PAINFUL MENSTRUATION

In these cases, the condition is called secondary dysmenorrhea. Secondary dysmenorrhea may be suspected when:
1. Pain lasts longer than the first one to three days of the menstrual cycle
2. Pain occurs between periods, with or without bleeding
3. Pain occurs a few days before the period begins
4. Pain is accompanied by spotting or by gushing blood.

Hormones And The Normal Menstrual Cycle
Hormones play an important role in the proper functioning of the menstrual cycle. In studying menstrual disorders, scientists have tried to determine how menstruation (menarche) occurs normally. Menarche usually occurs between the ages of 10 and 16. It represents the beginning of the development of a female's ability to bear children. At first the cycle may be irregular. Usually, a regular menstrual cycle is established by the end of the first year after menarche. Interrupted only for pregnancies or specific health problems, it continues month after month until a woman is in her forties or fifties when menstruation ceases (menopause). A typical cycle is about 28 days, but cycles varying from 24 to 30 days are not uncommon. Generally, a woman keeps to her individual, established pattern although stress, illness or the use of oral contraceptives may alter her personal cycle.
During each cycle, the inner wall or lining (endometrium) of the uterus thickens to provide a suitable environment for a pregnancy. A mature egg (ovum) is released from one of the two ovaries in midcycle (ovulation) and remains in the reproductive tract for about three days. For a pregnancy to occur, the ovum must be fertilized by a sperm. If there is no pregnancy, the lining of the uterus breaks down and is discharged as the menstrual flow (menses) over the course of three to eight days. Although the reproductive organs are located in the body's pelvic area, the reproductive cycle is controlled by an area at the base of the brain containing the hypothalamus and the pituitary gland. The hypothalamus and the pituitary gland orchestrate menstrual cycle activities, sending "start" and "stop" signals each month to the ovaries and uterus. On the first day of menstruation, hormone levels are low. But after one week and for most of the remaining cycle, estrogens are produced to promote ovulation and stimulate the development of the endometrium. During this time estrogens contribute to producing an appropriate environment in the reproductive organs for fertilization, implantation and nurturing of the embryo. Estrogen production drops off a few days before the next cycle begins. Progesterone, a hormone produced in large amounts during the latter half of the cycle, stimulates the development of the endometrium in preparation for a pregnancy. If there is no pregnancy, progesterone levels decrease and menstruation begins. If pregnancy occurs, production of progesterone continues throughout the nine months to help maintain the pregnancy. Other hormone-like substances, prostaglandins, are also produced during the latter half of the cycle. Although the role of prostaglandins is not completely understood, they are believed to stimulate uterine contractions which are recognized as cramps during the menstrual period. The prostaglandins may be one of the possible factors that start labor.

Treatment
The first step in arriving at treatment for dysmenorrhea is to rule out certain medical conditions other than dysmenorrhea that can cause pelvic pain. This is done by a thorough pelvic examination. For some women dietary adjustments are helpful: Reducing the amount of salt, caffeine and sugar in the diet, especially in the week before a period is due, often provides relief, as does moderate exercise and sufficient rest. For most women with dysmenorrhea, the source of their pain is the uterus, contracting too hard or too fast. Traditionally, analgesics and sedatives have been used to treat menstrual pain, although these drugs may affect a patient's normal activities, such as driving a car or taking an exam in school. As a result of scientific research, new types of medication are available. For moderate to severe dysmenorrhea, drugs that prevent or lessen the production of prostaglandins in the first hours or day of the menstrual period have proved effective without serious side effects in about 75 percent of the patients. The drugs provide relief from pain by reducing the level of prostaglandins which in turn moderates the uterine contractions. Not all women can tolerate these drugs, however, especially those who have gastrointestinal problems. For many women, over-the-counter medications effectively relieve discomfort. Medications, even those available without a prescription, however, are not without risks. Before making a decision to use medication, women should question the benefits, risks and costs of all treatment alternatives.

Search For A Cause
Primary dysmenorrhea usually does not begin until six to twelve months following menarche, when a woman's system has developed fully and ovulation occurs regularly. The disorder appears to affect young women and women who have not borne children more so than older women who have had children. Noting the similarity between menstrual cramps and mild labor pains, scientific investigation in the past had focused on the basic workings of uterine contractions. Prostaglandins were identified as one of the factors involved in causing contractions. These substances are secreted by the uterine lining and affect the smooth muscles of the uterus, thus assisting in the sloughing off of the lining during menstruation. While attention was directed to this area of research, reports began to appear that oral contraceptive users seemed to have less menstrual problems than nonusers. One explanation given is was that the decrease in menstrual flow associated with oral contraceptive use resulted in a reduction of prostaglandin concentration. Other researchers, however, observed that oral contraceptives suppress ovulation, and in the absence of ovulation uterine production of prostaglandins is diminished.

This observation, combined with the knowledge that prostaglandins stimulate uterine contractions, led researchers to conclude that an oversupply of prostaglandins is a likely cause of painful contractions of the uterus. Although oral contraceptives seem effective in relieving dysmenorrhea, their side effects have prevented many women from using them. Some women, too, have decided that the risks associated with oral contraceptives outweigh the benefits associated with relieving dysmenorrhea. As a result, other substances were sought to lessen or inhibit prostaglandin production. Now, through research and careful testing, such products are available. These agents, previously developed for the treatment of arthritis, are similar to aspirin, but many times more potent. For the treatment of secondary dysmenorrhea, however, the treatment varies with the underlying cause.