Menstrual Pain (PMS) Management

There is no single treatment or known cure for PMS, the woman should chart her symptoms so she can possibly anticipate and therefore cope with them. Exercise is encouraged for all patients as noncontrolled studies have shown a benefit. Many practitioners advise women to avoid caffeine, high-fat food, and refined sugars, but there is little research to demonstrate the efficacy of dietary changes. Alternative therapies that include vitamins B and E, magnesium, and oil of evening primrose capsules. No studies have evaluated the effectiveness of these therapies.

Pharmacologic remedies include selective serotonin reuptake inhibitors, gonadotropin-releasing hormone antagonists, prostaglandin inhibitors, and anxiety agents. Some clinicians prescribe analgesic agents, diuretic medications, and natural and synthetic progesterones, although the long-term risks of progesterone use are unknown.

Many women find over-the-counter carbohydrate products useful; they provide complex carbohydrates along with vitamins and minerals. Ratios of serum levels of tryptophan to other amino acids are elevated in patients who use tryptophan. It may relieve psychological symptoms and food cravings. Calcium (1,200mg/day) has been found to be effective, as has magnesium (200 to 400 mg/day).

The patient's goals may include reduction of anxiety (mood swings, crying, binge eating, fear of losing control), ability to cope with day-to-day stressors and relationships with family and coworkers, and increased knowledge about PMS with improved use of control measures.

Positive coping measures are facilitated. Partners can be advised to assist by offering support and increased involvement with childcare. The patient can try to plan her working time to accommodate the days she will be less productive because of PMS.

If the patient has severe symptoms of PMS or premenstrual dysphoric disorder, assessment is crucial for suicidal, uncontrollable, and violent behavior. Any suggestions of suicidal tendencies must be evaluated by psychiatric consultation immediately.

Uncontrollable behavior may lead to violence toward family members. If abuse of children or other members of the patient's family suspected, reporting protocols are implemented and followed. Referral is made for immediate psychiatric or psychological care and counseling.

Primary dysmenorrhea is painful menstruation, with no identifiable pelvic pathology. It occurs at the time of menarche or shortly thereafter. It is characterized by crampy pain that begins before or shortly after the onset of menstrual flow and continues for 48 to 72 hours. Pelvic examination findings are normal. Dysmenorrhea is thought to result from excessive production of prostaglandins, which causes painful contraction of the uterus and arteriolar vasospasm. Psychological factors, such as anxiety and tension, may contribute to dysmenorrhea. As women grow older, dysmenorrhea often decreases and frequently completely resolves after childbirth.

In secondary dymenorrhea, pelvic pathology such as endometriosis, tumor, or pelvic inflammatory disease (PID) exists. Patients with secondary dysmenorrhea frequently have pain that occurs several days before menses, with ovulation, and occasion-ally with intercourse.

In primary dysmenorrhea, the reason for the discomfort is explained, and the patient is assured that menstruation is a normal function of the reproductive system. If the patient is young and accompanied by her mother, the mother may also need assurance. Many young women expect to have painful periods if their mothers did. The discomfort of cramps can be treated once anxiety and concern over its cause are dispelled by adequate explanation. Symptoms usually subside with appropriate medication. Aspirin, a mild prostaglandin inhibitor, may be taken at recommended doses every 4 hours. Other useful prostaglandin antagonists include NSAIDs such as ibuprofen and mefenamic acid.

If one medication does not provide relief, another may be recommended. Usually these medications are well tolerated, but some women experience gastrointestinal side effects. Contraindications include allergy, peptic ulcer history, and sensitivity to aspirin-like medications, asthma, and pregnancy. Low-dose oral contraceptives provide relief in more than 90% of patients and are indicated in women with dysmenorrhea who are sexually active but do not desire pregnancy. Continuous low-level heat has recently been found to be effective in treating primary dysmenorrhea and may be as effective as medication.