Chapter 18 Dysmenorrhoea and menstrual complaints
AETIOLOGY AND CLASSIFICATION
Menstrual complaints are often broadly – and sometimes incorrectly – categorised under the broad moniter of premenstrual syndrome (PMS). PMS is defined as a recurrent set of physical and behavioural symptoms occurring cyclically 7–14 days before menstruation (the luteal phase) and are troublesome enough to interfere with some aspects of the female’s life.1 In common clinical usage this has also extended to symptoms (such as dysmenorrhoea) that occur during menstruation and cease by the end of the full flow of menses. Despite its high prevalence PMS remains poorly understood and often not prioritised in medical treatment.1 Multiple aetiologies have been proposed, most prominently those in Table 18.1. In reality a number of these may be responsible for underlying imbalances, even in the same patient. The numerous proposed aetiologies for PMS mean that more than 150 individual symptoms have been associated with the condition. The most common are listed in Table 18.2.1
| CATEGORY | EXAMPLE |
|---|---|
| Fluid and electrolyte balance |
Table 18.2 The most common symptoms of premenstrual syndrome
| Abdominal bloating | Depression | Lethargy |
| Anxiety | Dizziness | Low self-esteem |
| Back pain | Fatigue | Mood swings |
| Breast tenderness | Headache | Nervousness |
| Change in appetite | Insomnia | Social isolation |
| Clumsiness | Irritability | Sugar cravings |
| Constipation | Joint pain | Water retention |
Although diagnosis is difficult given the broad range of possible aetiologies and symptoms, premenstrual dysphoric disorder (PMDD), a more severe form of PMS, is a recent addition to the Diagnostic and Statistical Manual of Mental Disorders IV.2 To be diagnosed with PMDD a woman must have at least five of the following symptoms occurring cyclically at a level serious enough to interfere with normal daily activities:
Patients fulfilling the diagnositic criteria for PMDD also fulfil medical diagnostic criteria for PMS, but not necessarily vice versa. However, it may be viewed as disturbing that behavioural aspects form the focus of diagnosis in PMDD, when in clinical practice a vast array of hormonal and physiological interactions take place within a woman’s body around the time of menstruation, resulting in a variety of broader symptoms and forming a more complex basis of underlying aetiology.
Dysmenorrhoea
Primary dysmenorrhoea classically presents as a cramping lower abdominal pain that usually begins during the day before menstruation. The pain gradually eases after the start of menstruation and is sometimes gone by the end of the first day of bleeding. Primary dysmenorrhoea occurs in a high percentage of young women only in ovulatory cycles and the pain is normally limited to the first 48 to 72 hours of menstruation.1
Hormonal and biochemical influences
Endocrine studies have suggested that PMS is not the result of a simple excess or deficiency in certain hormone levels.3 Low progesterone,4 excessive oestrogen5 or normal levels of both6 have not been associated with increasing incidence of PMS. Though prolactin levels have been associated with several symptoms of PMS there has been little hard evidence to suggest that elevated prolactin levels are present in women with PMS.6,7 Similarly while aldosterone is thought to be at least partly responsible for the congestive symptoms of PMS there have been no reports of significant differences between women with and without PMS.5 It has been postulated that PMS is not associated with abnormal hormone levels, but rather an abnormal response to sex hormones8 which may be exacerbated during episodes of stress.9 High blood flow is also associated with an increased instance of dysmenorrhoea.10
It is thought that deviations from normal ovarian function—rather than hormone levels per se—are associated with changes to other body systems (such as neurotransmitters) seen in PMS.11 Serotonin is thought to be particularly affected by changes in hormone levels and responsible for many mood change symptoms associated with PMS.12
It has also been hypothesised that women with PMS may have lower levels of circulating endogenous opiates (or serotonin) or a more sudden withdrawal after the postovulation surge, leaving them more susceptible to depression and more sensitive to pain in the luteal phase.13–15 Prostaglandins are also associated with the PMS symptoms of breast pain, fluid retention, abdominal cramping, headaches, irritability and depression.16 The high levels of the leukotrienes that increase uterine muscle spasm (C4 and D4) in the menstrual blood of women with dysmenorrhoea also support the hypothesis that prostaglandins are an important part of the aetiology.17 Anti-inflammatory prostaglandins may also be associated with reducing the exaggerated effects of prolactin.18
Psychosocial factors can also influence the menstrual cycle. Emotional and physical stressors such as travel, illness, stress, weather changes and other environmental factors can influence the length of the menstrual cycle, ovulation and severity of PMS.19 One study found that 75% of women receiving care for PMS had another diagnosis that could account for their symptom complex—predominantly depression and other mood disorders.20
RISK FACTORS
Epidemiological data observe a strong relationship between smoking or exposure to tobacco products and a higher incidence of dysmenorrhoea.21–23 Obesity is also a risk factor for menstrual disturbances, with women who have a body mass index (BMI) over 30 incurring a threefold risk of developing them.24 Approximately three-quarters of women have a separate diagnosis—particularly mood disorders or other hormone-mediated diagnoses—that contribute significantly to their symptoms.25 High levels of caffeine may be associated with increased prevalence and severity of PMS symptoms,26,27 though this may be due to an additive relationship of sugar with caffeine.28 Many women medicate themselves with caffeine during PMS symptoms, which may exacerbate their symptoms.29
CONVENTIONAL TREATMENT
Various pharmaceutical agents are used in conventional treatment, including diuretics (such as spironolactone—particularly with fluid retention), vitamins (such as B6), SSRI agents or danazol (particularly with severe mastalgia).30 Hormone therapy is also common, and consists of hormonal agents such as oral contraceptive pill (OCP), progestogens or implants. However, these have little evidence of efficacy in PMS.31 Progesterone treatment is increasingly popular, particularly amongst integrative medical practitioners; however, the evidence for effective treatment with progesterone alone is unclear.32
KEY TREATMENT PROTOCOLS
Although various diagnoses can often present in menstrual disorders, naturopathic treatment focuses not on treatment of particular disorders, but rather the restoration of a normal menstrual cycle. Other chapters in the reproductive section focus on various aspects of hormone normalisation, so this chapter focuses on specific symptoms associated with PMS, particularly dysmenorrhoea as it is often the most encountered symptom in clinical practice. A normal menstrual cycle should be free of the discomfort associated with pathological conditions such as PMS, PMDD or dysmenorrhoea. This eturn to normalcy can be sought through a number of mechanisms, most commonly hormonal regulation via the hypothalamic–pituitary–ovarian (HPO) axis.
HPO-axis regulation
Dietary factors
Dietary factors may also play a significant role. Women with PMS typically consume more dairy products, refined sugar and high sodium foods than women without PMS.33 Fish, eggs and fruit have been associated with less dysmenorrhoea while wine is associated with more.36 Women following a low-fat, vegetarian diet also had lower incidence
of dysmenorrhoea.22,23,37 This was theorised to be due to increased sex-hormone binding globulin (which was measured in the study) and its effects on oestrogen or arachidonic acid. A diet high in oily fish and avoidance of foods with significant arachidonic acid content reduces the severity of dysmenorrhoea, possibly through improving the synthesis of anti-inflammatory prostaglandins and leukotrienes. Higher amounts of fibre have been associated with lower levels of menstrual pain.38 High intakes of total and saturated fats and low unrefined carbohydrate and fibre consumption were also associated with dysmenorrhoea.39
Regulating blood sugar levels may be important in modulating hormonal status. It has been observed that PMS symptoms are worse in women with abnormal glucose tolerance.40 The body appears more sensitive to insulin during the luteal phase; this has led some researchers to theorise that hypoglycaemia may account for some premenstrual symptoms. Consumption of foods high in sugar content—particularly chocolate—may also increase the severity of menstrual symptoms.28 Regulating eating patterns may therefore help to improve dysmenorrhoea—eating breakfast was associated with a lower incidence of dysmenorrhoea41 as was a history of calorie-restrictive dieting.42 This relationship was also observed irrespective of BMI.43
Other lifestyle factors
Increased or regular exercise is associated with lower incidence of dysmenorrhoea and most other premenstrual symptoms.44–49 This may be due in part to the apparent hormone normalisation role of exercise or increased physical activity,50 or its effects on stress reduction in women with dysmenorrhoea.51 More detailed information on the effects of stress on reproductive function can be found in Chapter 20 on polycystic ovarian syndrome and Chapter 31 on fertility, preconception care and pregnancy.
A study of 380 women found that those with higher levels of stress were twice as likely to experience dysmenorrhoea in their cycle.52 Relaxation therapy through various meditative or relaxation techniques has been demonstrated to improve premenstrual symptoms and dysmenorrhoea.53,54
PMS supplements
Herbal medicines
Vitex agnus-castus has had demonstrated effect in the treatment of a variety premenstrual symptoms.55–58 V. agnus-castus reduces prolactin through its action on dopamine receptors.57–62 However, other studies have suggested a dose-dependent effect, as lower doses (120 mg) were found to increase secretion while higher doses (204–480 mg) were found to decrease secretion.63 It may also have effects on progesterone levels; one study has shown it can normalise progesterone levels in women with hyperprolactinaemia within 3 months61 while another has suggested it can stimulate progesterone receptor expression.64 Recent research has suggested that V. agnus-castus may exert activity in the opiate system, and the activation of mood regulatory and analgesic pathways via this system may be at least partly responsible for its efficacy in menstrual disorders.65
Cimicifuga racemosa is thought to modulate oestrogen levels by reducing LH secretion.66,67 Although no clinical studies are available it has a strong tradition of use in dysmenorrhoea and menstrual disorders and has been approved by Commission E for use in these conditions.34,35,68
Tea from the leaves of Rosa gallica has also been demonstrated to mildly improve dysmenorrhoea and other menstrual symptoms in women.69
