Prostaglandins in primary dysmenorrhea. Comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives

Nonsteroidal antiinflammatory drugs and reproduction

The role of nonsteroidal antiinflammatory drugs in human reproduction and reproductive disorders is reviewed. Nonsteroidal antiinflammatory drugs inhibit the biosynthesis of prostanoids and can cross the placental barrier into the fetal circulation. Nonsteroidal antiinflammatory drugs are the treatment of choice in primary dysmenorrhea and intrauterine contraceptive device-induced dysmenorrhea and menorrhagia. Nonsteroidal antiinflammatory drugs can be used for effective control of menorrhagia, preterm labor, and polyhydramnios and for prevention of preeclampsia, but larger definitive clinical trials are needed. Prostaglandin inhibition with some nonsteroidal antiinflammatory drugs appear promising in the relief of some premenstrual symptoms and in the prevention of postoperative pelvic adhesion formation, but more studies are needed in women. Whereas implantation and tubal mobility are mediated by local prostaglandins, the potential use of nonsteroidal antiinflammatory drugs to suppress prostaglandin in these reproductive processes for enhancing or reducing fertility warrants further studies. In the last 2 decades nonsteroidal antiinflammatory drugs have been used increasingly in the treatment of some reproductive disorders and are promising for many others.

Measurement of eicosanoids in menstrual fluid by the combined use of high pressure chromatography and radioimmunoassay

Methods are described for the quantification of various eicosanoids (cyclooxygenase products: 6-KETO, TXB2, PGE2, PGF2 alpha, DHK; lipoxygenase products: 5-, 12-, 15-HETE, LTB4, LTC4, LTD4, LTE4) in menstrual blood collected by tampons. Samples were extracted with acidified ethanol. After purification by SEP-PACK C18 columns, the compounds were separated by reversed phase HPLC using a ternary gradient system. The eicosanoid concentrations of the fractionated eluents were measured by radioimmunoassay and corrected for recovery. 12-HETE was the most prominent metabolite of arachidonic acid in menstrual blood (mean: 1174 ng/g blood). With the exception of PGF2 alpha and TXB2 (mean: 343 and 212 ng/g blood, respectively) other eicosanoids were detected in remarkable lower concentrations.

Mechanism of analgesic effect of clonidine in the treatment of dysmenorrhea

Clonidine substantially reduces the pain and cramping of dysmenorrhea. The mechanisms for this effect may lie in increased release of analgesic opioids. It is suggested that perhaps a thromboxane synthetase inhibitor such as ginger which activates endorphin receptors may also be an effective treatment.

Negative correlation of cigarette smoking and dysmenorrhea: reduced prostaglandin synthesis due to beta-endorphin, nicotine, or acrolein antagonism

It is suggested that the mechanism for decreased incidence of dysmenorrhea in female cigarette smokers may lie in the possible inhibition of algesic prostaglandins smoking induced stimulation of beta-endorphin, nicotine, or acrolein.

Eicosanoids in primary dysmenorrhea, endometriosis and menstrual migraine

This paper summarizes what has been learned over the years about the role of eicosanoids in the pathogenesis of primary dysmenorrhea, endometriosis and menstrual migraine. The role of prostaglandins (PGs) in the pathogenesis of primary dysmenorrhea is inferred from four main observations: firstly, the clinical symptoms of primary dysmenorrhea are similar to those induced by the administration of PGF2 alpha and PGE2 for the induction of labour; secondly, the increased production of PGs by the endometrium during the luteal and menstrual phases of ovulatory cycles is consistent with the occurrence of primary dysmenorrhea mainly in ovulatory cycles; thirdly, the concentrations of PGF2 alpha and PGE2 in the endometrium and menstrual fluid of dysmenorrheic women are significantly higher than in controls; fourthly, certain PG inhibitors have been proved to be effective in the treatment of dysmenorrhea. The change in PG production can explain the major symptoms of primary dysmenorrhea, including the increased uterine contractility, uterine ischemia and the lowering of the pain threshold to chemical and physical stimuli in the pelvic nerve terminals. Moreover, recent experimental data suggest that leukotrienes (LTs) might be among the alternative pathogenetic causes of primary dysmenorrhea. The data which support a relationship between eicosanoids and endometriosis are as follows: endometriotic tissue produces PGs; the peritoneal fluid concentration of PGF2 alpha increases significantly after the induction of endometriosis in laboratory animals; the concentration of PGs in peritoneal fluid of some patients with endometriosis is greater than in controls and, finally, the number and activation of pelvic macrophages which are able to synthesize eicosanoids increase in patients with endometriosis. Possible roles for eicosanoids in the pathogenesis of infertility and secondary dysmenorrhea induced by endometriosis have been suggested. Eicosanoids are probably also involved in the pathogenesis of menstrual migraine. Different types of PGs might play a role both in the initial vasoconstriction during the prodromal phase of migraine and in the vasodilation and sensitization to pain typical of the pain phase.

The effectiveness of activity scheduling and relaxation training in the treatment of spasmodic dysmenorrhea

The first purpose of this study was to examine the effectiveness of activity scheduling as a treatment for spasmodic dysmenorrhea, compared to relaxation training (a treatment of demonstrated effectiveness) and to a waiting-list control condition. The second purpose was to examine the differential effectiveness of these treatments on different measures. Forty women suffering from spasmodic dysmenorrhea completed six individualized treatment sessions or remained on the waiting list. Results showed that both activity scheduling and relaxation training were effective treatments for spasmodic dysmenorrhea, with both treatments producing improvements on general measures of dysmenorrhea, a symptom severity measure, and an activity measure.

Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea

Are adolescent women aware of the relatively specific pharmacologic intervention now available for dysmenorrhea? A multiple-choice questionnaire was administered to 182 adolescent women, ages 14-18 years, to assess the prevalence of dysmenorrhea, the morbidity associated with dysmenorrhea, and the level of knowledge regarding available treatment. Of the study group, 72.7% reported "pain or discomfort" during their period, 58.9% reported decreased activity, and 45.6% reported school or work absenteeism. Of the dysmenorrheic sample, only 15.5% had used a prescription medication and only 14.7% could name any nonsteroidal antiinflammatory agent, except aspirin, as potentially effective in relieving dysmenorrhea. These data suggest that there is substantial ignorance or misinformation among adolescent females regarding effective treatment for dysmenorrhea. The prevalence of school and work absenteeism provides evidence for the continuing importance of dysmenorrhea as a public health problem of this age group. Discussion of effective therapeutic options for dysmenorrhea should be part of routine health care visits for adolescent women.

Nonsteroidal anti-inflammatory drugs and changing attitudes toward dysmenorrhea

Dysmenorrhea, which may be primary or secondary, is the occurrence of painful uterine cramps during menstruation. Until a decade ago, medical and social attitudes toward dysmenorrhea were shrouded with folklore, psychoanalytical profiles, or psychosomatic bases. In secondary dysmenorrhea, there is a visible pelvic lesion to account for the pain, whereas only a biochemical abnormality is responsible for primary dysmenorrhea. Recent advances in the biochemistry of prostaglandins and their role in the pathophysiology of primary dysmenorrhea and intrauterine device (IUD)-induced dysmenorrhea have now firmly established a rational basis for the disorder. In primary dysmenorrhea, menstrual prostaglandin release is significantly increased but can be readily suppressed to normal levels when nonsteroidal anti-inflammatory drugs (NSAIDs) capable of inhibiting cyclo-oxygenase are given during menstruation. Many clinical trials (controlled and uncontrolled) have demonstrated the efficacy of NSAIDs such as the fenamates, indole-acetic acid derivatives, and arylpropionic acid derivatives in relieving primary dysmenorrhea as well as IUD-induced dysmenorrhea that is also due to elevated prostaglandin levels. With a few of these NSAIDs, it has been shown that the relief of pain is associated with a significant decrease in menstrual fluid prostaglandin levels. Cumulative data of clinical trials indicate that with the effective NSAIDs, 80 percent of patients with significant primary dysmenorrhea can be adequately relieved. Ongoing studies suggest that in some women, endometrial leukotriene, but not PGF2a production, is increased. With the official approval and availability of several effective NSAIDs for the specific treatment of primary dysmenorrhea in the United States, women who have primary dysmenorrhea have been greatly relieved and their productivity increased. Primary dysmenorrhea affects 50 percent of postpubescent women and absenteeism among the severe dysmenorrheics has been estimated to cause about 600 million lost working hours or 2 billion dollars annually. Thus, an effective, simple, and safe treatment of primary dysmenorrhea for two to three days during menstruation will not only have a positive economic impact but will also enhance the quality of life. The availability of effective dysmenorrhea therapy with NSAIDs has induced greater expectations of relief by the patient, as well as greater willingness to seek medical help, a more rational approach to patient management by physicians, changes in attitude toward women with primary dysmenorrhea, and the debunking of myths about dysmenorrhea that often have been perpetuated as fact.(ABSTRACT TRUNCATED AT 400 WORDS)

Ibuprofen is a useful treatment for primary dysmenorrhoea

A double-blind crossover placebo-controlled trial over 6 cycles in 38 Australian women has confirmed that ibuprofen is a valuable drug for the treatment of primary spasmodic dysmenorrhoea. This drug was highly effective when given in a dosage of one 400mg tablet at the first sign of pain or bleeding followed by further 400mg tablets every 4 to 6 hours for the duration of expected symptoms. Side-effects were mild and noted with equal low frequency during placebo treatment.

Grave anaphylactic-like reaction in the course of menstruation. A case report

The case of a woman with a serious anaphylactic pattern during menstruation is described. The patient had a clinical picture of urticaria, angioedema and shock at each menstruation for a period of 2 years until hysterectomy was performed. The studies showed no hormonal or immunological change. The only relevant finding was the extraordinarily strong vasodilating action of the menstrual fluid in the patient, and not in the controls. The results of the study suggest the possibility of two mechanisms: 1) an IgE-mediated mechanism causing hypersensitivity to some metabolic substance in the menstrual fluid and 2) an excessive pharmacological vasodilatory action produced by the prostacyclin in the fluid itself.

Flurbiprofen for the treatment of primary dysmenorrhea

Following the demonstration that increased prostaglandin F2 alpha production causes pain similar to dysmenorrhea, and the finding that prostaglandin synthetase inhibitors are capable of relieving menstrual pain, the early theory of uterine ischemia has once again gained support as the most likely explanation for this condition. In a double-blind, placebo-controlled, crossover study, 30 of 43 women with moderate to severe dysmenorrhea who completed the trial preferred flurbiprofen (Ansaid, Upjohn), a potent new analgesic/anti-inflammatory agent (50 mg four times daily), to aspirin (650 mg four times daily) and placebo. Flurbiprofen was also rated superior to aspirin and placebo in the degree of pain relief. An algorithm for the diagnosis and treatment of 90 percent of women with primary dysmenorrhea is presented.

The Effect of Cycle Phase on the Adolescent Swimmers

In brief: Performance times of six postmen-archeal adolescents who competed on junior and senior national levels were recorded during a 12-week period. The fastest times for the 100-yd freestyle and 100-yd best event occurred during the menstrual phase and the slowest times during the premenstruum. Symptoms were rated biweekly with the Moos Menstrual Distress Questionnaire. Subjects reported feeling better during menstruation than premenstruation, and none reported dysmenorrhea. Based on basal body temperature, five of ten cycles were clearly biphasic, two were monophasic, and three were possibly biphasic with very short luteal phases. These results, albeit from a small sample, suggest that menstrual cycle phase may affect athletic performance as measured by practice times.

Efficacy and quality of ibuprofen and acetaminophen plus codeine analgesia

Ibuprofen, 400 mg, was compared with 300 mg acetaminophen plus 30 mg of codeine and placebo in 120 post-orthopedic surgery patients with moderate to severe pain. The study was designed as a double-blind, single-dose, parallel-group analgesic efficacy assay. Estimates of analgesia were obtained up to 6 h using categorical and visual analog measures of pain intensity and pain relief. Estimates of selected elements of mood and of sensory and affective components of pain were obtained at 0 and 2 h using contrasting mood word/phrase pairs and a portion of the McGill Pain Questionnaire, respectively. Drugs were distinguishable from placebo in total analgesic effect, and ibuprofen was more effective than acetaminophen plus codeine, especially in terms of duration. While peak effects were comparable, they occurred 1 h later following ibuprofen. Differences among treatments were more discernible using visual analog measures. Side effects were minimal. Ibuprofen provided greater improvement in selected elements of mood than acetaminophen plus codeine at comparable levels of pain relief. While decreases in the sensory component of pain were most highly associated with pain relief provided by ibuprofen, decreases in the affective component were most highly associated with pain relief following acetaminophen plus codeine. These latter results indicate that mood assessment and the discrimination between sensory and affective components of pain could be particularly useful within analgesic drug assays, especially when comparing analgesics of differing pharmacologic class and when comparing the results of such assays in pain syndromes characterized by differing pain quality.

Photogrammetry used to assess post-operative facial swelling in a drug trial

A trial was designed to test the efficacy of ibuprofen in controlling post-operative pain and swelling following the surgical removal of lower third molar teeth. Because of the rigid criteria imposed on the trial it was not satisfactorily completed but the method of measuring the volume of the swelling by stereometric photogrammetry, which is reproducible, versatile and non-invasive, was considered to be worth reporting in context.

Menstrual-PGF2 alpha, PGE2 and TXA2 in normal and dysmenorrheic women and their temporal relationship to dysmenorrhea

Although it has been demonstrated that primary dysmenorrhea is associated with elevated levels of PGF2 alpha in the menstrual fluid, little is actually known of the menstrual-PG profiles of either dysmenorrheic or normal women. In this study, menstrual fluid from normal and dysmenorrheic women was collected from tampons and extracted for PG-like substances. The PGF2 alpha, PGE2 and TXA2 content was analyzed by RIA. This study demonstrates that dysmenorrheics have significantly higher levels/concentrations of menstrual-PGF2 alpha and PGE2 than do normal women, and that there is no difference in the menstrual-PGF2 alpha : PGE2 ratio between the two groups. Also, there is no significant difference in the amount/concentration of menstrual-thromboxane between dysmenorrheic and normal women. Of the parameters considered, the levels/-concentrations of menstrual-PGF2 alpha, PGE2 and TXA2, dysmenorrheic pain correlates best with the rate of menstrual-PGF2 alpha release.

Ibuprofen and dysmenorrhea

Primary dysmenorrhea and secondary dysmenorrhea induced by an intrauterine device are associated with increased production and release of endometrial prostaglandins. The condition may be treated by oral contraceptives, which reduce overall menstrual fluid volume, or by a prostaglandin synthetase inhibitor, such as ibuprofen. Unless the patient wishes to use oral contraceptives for birth control, ibuprofen (Motrin) is the drug of choice because it need only be given for two to three days each cycle, does not suppress the pituitary ovarian axis, and does not cause metabolic alterations. Clinical trials have shown ibuprofen to be highly efficacious, and more effective than indomethacin, aspirin, or propoxyphene, with no or few side effects.

Differential effects of ibuprofen and naproxen sodium on menstrual prostaglandin release and on prostaglandin production in the rat uterine homogenate

In two independent studies, ibuprofen and naproxen sodium were found to be equi-effective in alleviating dysmenorrheic symptoms. However, the effects of these drugs on menstrual PG release were found to be dissimilar. Ibuprofen primarily inhibited menstrual PGF2 alpha release with little effect on PGE2 release, whereas, naproxen sodium inhibited both PGF2 alpha and PGE2 release equally. To verify these results, we determined the inhibitory potency, IC50, of ibuprofen and naproxen sodium on PGF2 alpha and PGE2 synthesis in the rat uterine homogenate system. The preferential PGF2 alpha inhibitory activity of ibuprofen was confirmed. These findings suggest that ibuprofen may, in addition to inhibiting fatty acid cyclooxygenase, also inhibit PGF2 alpha reductase, or some other PG metabolic pathways which affect PGF2 alpha and PGE2 synthesis differently. The significance of this differential PG synthesis inhibitory effect in dysmenorrheic therapy is discussed.

Therapeutic management of primary dysmenorrhea

Primary dysmenorrhea is a common gynecologic disorder. Dysmenorrheic pain normally has an onset of from 2-12 hours before the start of menses and tapers over the next one to two days. Although the exact etiology is unknown, this condition is associated with an increase in prostaglandin F2 alpha. In the past, nonspecific treatments such as heat and exercise were tried, with poor results. Little relief was offered by antispasmodics or low-dose aspirin. Currently, effective therapy for primary dysmenorrhea includes oral contraceptives and prostaglandin synthetase inhibitors. Oral contraceptives should be prescribed only for women who desire contraception and who are candidates for this type of therapy. Prostaglandin synthetase inhibitors can be given to women who do not desire oral contraceptives or those who do not respond to hormonal therapy. Secondary dysmenorrhea should be suspected in women who do not respond to either treatment modality.

Nonrheumatologic uses of NSAIDS

Nonsteroidal antiinflammatory drugs (NSAIDs) have several salient indications outside of their role in rheumatology. Two major uses are treatment of dysmenorrhea and patent ductus arteriosus. Other established roles encompass treatment of fever, pain, Bartter's syndrome, and thromboembolic disorders. Animal and human studies are being done on the use of NSAIDs in cancer, diabetes, psoriasis, and shock, just to name a few investigative areas. NSAIDs are not a panacea nor are they wonder drugs to be used indiscriminately. When these drugs first were marketed in the 1970s, they were considered safe agents with little toxicity. However, the side-effect profile of the NSAIDs has been, and continues to be, better identified over the past few years and warrants judicious use of these drugs. Their adverse effects potentially include gastric distress (possibly hemorrhage), allergic urticaria or bronchospasm in asthma patients, azotemia, arrested labor, skin reactions, and water retention. NSAIDs are relatively safe agents with a growing list of new indications. Future clinical evaluation holds the key to the balance between their emerging toxicities and indications.

Prostaglandin synthetase inhibitors in the treatment of primary dysmenorrhea. Outcome trials reviewed

Clinical trials of prostaglandin synthetase inhibitors (PGSIs) prescribed for the treatment of primary dysmenorrhea were reviewed as to pain relief effectiveness, frequency and nature of side effects, and methodological adequacy. The review investigated 51 PGSI trials for a total of 1,649 women and 682 menstrual cycles and found that, over all, 72% of dysmenorrheic women reported significant pain relief to PGSI, 18% reported minimal or no pain relief, and 15% showed placebo response. Comparisons among the fenamatic compounds, ibuprofen, indomethacin, and naproxen showed the fenamates to be more effective in providing pain relief. PGSI-associated side effects were minimal for all PGSIs with the exception of indomethacin. Results were evaluated with respect to several methodological problems. Conclusions were drawn that despite these shortcomings, PGSIs are undoubtedly effective and safe for the majority of women with primary dysmenorrhea.

Influence of certain prostaglandin synthetase inhibitors on cytoplasmic estrogen receptors in the uterus

Prostaglandin synthetase inhibitors are widely used in the treatment of primary dysmenorrhea. They are thought to act by inhibiting endometrial synthesis of prostaglandins and subsequently altering endometrial receptor concentration. Since prostaglandins are known to vary with the menstrual cycle in women, implicating an effect associated with sex steroid hormones, we examined the influence of certain prostaglandin synthetase inhibitors on specific estrogen binding capacity of uteri from rats. Ibuprofen (Motrin), 25 mg/kg, indomethacin (Indocin), 15 mg/kg, mefenamic acid (Ponstel), 25 mg/kg, and sulindac (Clinoril), 40 mg/kg, were evaluated at 6 and 24 hours after injection. Specific estrogen-binding capacity was elevated twofold by mefenamic acid; the other agents showed no statistically significant effect. No alteration in the dissociation constant values of the estrogen receptors was observed with these agents. These data suggest that prostaglandin synthetase inhibitors do not influence the estrogen response mechanism in rodents.

Stressful life events and perimenstrual symptoms

The purpose of this study was to determine whether the effects of stressful life events on perimenstrual symptoms were due to operational confounding of the instruments used to measure the independent and dependent variables. Women aged 18 to 35 (n = 179) completed the Schedule of Recent Events (SRE) and the Moos Menstrual Distress Questionnaire during a home interview. When variance in PMS scores attributable to age, parity, education, and contraceptive method was controlled using hierarchical multiple regression, total SRE scores were correlated with premenstrual and menstrual negative affect, menstrual water retention, and menstrual performance impairment. When health-related components of the SRE score were controlled in a similar manner, however, the residual SRE scores explain a diminished amount of the variance in premenstrual and menstrual negative affect and menstrual performance impairment. Future investigations are needed to clarify whether the effects of health-related life events on perimenstrual symptoms are simply a matter of operational confounding of measures of the independent and dependent variables, or whether women who recently have experienced personal illness or injury are at greater risk of developing perimenstrual symptoms.

Evaluation of the analgesic efficacy of ibuprofen

Ibuprofen is a derivative of propionic acid that was originally marketed in the United States as an antirheumatic agent in 1974. In 1979, it was approved for use as an analgesic. Of the 18 published double-blind clinical trials reviewed, only 6 were well designed. These six studies provide strong evidence that ibuprofen is effective for dental pain due to tooth extractions, dysmenorrhea and episiotomy pain. Thus, ibuprofen appears to be an effective drug for mild to moderate pain. It is as effective or more effective than aspirin, codeine or propoxyphene. Recommended initial dosage is 300 mg every six hours, increasing as needed to 400 mg every four hours. Adverse effects are relatively minor and infrequent.