Dysmenorrhea

Dysmenorrhea and Exercise

Anecdotal claims assert that physical activity alleviates symptoms of dysmenorrhea. Lay magazines and websites often include these statements. A comprehensive review of the literature in 2008 showed no well-designed studies to prove these claims. Many studies cited had methodological flaws and contradictory results. Yet the belief remains popular. As exercise does not adversely affect symptoms or menstrual irregularities and exercise has numerous other physical and emotional benefits, patients should be encouraged to maintain their routine as tolerated. The dysmenorrheic athlete should be evaluated and treated similarly as a sedentary individual.

Etiology of Primary Dysmenorrhea

The physiologic etiology is generally attributed to the effects of prostaglandins, specifically PGF2α and PGE. These compounds are released during the second half of a woman's menstrual cycle as a result of falling hormone levels. They are linked to uterine contractions, decreased uterine blood flow, and increased sensitization of pain fibers. As the prostaglandins distribute through the systemic blood stream, they also affect other organ systems. Medical inhibition of prostaglandin synthesis leads to reduction of symptoms.

Behavioral factors can also influence the disease course. Stress can lead to worsening of symptoms. Cultural taboos surrounding the menstrual cycle can influence associated behaviors. Benefits of secondary gain (e.g., time off work) can also be considered. The incidence of dysmenorrhea increases significantly among relatives. Whether this is related to a genetic predisposition or learned behavior is not known.

Clinical Evaluation

A thorough history and physical examination are essential during the initial evaluation. The medical history should include age at menarche, menstrual cycle length and regularity, sexual and obstetric history, risk factors for sexually transmitted infections, and whether the patient had previously undergone abdominal or pelvic surgery. Additionally, family history and evidence of increased psychological stress are important keys to the underlying etiology.

The physical exam should include a brief evaluation of major organ systems and should focus on the abdomen and pelvis. By definition, the examination [Page 394]of a patient with primary dysmenorrhea will be normal. During the pelvic exam, attention should be paid to signs of secondary etiologies. A scarred external cervical os may indicate cervical stenosis. Inflammation and purulent discharge suggest infection, and appropriate cultures should be taken. Occasionally, the clinician may see tissue consistent with endometriosis in the vagina or on the cervix, which implies more extensive pelvic involvement. A bimanual exam may reveal reproductive tract abnormalities or abnormal pelvic masses.

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