

Prevalence. The true incidence of PMS is unknown, as there is no laboratory test to confirm or rule out its presence. Furthermore, many females affected do not seek physician care, preferring to treat the problem themselves.[1,2] Approximately 40% to 90% of females report symptoms of PMS.[3,4] However, for 60% of this group, symptoms do not cause them to alter their daily activities. In most of the rest, symptoms are moderately severe. However, for about 3% to 8% of American women, the premenstrual condition known as premenstrual dysphoric disorder (PMDD) causes major disruptions of at least one area of daily life.[5,6]

Range of Severity. At one end of the extreme, PMS is mild, presenting little problem for the patient. Some patients have moderate PMS, and at the far end of the spectrum of severity, a small group of women experience PMS symptoms that are sufficiently severe to cause significant impairment.[4] For these patients, the severe condition is defined by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM-IV-R) and designated as PMDD, a subcategory of depressive disorders.[7]

Manifestations of PMS and PMDD. Except for girls prior to the onset of menarche or women following menopause, females of any age may experience PMS or PMDD.[4] The patient should keep a record of symptoms for two or more cycles to aid in diagnosis. Symptoms should begin two weeks or less before the onset of flow but should remit at onset or within one to two days thereafter, at the latest.[1,8]

Manifestations of PMS fall into three broad categories: mood disruptions, behavior disorders, and changes in physical function. Mood disruptions include mood swings, irritability, hostility, depression, anxiety, nervousness, forgetfulness, confusion, and insomnia.[9] Behavioral problems, such as sweet cravings, increased eating of all foods, crying, impaired concentration, heightened sensitivity to noises, and changes in the ability to tolerate alcohol consumption, can occur. Noticeable changes in physical function include weight gain (perhaps secondary to overeating and/or water retention), headache, palpitations, fatigue, dizziness, bloating, tenderness and swelling of the breasts, constipation, or diarrhea.[5,10] While all of these manifestations can occur without PMS, it is their cyclical nature and occurrence in relation to the menstrual cycle that mark them as part of PMS. In a study of adolescent girls, researchers discovered that the most common manifestation of PMS was negative affect, characterized by mood swings, stress, and nervousness.[11] as breast tenderness, abdominal bloating, fatigue, and edema.

As a formal psychiatric diagnosis, PMDD has strict symptomatic criteria.[8] DSM-IV-R categorizes manifestations as follows:

  • Depressive: Marked depression, hopeless feelings, self-deprecation, sudden sadness, lack of interest in typical activities, lethargy or fatigue, appetite changes/food cravings, sleep disturbances (insomnia, hypersomnia);

  • Anxiety: Tension, irritability, anger, feelings of being overwhelmed/out of control; and

  • Physical: Swelling or tenderness of the breasts, headaches, joint/muscle pain, weight gain, bloating, swelling of ankles, feet, and thighs.

The criteria for PMDD require that five of the above symptoms be present and that one must occur during the last premenstrual week, improve after the onset of menses, and be absent in the first full week after menses. In addition, manifestations must markedly interfere with a vital area of life (e.g., sexual, school, occupational, or social). They cannot merely be due to another disorder, such as existing depression or anxiety. Finally, the patient must have one of the following: (1) markedly depressed mood with hopeless feelings, (2) marked anxiety or tension, (3) affective lability, or (4) irritability and anger.[6]

Dysmenorrhea, also known as menstrual cramping, is a cyclical pain in the suprapubic area or lower abdomen, with onset near the time of the beginning of menstrual flow or just before the onset of flow, and ceasing when flow ends.[12,13] Perhaps 90% of adolescent females experience painful dysmenorrheal cramping.[3] It is the primary cause of missed work and school.[14,15]

Primary versus Secondary Dysmenorrhea. Primary dysmenorrhea is the medical term for menstrual cramping that does not reflect any pathology but is solely due to prostaglandin-induced uterine contractions.[16,17] The condition is benign and self-treatable. However, secondary dysmenorrhea is caused by an underlying disease process and the patient must be referred to a physician. The pharmacist should question the patient closely to ensure that she does not have the hallmark indications of secondary dysmenorrhea. These are: (1) occurrence after a duration (perhaps many years) of painless menstrual periods; (2) heavier bleeding than normal; (3) poorer response to NSAIDs than in patients with primary dysmenorrhea; (4) abnormal vaginal discharge; and (5) pelvic tenderness at times other than of menstrual flow.[14,15]

Secondary dysmenorrhea may be caused by endometriosis (the most common cause), benign or malignant pelvic or abdominal growths or tumors, chronic pelvic inflammatory disease, uterine fibroids, irritable bowel syndrome, or celiac disease.[13,14]

Self-care interventions for menstrual discomfort can be placed into one of three categories: lifestyle changes, thermotherapy, and internal medications.

Lifestyle Changes. Authorities recommend several helpful lifestyle changes to lessen the risk of menstrual discomfort. For instance, the patient should reduce intake of sodium and sugar, eliminate caffeine and alcohol, and be mindful of dairy product ingestion.[11] Any of these can worsen such symptoms as fluid retention, irritability, and bloating. Increasing the proportion of complex carbohydrates in the daily diet can improve mood.

Thermotherapy. Thermotherapy for menstrual discomfort is a traditional treatment, especially for dysmenorrhea.[17,18] However, it has been impractical for most patients, as previously existing modalities were cumbersome at best and delivered fluctuating and uncertain levels of heat at worst. Patients could not remain ambulatory to carry out normal daily activities with such devices as hot water bottles and heating pads. Hot water bottles are heavy and require serial refilling to deliver heat. Heating pads have caused numerous injuries and force the patient to be tethered to an electrical outlet.

Thermotherapy for dysmenorrhea made great strides when a practical, portable, wearable device was marketed. In the form of a continuous, low-level, topical heat wrap (i.e., ThermaCare), the device activates when the package is opened. Within 30 minutes, oxidation of iron cells within the heat wrap provides a constant, safe 104°C temperature. The device is worn for eight hours and provides pain relief for 24 hours. An adhesive side is attached to the patient's underwear, allowing the heat disks to directly touch the skin. The device should not be used with a topical external analgesic. In a blinded, active-controlled study of acetaminophen versus heat-wrap therapy for dysmenorrhea, the heat wrap was found to be superior to acetaminophen 1,000 mg in relieving pain, muscle tightness, and cramping.[19] It also was superior in

Internal Medications. Internal medication marketed specifically for menstrual problems is usually combination therapy that contains one or more ingredients of unknown efficacy. Pyrilamine has never been proven effective for any use in menstrual problems but remains a common ingredient in many products. Thus, its inclusion contributes to adverse reactions and contraindications without any accompanying benefit. Diuretics, such as pamabrom (e.g., Aqua-Ban), are safe and beneficial but are limited to providing relief of symptoms related only to water accumulation. Internal analgesics are also safe and effective for relieving discomfort. However, the study cited above demonstrates that topical heat-wrap therapy is superior to acetaminophen. In contrast, NSAIDs like ibuprofen (e.g., Motrin IB) or naproxen (e.g., Aleve) may relieve discomfort and can be used with the topical heat wrap.[14] A Cochrane Database study confirmed that NSAIDs are more effective than placebo for primary dysmenorrhea pain, but evidence for comparative superiority of one drug versus another was lacking.[20]

Does Guaifenesin Help Dysmenorrhea?

Patient Information: Dealing with Menstrual Discomfort

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