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

The Influence of the Menstrual Cycle on Electrical Thresholds for Sensory and Pain Perception: Implications for Exercise and Rehabilitation in Women With and Without Primary Dysmenorrhea-A Pilot Study

Background: Hormonal fluctuations during the menstrual cycle (MC) influence pain perception, potentially affecting exercise performance and rehabilitation in women. This effect may be more pronounced in individuals with primary dysmenorrhea (PD), requiring tailored physiotherapeutic and exercise interventions. Objective: To analyze the influence of MC phases on sensory electrical threshold (SET) and pain electrical threshold (PET) in eumenorrheic women with and without PD, considering the potential implications for physical activity and rehabilitation. Methods: An observational longitudinal study was conducted with 34 physically active women, divided into a control group (CG) and a PD group. SET and PET were measured using transcutaneous electrical nerve stimulation (TENS) at the forearm (peripheral site) and lower abdomen (pain-referred site) across five MC phases. Pain intensity was assessed using a Visual Analog Scale (VAS). Results: SET and PET were significantly lower in the premenstrual phase (p < 0.001), suggesting increased pain sensitivity. VAS scores were higher in the PD group during all phases, except for the follicular phase (p < 0.033), with the highest pain levels recorded in the menstrual and premenstrual phases. While no significant differences in SET and PET were found between groups across most phases, the PD group exhibited a significantly higher SET in the forearm during the premenstrual phase (p = 0.005), potentially indicating altered central pain modulation. Conclusions: MC-related hormonal fluctuations affect pain sensitivity, particularly in women with PD. These findings underscore the need for phase-specific exercise adaptations and rehabilitation strategies to improve performance, pain management, and recovery in physically active women.

Does an alternate-day modified fasting diet improve premenstrual syndrome symptoms and health-related quality of life in obese or overweight women with premenstrual syndrome? A randomized, controlled trial

Background

Premenstrual syndrome disorder (PMS) is a condition that affects health-related quality of life (HRQoL) and encompasses a variety of symptoms, including psychological, physical, and behavioral symptoms. Some evidence suggests that an increase in body mass index (BMI) can reduce both HRQoL and menstrual quality. This is because the body fat tissue can affect menstrual cycles by changing the estrogen/progesterone ratio. This study investigated the impact of two diets alternate-day modified fasting (ADMF) and daily calorie restriction (DCR) - on PMS syndrome and HRQoL.

Methods

The study was a randomized controlled, open-label trial that lasted for 8 weeks and involved 60 obese/overweight women. Participants were recruited from the Health Service Centers of Kashan University of Medical Sciences using simple random sampling. The study compared the impact of the ADMF and DCR diets on HRQoL and PMS symptoms. Patients were classified based on their BMI and age and then allocated to either the intervention (ADMF) or control (DCR) group using a random numbers table. The study measured HRQoL, PMS severity, weight, BMI, body fat mass, waist circumference, fat-free mass, and skeletal muscle mass before and after the study. The study had an almost 18% dropout rate.

Results

Significant improvements were observed in mood lability (p = 0.044) and expressed anger (p < 0.001) in relation to PMS symptoms. However, no significant differences were detected in the changes of other COPE subscales. The ADMF diet had a significant impact on the 12-item Short-Form Health Survey (SF-12) total score (p < 0.001) and physical function subscales (p = 0.006) as well as mental health (p < 0.001) when compared to the control diet. This implies that the ADMF diet increased both SF-12 total score and its subscales. The intervention led to improvements in HRQoL, physical function, and mental health. Additionally, significant improvements in BMI and weight were observed between the two groups pre- and post-study (p < 0.001). Anthropometric data, including body fat mass and waist circumference, showed a significant improvement (p < 0.001 and p = 0.029, respectively) before and after the study. However, there were no significant changes in fat-free mass (p = 0.936) and skeletal muscle mass (p = 0.841) between the two groups.

Conclusion

The study suggested that ADMF can improve HRQoL, mood lability, and expressed anger. It also showed that ADMF can reduce waist circumference, weight, and body fat mass in obese/overweight women.

Clinical trial registration

The Iranian Registry of Clinical Trials (IRCT20220522054958N1).

Scientific Knowledge Graph of Dysmenorrhea: A Bibliometric Analysis from 2001 to 2021

Purpose

This study aims to help researchers master the most active hotspots and trends quickly through bibliometric analysis in the field of dysmenorrhea.

Methods

We retrieved literature on Web of Science from 2001 to 2021, and bibliometric analysis software CiteSpace was used in combination with VOSviewer.

Results

We finally acquired 944 papers and an upward trend in articles continued in this field overall. Through the map, China contributed the most, followed by the USA and Turkey. For institutions, Beijing University of Chinese Medicine in China contributed the most, followed by National Yang-Ming University in Taiwan, China. Hsieh JC and Hellman KM were both the most prolific authors with 14 articles. Five major research groups, respectively, with Hsieh JC, Hellman KM, Zhu J, Liang F and Dun W were the key group. Dawood MY was the most dominant author and most frequently cited author. The Cochrane Database of Systematic Reviews Journal was the most productive, and the Fertility and Sterility Journal was the most cited. Advances in pathogenesis and management for primary dysmenorrhea written by Dawood MY was most cited and influential. Pathophysiology, the potential central mechanism, syndrome, evaluation index, diagnosis of adenomyosis-associated dysmenorrhea, treatment, etc., were the main trends and hotspots.

Conclusion

Dysmenorrhea research has received a lot of attention from scholars. Strengthening international cooperation may promote the development of this field. The pathophysiology of dysmenorrhea, its impact on public health and its treatment are current research hotspots and are likely to be the focus of future study.

Effect of modified alternate day fasting diet on the severity of premenstrual syndrome and health-related quality of life in women with overweight or obesity: a trial study protocol

INTRODUCTION

Premenstrual syndrome (PMS) includes a range of physical, behavioural and psychological symptoms and decreases women's health-related quality of life (HRQoL). It has been proposed that increased body mass index (BMI) is associated with menstrual problems and decreased HRQoL. The body fat amount plays a role in menstrual cycles by altering the oestrogen/progesterone ratio. Alternate day fasting as an unusual diet results in the improvement of anthropometric indices and reduction of body weight. This study aims to investigate the effect of a daily calorie restriction diet and a modified alternate day fasting diet on PMS and HRQoL.

METHODS AND ANALYSIS

This 8-week open-label parallel randomised controlled trial examines the impact of a modified alternate-day fasting diet and daily caloric restriction on the severity of PMS and HRQoL in obese or overweight women. Using simple random sampling, women between the ages of 18 years and 50 years and 25 ≤ BMI ˂ 40 who meet the inclusion and exclusion criteria will be chosen from the Kashan University of Medical Sciences Centre. Patients will be randomised, based on BMI and age through stratified randomisation. Then by the random numbers table, they are allocated to fasting (intervention) or daily calorie restriction (control) groups. Outcomes are chosen for the trial: the difference in the severity of PMS, HRQoL, BMI, body fat mass, fat-free mass, waist-to-hip ratio, waist circumference, hip circumference, per cent body fat, skeletal muscle mass and visceral fat area from baseline to 8 weeks.

ETHICS AND DISSEMINATION

The Kashan University of Medical Sciences Ethics Committee has approved the trial (IR.KAUMS.MEDNT.REC.1401.003) (17 April 2022). Results will be published in peer-reviewed academic journals and the participants will be informed via phone calls.

TRIAL REGISTRATION NUMBER

IRCT20220522054958N1.

The effect of a probiotic on gastrointestinal symptoms due to menstruation in healthy adult women on oral contraceptives: randomized, double-blind, placebo-controlled trial protocol

Introduction

For many women, uncomfortable and stressful symptoms accompany the menstrual cycle each month, sometimes in a debilitating manner. Previous studies have reported that gastrointestinal symptoms in healthy women significantly differ by the day of the menstrual cycle, but few studies have assessed interventions intended to minimize these symptoms. Probiotics supplements have been shown to attenuate gastrointestinal symptom severity as well as self-reported feelings of stress in various populations. This study evaluates the effect of a probiotic on abdominal pain and gastrointestinal symptoms in healthy women who take an oral contraceptive, have regular menses, and typically experience these symptoms during menstruation with the primary aim being change in abdominal pain intensity related to the menstrual cycle with probiotic versus placebo supplementation.

Methods and analysis

In this randomized, double-blind, placebo-controlled parallel study, participants will receive either a probiotic or placebo supplement. Participants will begin answering questionnaires approximately 7 days before the start of menstruation (i.e., active bleeding), and 3 days later, they will begin consuming the study supplement for 8 weeks. The questionnaires administered will collect data about abdominal pain severity (primary outcome) and duration related to the menstrual cycle, digestive health, dietary intake, stress, and digestion-associated quality-of-life. A subgroup of women will provide weekly vaginal swabs and stool samples to examine the effect of the probiotic supplement on microbiota composition and diversity for exploratory purposes. Two-sided tests using a linear model and a type I error rate of α = 0.05 will be employed to test all hypotheses. Continuous variables will be presented as means with standard errors and categorical variables, as counts or proportions.

Ethics and dissemination

This study was reviewed and approved by the University of Florida Institutional Review Board 01. Written informed consent will be obtained from all participants prior to any study activities. Study findings will be disseminated at scientific conferences and publication in the trial registry or in a peer-reviewed journal. Any protocol amendments will be reported in the final manuscript of this study.

Trial registration

ClinicalTrials.gov NCT04457401. Registered prospectively on 07 July 2020. The trial was completed in December of 2021.

Protocol version

V4.0 (11-04-2020)

Trial status

Currently recruiting. Recruitment began in November 2020 and extend until December 2021.

A one-year observational cohort study of menstrual cramps and ovulation in healthy, normally ovulating women

This is a prospective, observational community cohort study with the objective of investigating menstrual cramp occurrence related to ovulatory characteristics. Women reported cramp intensity on daily Menstrual Cycle Diary© records over one year. Ovulation and luteal phase lengths were assessed by validated Quantitative Basal Temperature© (QBT) analysis. Healthy, normal-weight, non-smoking community dwelling premenopausal women ages 21-41 years with two consecutive, normally ovulatory, normal-length menstrual cycles were enrolled. All 53 women, with 13.6 ± 2.8 cycles per woman, reported at least one cramp episode of median intensity 1.5 [0-4 scale; range 1.0-3.5], and 2.2 days' [range 1.0-10.2] duration. Within the 49 women who experienced all ovulatory cycle types (normal, short luteal length [SLL < 10 days] and anovulatory), median cramp intensity was greater in normal-length cycles having subclinical ovulatory disturbances (SLL and anovulatory; median 1.4 [range 0.0-2.8]) than in normally ovulatory cycles (median 1.2 [range 0.0-2.3]) (P = 0.023). Cramp Scores did not differ by ovulatory status within the 19 women having both normally ovulatory and anovulatory cycles (P = 0.222). Within-woman 1-year Cramp Scores were not different in anovulatory and normally ovulatory menstrual cycles but were more intense with ovulatory disturbances.

Adjuvant use of melatonin for pain management in dysmenorrhea - a randomized double-blinded, placebo-controlled trial

Purpose

Dysmenorrhea is a common, recurring, painful condition with a global prevalence of 71%. The treatment regime for dysmenorrhea includes hormonal therapies and NSAID, both of which are associated with side effects.

A dose of 10 mg melatonin daily has previously been shown to reduce the level of pelvic pain in women with endometriosis. We chose to investigate how this regime, administered during the week of menstruation, would affect women with dysmenorrhea but without any signs of endometriosis, as adjuvant analgesic treatment.

Methods

Forty participants with severe dysmenorrhea were randomized to either melatonin or placebo, 20 in each group. Our primary outcome was pain measured with numeric rating scale (NRS); a difference of at least 1.3 units between the groups was considered clinically significant. Secondary outcomes were use of analgesics, as well as absenteeism and amount of bleeding. Mixed model was used for statistical analysis.

Results

Eighteen participants completed the study in the placebo group and 19 in the melatonin group. Mean NRS in the placebo group was 2.45 and 3.18 in the melatonin group, which proved to be statistically, although not clinically significant.

Conclusion

This randomized, double-blinded, placebo-controlled trial could not show that 10 mg of melatonin given orally at bedtime during the menstrual week had better analgesic effect on dysmenorrhea as compared with placebo. However, no adverse effects were observed.

Clinical trials

NCT03782740 registered on 17 December 2018.

Regulation of Mild Moxibustion on Uterine Vascular and Prostaglandin Contents in Primary Dysmenorrhea Rat Model

Objective

Primary dysmenorrhea (PD) is a common and high incidence disease in gynecology, which seriously affects the quality of life in young women. Our previous study found that mild moxibustion could treat abdominal pain of PD patients, but the mechanism is still unclear. Therefore, this study aims to partly investigate the treatment mechanism of moxibustion for PD, especially on uterine microcirculation.

Methods

Forty 3-month-old Sprague Dawley female rats were randomly divided into four groups, including group A (saline control group, n = 10), group B (control plus moxibustion group, n = 10), group C (PD model group, n = 10), group D (PD. model plus moxibustion group, n = 10). The PD rat model was established by injecting estradiol benzoate and oxytocin. Mild moxibustion on Sanyinjiao (SP6) and Guanyuan (CV4) acupoints was once a day, 20 minutes per time, for 10 consecutive days. A vaginal smear was used to test the estrous cycle of rats. Uterine microvascular thickness was observed by stereomicroscope. And we detected the content of prostaglandin F_2α (PGF_2α ) and prostaglandin E₂ (PGE₂) in uterine tissue by enzyme-linked immunosorbent assay.

Results

Mild moxibustion can enlarge the microvessels, improve the microcirculation disturbance, and relieve the swelling of the uterus in PD rats. During the mild moxibustion intervention, the contents of PGF_2α and PGE₂ in uterus issues were synchronous increases or decreases and the changes of PGE₂ were more obvious, but the changes of uterine microvasculature and morphology caused by the decrease of PGF_2α were greater than PGE₂.

Conclusion

Mild moxibustion at SP6 and CV4 acupoints may relax uterine microvascular obstacle by reducing the content of PGF_2α in uterine tissue, improve the microcirculation disorder, and then alleviate the PD rat's uterine swelling.

The Relationship Between Androgens and Days per Month of Period Pain, Pelvic Pain, Headache, and TLR4 Responsiveness of Peripheral Blood Mononuclear Cells in Young Women with Dysmenorrhoea

Purpose

Women bear a disproportionate burden of persistent pain conditions when compared to men. To determine whether the hormonal environment affects the clinical experience of pain, as measured by the days per month of pelvic pain (DPelvicPM), period pain (DPeriodPM), headache (DHeadachePM) or the in vitro EC₅₀ for Interleukin-1β (IL-1β) release following TLR4 stimulation with Lipopolysaccharide from Peripheral Blood Mononuclear Cells (PBMCs). Findings were stratified according to use or non-use of the oral contraceptive pill.

Patients and Methods

Fifty-six women aged 16–35 years, with minimal or severe dysmenorrhea, and use or non-use of the OC, were enrolled. Blood was collected on two occasions in a single menstrual cycle: Days 1–2 and Days 7–10. Hormonal analysis for testosterone, dihydrotestosterone, dehydroepiandrosterone, Androstenedione, 3α-Androstanediol, 3β-androstanediol, estradiol, estrone, 17α-hydroxyprogesterone, progesterone, cortisol and sex-hormone binding globulin was undertaken using ultra-sensitive Liquid Chromatography Mass–Spectrometry (LC-MS). PBMCs were exposed to lipopolysaccharide (LPS) and the resulting Interleukin-1β output was determined.

Results

Non-users of the OC showed a strongly inverse correlation between a reducing free androgen index (FAI) and increasing DPelvicPM (p=0.0032), DPeriodPM (p=0.013), DHeadachePM (p=0.041). Non-users of the OC showed a significant increase in DPelvicPM (p=0.049) on Days 7–10. Modestly significant associations were found between reduced androgens and potentiated LPS-induced IL-1β (lower EC₅₀).

Conclusion

This is the first study to investigate the relationship between the hormonal environment and activation of the immune system in young women with dysmenorrhoea-related pain conditions. Low androgen levels were consistently associated with increased pain. Translational implications for the findings are discussed.

Ultrasound Assessment of the Abdominal Wall Muscles in Women with and without Primary Dysmenorrhea: A Cross-Sectional Study

Background: Primary dysmenorrhea (PD) is one of the most common gynecological disorders in women of reproductive age that may affect quality of life. It is believed that the underlying cause of PD may be the excessive production of prostaglandins (PGs), however, between 20%–25% of women with PD did not respond to pharmacological treatments, showing that nociceptive mechanisms underlying PD are still not understood. The purpose of this study was to measure and compare, through the use of ultrasound imaging, the thickness at rest of the abdominal wall, as well as the interrecti distance (IRD), in women with and without PD. Methods: A cross-sectional study has been performed using ultrasound imaging (USI) to measure the resting thickness of the external oblique (EO), internal oblique (IO), transversus abdominis (TrAb), rectus abdominis (RA), as well as the IRD in a sample of 39 women, 19 with PD and 20 without PD (median ± IR age: 20 ± 4 and 22.5 ± 7 years, respectively). Results: Findings of muscular thickness did not reveal statically significant differences (p < 0.05) in EO, IO, TrAb, RA, and the IRD between the PD group and control group. Conclusions: These findings suggest that the thickness of the abdominal wall is not associated with PD.

Prevalence and impact of dysmenorrhea in Swedish adolescents

INTRODUCTION

The objective of this study was to estimate the prevalence of dysmenorrhea among adolescents and its effect on daily life.

MATERIAL AND METHODS

A web-based questionnaire with questions regarding menstrual symptoms was distributed to all girls born in 2000 and residing in Stockholm City (n = 3998). Questions regarding pain severity, other menstrual-related symptoms, medical treatment, healthcare visits, and social and academic absenteeism were included in the questionnaire.

RESULTS

A total of 1785 (45%) young women responded to the questionnaire. Of these, 1580 (89%, 95% CI 87-90) stated that they had dysmenorrhea. Severe dysmenorrhea, scores 8-10 on the numeric rating scale for pain, was reported by 574 of 1580 women (36%, 95% CI 34-39). Fatigue was reported by 1314 of 1580 women (83%, 95% CI 81-85), headache by 1296 (82%, 95% CI; 80-84), dyschezia by 578 (37%, 95% CI 34-39) and dysuria by 560 (35%, 95% CI 33-38). A suboptimal use of analgesics was reported. Hormonal therapy as pain treatment was used by 10% (157/1580, 95% CI 9-12). Healthcare facilities, including school nurses, had been visited by 525 of 1580 women (33%, 95% CI; 31-36). Doctors had been consulted by 7% (116/1580, 95% CI 6-9). Fifty-nine percent (930/1580, 95% CI 56-61) reported refraining from social activities due to dysmenorrhea. Absenteeism from school was reported to occur monthly by 228 of 1580 women (14%, 95% CI 13-16), and several times per year by 716 (45%, 95% CI 43-48).

CONCLUSIONS

Our findings demonstrate that menstrual pain is prevalent among teenagers in Stockholm. The results indicate that many women are disabled in their daily life and that only a small number of women seek medical attention, although possible selection bias might have affected the results. Information and education are needed to optimize the use of existing treatment options and more awareness is needed to reduce normalization of disabling dysmenorrhea.

Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment

Although nonsteroidal antiinflammatory drugs can alleviate menstrual pain, about 18% of women with dysmenorrhea are unresponsive, leaving them and their physicians to pursue less well-studied strategies. The goal of this review is to provide a background for treating menstrual pain when first-line options fail. Research on menstrual pain and failure of similar drugs in the antiplatelet category suggested potential mechanisms underlying nonsteroidal antiinflammatory drug resistance. Based on these mechanisms, alternative options may be helpful for refractory cases. This review also identifies key pathways in need of further study to optimize menstrual pain treatment.

Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs for patients with primary dysmenorrhea: A network meta-analysis

Objective Non-steroidal anti-inflammatory drugs are used as first-line treatment of primary dysmenorrhea, but there has been no optimal clinical choice among non-steroidal anti-inflammatory drugs yet. The present study was to assess the relative benefits of different common non-steroidal anti-inflammatory drugs for primary dysmenorrhea patients with a network meta-analysis. Methods Randomized controlled trials were screened by our criteria and included in the network meta-analysis. Pain relief was considered as primary outcomes and adverse effect was supplied as a safety outcome, while additional rescue, assessment score, and pain intensity difference were secondary outcomes. All the indexes were evaluated with odds ratio or standardized mean difference. Surface under cumulative ranking curve result was used to calculate the ranking of each treatment. Results Totally, 72 randomized controlled trials of 5723 patients and 13 drugs were included in our study after screening. As for pain relief, all drugs except nimesulide, rofecoxib, and waldecoxib were superior to aspirin (odds ratio with 95% credible intervals, diclofenac: 0.28 (0.08, 0.86), flurbiprofen: 0.10 (0.03, 0.29), ibuprofen: 0.32 (0.14, 0.73), indomethacin: 0.21 (0.07, 0.58), ketoprofen: 0.25 (0.10, 0.64), mefenamic acid: 0.28 (0.09, 0.87), naproxen: 0.31 (0.15, 0.64), piroxicam: 0.15 (0.03, 0.59), and tiaprofenic acid: 0.17 (0.04, 0.63)). Aspirin also required additional rescue when compared with the majority of other drugs (flurbiprofen: 3.46 (1.15, 11.25), ibuprofen: 6.30 (2.08, 20.09), mefenamic acid: 7.32 (1.51, 37.71), naproxen: 2.66 (1.17, 6.55), and tiaprofenic acid: 9.58 (1.43, 94.63)). As for assessment of the whole treatment, ketoprofen, naproxen, rofecoxib, and ibuprofen got higher score significantly than placebo. In addition, ibuprofen performed better than placebo in pain intensity difference. Considering the safety, tiaprofenic acid and mefenamic acid were noticeable in low risk, and indomethacin revealed higher risk than any other drugs. According to the results of network analysis and surface under cumulative ranking curve, flurbiprofen was considered to be the best one among all the treatments in efficacy, and aspirin was worse than most of others. On the other hand, tiaprofenic acid and mefenamic acid were indicated as the safest drugs. Conclusion Considering the efficacy and safety, we recommended flurbiprofen and tiaprofenic acid as the optimal treatments for primary dysmenorrhea.

Common variants in ZMIZ1 and near NGF confer risk for primary dysmenorrhoea

Primary dysmenorrhoea, defined as painful menstrual cramps in the absence of pelvic pathology, is a common problem in women of reproductive age. Its aetiology and pathophysiology remain largely unknown. Here we performed a two-stage genome-wide association study and subsequent replication study to identify genetic factors associated with primary dysmenorrhoea in a total of 6,770 Chinese individuals. Our analysis provided evidence of a significant (P<5 × 10⁻⁸) association at rs76518691 in the gene ZMIZ1 and at rs7523831 near NGF. ZMIZ1 has previously been associated with several autoimmune diseases, and NGF plays a key role in the generation of pain and hyperalgesia and has been associated with migraine. These findings provide future directions for research on susceptibility mechanisms for primary dysmenorrhoea. Furthermore, our genetic architecture analysis provides molecular support for the heritability and polygenic nature of this condition.

Primary dysmenorrhoea, the most common gynaecologic complaint, remains genetically and pathophysiologically elusive. Here, Li and colleagues identify common variants in ZMIZ1 and near NGF conferring risk for primary dysmenorrhoea using genome-wide association study in a Chinese population.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that act by blocking prostaglandin production. They inhibit the action of cyclooxygenase (COX), an enzyme responsible for the formation of prostaglandins. The COX enzyme exists in two forms, COX-1 and COX-2. Traditional NSAIDs are considered 'non-selective' because they inhibit both COX-1 and COX-2 enzymes. More selective NSAIDs that solely target COX-2 enzymes (COX-2-specific inhibitors) were launched in 1999 with the aim of reducing side effects commonly reported in association with NSAIDs, such as indigestion, headaches and drowsiness.

OBJECTIVES

To determine the effectiveness and safety of NSAIDs in the treatment of primary dysmenorrhoea.

SEARCH METHODS

We searched the following databases in January 2015: Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, November 2014 issue), MEDLINE, EMBASE and Web of Science. We also searched clinical trials registers (ClinicalTrials.gov and ICTRP). We checked the abstracts of major scientific meetings and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trial (RCT) comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed their risk of bias and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). We used inverse variance methods to combine data. We assessed the overall quality of the evidence using GRADE methods.

MAIN RESULTS

We included 80 randomised controlled trials (5820 women). They compared 20 different NSAIDs (18 non-selective and two COX-2-specific) versus placebo, paracetamol or each other. NSAIDs versus placeboAmong women with primary dysmenorrhoea, NSAIDs were more effective for pain relief than placebo (OR 4.37, 95% CI 3.76 to 5.09; 35 RCTs, I(2) = 53%, low quality evidence). This suggests that if 18% of women taking placebo achieve moderate or excellent pain relief, between 45% and 53% taking NSAIDs will do so.However, NSAIDs were associated with more adverse effects (overall adverse effects: OR 1.29, 95% CI 1.11 to 1.51, 25 RCTs, I(2) = 0%, low quality evidence; gastrointestinal adverse effects: OR 1.58, 95% CI 1.12 to 2.23, 14 RCTs, I(2) = 30%; neurological adverse effects: OR 2.74, 95% CI 1.66 to 4.53, seven RCTs, I(2) = 0%, low quality evidence). The evidence suggests that if 10% of women taking placebo experience side effects, between 11% and 14% of women taking NSAIDs will do so. NSAIDs versus other NSAIDsWhen NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain relief or safety. However, the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials. Non-selective NSAIDs versus COX-2-specific selectorsOnly two of the included studies utilised COX-2-specific inhibitors (etoricoxib and celecoxib). There was no evidence that COX-2-specific inhibitors were more effective or tolerable for the treatment of dysmenorrhoea than traditional NSAIDs; however data were very scanty. NSAIDs versus paracetamolNSAIDs appeared to be more effective for pain relief than paracetamol (OR 1.89, 95% CI 1.05 to 3.43, three RCTs, I(2) = 0%, low quality evidence). There was no evidence of a difference with regard to adverse effects, though data were very scanty.Most of the studies were commercially funded (59%); a further 31% failed to state their source of funding.

AUTHORS' CONCLUSIONS

NSAIDs appear to be a very effective treatment for dysmenorrhoea, though women using them need to be aware of the substantial risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea. We rated the quality of the evidence as low for most comparisons, mainly due to poor reporting of study methods.

A randomised controlled trial of oral zinc sulphate for primary dysmenorrhoea in adolescent females

BACKGROUND

Primary dysmenorrhoea, the most common gynaecologic problem of adolescent females, is commonly treated with nonsteroidal anti-inflammatory drugs or oral contraceptive pills.

AIM

To compare the effect of zinc sulphate with that of placebo on the control of pain severity and duration in adolescent girls with primary dysmenorrhoea.

MATERIALS AND METHODS

In a three-month randomised double-blind placebo-controlled clinical trial, 120 adolescent females with primary dysmenorrhoea were randomly divided into two groups of sixty: an intervention group (zinc) and a control group (placebo). Zinc was administered in the form of a capsule containing 50 mg/day zinc sulphate beginning on the first day of menses and continuing until three days prior to the end of menses. Each month, the duration and severity of primary dysmenorrhoea were determined. Severity scoring was performed by using a 0-10 scaling system.

RESULTS

In the first month, the duration of pain was significantly lower in the zinc group compared with the placebo group (P-value = 0.044), while there was no significant difference in pain severity between the groups (P-value = 0.497). In the second and third month, pain severity and duration in the zinc group were significantly lower than the placebo group (P-value <0.001).

CONCLUSION

Both pain duration and pain severity were decreased by taking oral zinc. The results of our interventional study suggests that zinc may be used to treat primary dysmenorrhoea in adolescents.

A primer on the hormone-free interval for combined oral contraceptives

BACKGROUND

The dosing, schedules, and other aspects of combined oral contraceptive (COC) design have evolved in recent years to address a variety of issues including short- and long-term safety, bleeding profiles, and contraceptive efficacy. In particular, several newer formulations have altered the length of the hormone-free interval (HFI), in order to minimize two key undesired effects that occur during this time: hormone-withdrawal-associated symptoms (HWaS) and follicular development.

OBJECTIVE

This primer reviews our current understanding of the key biological processes that occur during the HFI and how this understanding has led to changes in the dosing and schedule of newer COC formulations.

MAIN MESSAGE

In brief, HWaS are common, underappreciated, and a likely contributor to COC discontinuation; because of this, shortening the HFI and/or supplementing with estrogen during the progestin-free interval may provide relief from these symptoms and improve adherence. A short HFI (with or without estrogen supplementation) may also help maintain effective follicular suppression and contraceptive efficacy, even when the overall dose of estrogen throughout the cycle is low.

CONCLUSIONS

Taken together, the available data about HWaS and follicular activity during the HFI support the rationale for recent COC designs that use a low estrogen dose and a short HFI. The availability of a variety of COC regimens gives physicians a range of choices when selecting the most appropriate COC for each woman's particular priorities and needs.

Menstrual pain and epithelial ovarian cancer risk

PURPOSE

Menstrual pain is associated with increased production of inflammatory molecules, such as prostaglandins. Inflammation is involved in pathogenesis of several cancers, including ovarian cancer. In this study, we examined the association between menstrual pain and risk of ovarian cancer.

METHODS

We conducted a case-control study with 2,028 cases of epithelial ovarian cancer and 2,091 age- and study center-matched controls. Women were asked to report the severity of menstrual pain during their twenties and thirties, when not using oral contraceptives or breastfeeding. We used an unconditional logistic regression to evaluate the association between menstrual pain and epithelial ovarian cancer risk overall, and polytomous logistic regression to evaluate whether the association differed across tumor subtypes.

RESULTS

Risk of ovarian cancer was increased in women with moderate (OR 1.22, 95 % CI 1.05-1.42) and severe pain (OR 1.34, 95 % CI 1.09-1.65) compared to women with no or mild pain during menstrual period. The association differed by histologic subtypes, with significant associations for severe pain with endometrioid (OR 1.64, 95 % CI 1.15-2.34) and clear cell tumors (OR 1.91, 95 % CI 1.11-3.28).

CONCLUSIONS

Our data suggest that moderate and severe pain during menstrual period are associated with increased risk of epithelial ovarian cancer. Due to high prevalence of menstrual pain in women of reproductive age, this observation warrants further studies.

Primary dysmenorrhea is potentially predictive for initial orthodontic pain in female patients

OBJECTIVE

To investigate the relationship between primary dysmenorrhea (PD) and orthodontic pain in female patients, and to test the hypothesis that the intensity and duration of orthodontic pain could be roughly predicted by severity of PD.

MATERIALS AND METHODS

One hundred twenty college females were enrolled and put into one of three groups-mild (Mi), moderate (Mo), or severe (S)-according to level of menstrual pain. Intensity of the orthodontic pain was measured by visual analog scale (VAS) on days 1, 2, 4, 7, 14, and 28 after archwire placement.

RESULTS

As the intensity of orthodontic pain declined with time, the three groups demonstrated different changes during the initial week. Mi had the lowest VAS scores, whereas S possessed the highest scores. In contrast, Mo stayed in between. Significantly positive correlations were found between the severity of PD and the intensity of orthodontic pain at each time point within the first 2 weeks. In addition, though the majority of subjects reported disappearance of pain by the end of the second week in both Mi and Mo, a large proportion of females still perceived pain in S.

CONCLUSION

Females with higher levels of menstrual pain tended to perceive orthodontic pain with higher intensity and more prolonged duration. Thus, PD could potentially serve as a reference to predict orthodontic pain in clinical settings.

A double-blind, randomised, crossover study of two doses of a single-tablet combination of ibuprofen/paracetamol and placebo for primary dysmenorrhoea

OBJECTIVES

Efficacy of pain relief may potentially be enhanced by combining two or more analgesics with different mechanisms of action. The objective of this study was to assess the efficacy and tolerability of a novel single-tablet combination of ibuprofen and paracetamol compared with placebo in females experiencing moderate-to-severe pain due to primary dysmenorrhoea, a prevalent, recurrent condition characterised by pain at the time of menses.

METHODS

This was a phase II/III, double-blind, randomised, cross-over, single-dose study in 94 women with moderate-to-severe dysmenorrhoea, examining the efficacy and tolerability of one or two tablets of a single-tablet combination of ibuprofen 200 mg/paracetamol 500 mg compared with placebo.

CLINICAL TRIAL REGISTRATION

ISRCTN42521357

RESULTS

Total pain relief over 6 hours post-dose (TOTPAR(0-6h)) was significantly greater following administration of two tablets of the single-tablet combination of ibuprofen 200 mg/paracetamol 500 mg compared with placebo (LS means: 2.35, 1.85, respectively; p = 0.0001) and approached significance for one tablet (LS mean: 2.10; p = 0.054). Statistically superior pain relief and reductions in pain intensity were achieved from 2 hours and 90 minutes post-dose, respectively, with the higher dose combination, and from 4 hours with the lower dose combination compared with placebo. Overall effectiveness (sum of pain intensity difference and pain relief score [SPRID] over 6 hours) were statistically superior to placebo for both one and two tablets of the ibuprofen/paracetamol combination (p = 0.0011 and p = 0.03, respectively). Both dose combinations were well-tolerated. Adverse events were minor and their frequency and nature did not differ with either treatment compared with placebo.

CONCLUSIONS

One or two tablets of a single-tablet combination of ibuprofen 200 mg/paracetamol 500 mg is well-tolerated and provides superior analgesic efficacy to placebo in patients with primary dysmenorrhoea.

Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem. Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs which act by blocking prostaglandin production.

OBJECTIVES

The purpose of this review is to compare nonsteroidal anti-inflammatory drugs used in the treatment of primary dysmenorrhoea versus placebo, versus paracetamol and versus each other, to evaluate their effectiveness and safety.

SEARCH STRATEGY

We searched the following databases to May 2009: Cochrane Menstrual Disorders and Subfertility Group trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Web of Science. The National Research Register and the Clinical Trials Register were also searched. Abstracts of major scientific meetings and the reference lists of relevant articles were checked.

SELECTION CRITERIA

All randomised controlled comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). Inverse variance methods were used to combine data.

MAIN RESULTS

Seventy-three randomised controlled trials were included. Among women with primary dysmenorrhoea, NSAIDs were significantly more effective for pain relief than placebo (OR 4.50, 95% CI: 3.85, 5.27). There was substantial heterogeneity for this finding (I(2) statistic =53%): exclusion of two outlying studies with no or negligible placebo effect reduced heterogeneity, resulting in an odds ratio of 4.14 (95% CI: 3.52, 4.86, I(2)=40%). NSAIDs were also significantly more effective for pain relief than paracetamol (OR 1.90, 95% CI:1.05 to 3.44). However, NSAIDS were associated with significantly more overall adverse effects than placebo (OR 1.37, 95% CI: 1.12 to 1.66). When NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain-relief or safety. However the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials.

AUTHORS' CONCLUSIONS

NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea.

Oral contraceptive pill for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea (painful menstrual cramps) is common. Combined OCPs are recommended in the management of primary dysmenorrhoea.

OBJECTIVES

To determine the effectiveness and safety of combined oral contraceptive pills for the management of primary dysmenorrhoea.

SEARCH STRATEGY

We conducted electronic searches for randomised controlled trials (RCTs) in the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials CENTRAL, CCTR, MEDLINE, EMBASE, and CINAHL (first conducted in 2001, updated on 5 November 2008).

SELECTION CRITERIA

RCTs comparing all combined OCPs with other combined OCPs, placebo, no management, or management with nonsteroidal anti-inflammatories (NSAIDs) were considered.

DATA COLLECTION AND ANALYSIS

Twenty three studies were identified and ten were included. Six compared the combined OCP with placebo and four compared different dosages of combined OCP.

MAIN RESULTS

One study of low dose oestrogen and four studies of medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement. For the outcome of pain relief across the different OCPs the pooled OR suggested benefit with OCPs compared to placebo (7 RCTs: Peto OR 2.01 [95% CI 1.32, 3.08]).The Chi-squared test for heterogeneity showed there is significant heterogeneity with an I(2) statistic of 64% and a significant chi-square test (14.06, df=5, p=0.02). A sensitivity analysis removing the studies with inadequate allocation concealment suggested significant benefit of treatment with the pooled OR of 2.99 (95% CI 1.76, 5.07) and heterogeneity no longer statistically significant and I(2) statistic of 0%.Three studies reported adverse effects (Davis 2005; Hendrix 2002; GPRG 1968) The adverse effects were nausea, headaches and weight gain. Two studies reported if women experienced any side effect and no evidence of an effect was found (3 RCTs: OR = 1.45 (95% 0.71, 2.94). There was no evidence of statistical heterogeneity.There were no studies identified that compared combined OCP versus non steroidal anti-inflammatory drugsThere was no evidence of a difference for the pooled studies for 3rd generation pro gestagens (OR = 1.11 (95% CI 0.79 - 1.57)). For the 2nd generation versus 3rd generation the OR was 0.44 (95% CI 0.23-0.84) suggesting benefit of the 3rd generation OCP but this was for a single study (Winkler 2003).

AUTHORS' CONCLUSIONS

There is limited evidence for pain improvement with the use of the OCP (both low and medium dose oestrogen) in women with dysmenorrhoea. There is no evidence of a difference between different OCP preparations.

Oral contraceptive pill as treatment for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea (painful menstrual cramps) is common. Combined OCPs are recommended in the management of primary dysmenorrhoea.

OBJECTIVES

To determine the effectiveness and safety of combined oral contraceptive pills for the management of primary dysmenorrhoea.

SEARCH STRATEGY

We conducted electronic searches for randomised controlled trials (RCTs) in the Cochrane Menstrual Disorders and Subfertility Group Register of controlled trials CENTRAL, CCTR, MEDLINE, EMBASE, and CINAHL (first conducted in 2001, updated on 5 November 2008).

SELECTION CRITERIA

RCTs comparing all combined OCPs with other combined OCPs, placebo, no management, or management with nonsteroidal anti-inflammatories (NSAIDs) were considered.

DATA COLLECTION AND ANALYSIS

Twenty three studies were identified and ten were included. Six compared the combined OCP with placebo and four compared different dosages of combined OCP.

MAIN RESULTS

One study of low dose oestrogen and four studies of medium dose oestrogen combined OCPs compared with placebo, for a combined total of 497 women, reported pain improvement. For the outcome of pain relief across the different OCPs wthe pooled OR suggested benefit with OCPs compared to placebo (7 RCTs: Peto OR 2.01 [95% CI 1.32, 3.08]).The Chi-squared test for heterogeneity showed there is significant heterogeneity with an I(2) statistic of 64% and a significant chi-square test (14.06, df=5, p=0.02). A sensitivity analysis removing the studies with inadequate allocation concealment suggested significant benefit of treatment with the pooled OR of 2.99 (95% CI 1.76, 5.07) and hereterogeneity no longer statistically significant and I(2) statistic of 0%.Three studies reported adverse effects (Davis 2005; Hendrix 2002; GPRG 1968) The adverse effects were nausea, headaches and weight gain. Two studies reported if women experienced any side effect and no evidence of an effect was found (3 RCTs: OR = 1.45 (95% 0.71, 2.94). There was no evidence of statistical heterogeneity.There were no studies identified that compated combined OCP versus non steroidal anti-inflammatory drugs. There was no evidence of a difference for the pooled studies for 3rd generation progestagens (OR = 1.11 (95% CI 0.79 - 1.57)). For the 2nd generation versus 3rd generation the OR was 0.44 (95% CI 0.23-0.84) suggesting benefit of the 3rd generation OCP but this was for a single study (Winkler 2003).

AUTHORS' CONCLUSIONS

There is limited evidence for pain improvement with the use of the OCP (both low and medium dose oestrogen) in women with dysmenorrhoea. There is no evidence of a difference between different OCP preparations.

Differential suppression of menstrual fluid prostaglandin F2a, prostaglandin E2, 6-keto prostaglandin F1a and thromboxane B2 by suprofen in women with primary dysmenorrhea

Eleven women with primary dysmenorrhea completed a randomized, double-blind, placebo-controlled, three-way cross-over study comparing 200 and 400mg suprofen. Menstrual fluid volume did not change. Mean+/-S.E.M. menstrual fluid PGF2a was significantly suppressed from 18.9+/-1.9 microg (placebo) to 10.9+/-1.7 and 9.3+/-2.1 microg with 200 and 400 mg suprofen, respectively (p=<0.005). PGE2 dropped from 7.8+/-0.9 to 4.6+/-0.8 and 4.6+/-1.1 microg (p=<0.05) and TxB2 from 17.5+/-4.3 to 7.5+/-2.9 and 3.6+/-1.3 microg (p=<0.01), respectively. 6-Keto PGF1a was significantly suppressed (2.7+/-0.4 to 1.9+/-0.5 microg, p=<0.025) with only 400 mg suprofen. Six subjects rated placebo poor and five fair to very good. In contrast, nine rated suprofen excellent to fair while two rated poor. Thus, suprofen was clinically effective but the differential suppression of prostanoids favors 200mg which spares 6-keto PGF1a.

Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2alpha in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea

OBJECTIVE

The purpose of this study was to compare acetaminophen with ibuprofen for pain relief and menstrual fluid prostaglandin F2alpha (PGF2alpha) suppression in primary dysmenorrhea.

STUDY DESIGN

Twelve subjects were randomized to placebo, acetaminophen (1000 mg orally, 4 x daily for 3 days) or ibuprofen (400 mg orally, 4 x daily for 3 days), once during each cycle in a prospective, double-blinded, crossover study. Using preweighed super absorbent tampons, menstrual fluid was collected, extracted, and PGF2alpha radioimmunoassayed.

RESULTS

Ten patients completed the study. Ibuprofen (P = .002) and acetaminophen (P = .022) were rated significantly better than placebo. Total menstrual fluid PGF2alpha with placebo was 36.2 + 6.1 microg but were 14.8 + 3.0 microg with ibuprofen (P = .001) and 21.4 + 3.4 microg with acetaminophen (P = .008). PGF2alpha concentrations with placebo were 0.34 + 0.054 microg/mL, with ibuprofen 0.16 + 0.026 microg/mL (P = .001), and with acetaminophen 0.23 + 0.029 microg/mL (P = .016).

CONCLUSION

Both ibuprofen and acetaminophen were superior to placebo for pain relief and menstrual fluid PGF2alpha suppression, with ibuprofen being more potent.

Primary dysmenorrhea: advances in pathogenesis and management

Primary dysmenorrhea is painful menstrual cramps without any evident pathology to account for them, and it occurs in up to 50% of menstruating females and causes significant disruption in quality of life and absenteeism. Current understanding implicates an excessive or imbalanced amount of prostanoids and possibly eicosanoids released from the endometrium during menstruation. The uterus is induced to contract frequently and dysrhythmically, with increased basal tone and increased active pressure. Uterine hypercontractility, reduced uterine blood flow, and increased peripheral nerve hypersensitivity induce pain. Diagnosis rests on a good history with negative pelvic evaluation findings. Evidence-based data support the efficacy of cyclooxygenase inhibitors, such as ibuprofen, naproxen sodium, and ketoprofen, and estrogen-progestin oral contraceptive pills (OCPs). Cyclooxygenase inhibitors reduce the amount of menstrual prostanoids released, with concomitant reduction in uterine hypercontractility, while OCPs inhibit endometrial development and decrease menstrual prostanoids. An algorithm is provided for a simple approach to the management of primary dysmenorrhea.

Safety concerns and health benefits associated with oral contraception

Since the introduction of hormonal contraceptives in the 1960s, there have been a variety of both health benefits and safety concerns attributed to their use. In most instances, the noncontraceptive benefits of oral contraceptives (OCs) outweigh the potential cardiovascular risks. In fact, the probability of a patient experiencing a cardiovascular event while taking a low-dose OC is very low. However, smoking, hypertension, obesity, and diabetes are risk factors that must be taken into account when prescribing OCs. The neoplastic effects of hormonal contraceptives have been extensively studied, and recent meta-analyses indicate that there is a reduction in the risk of endometrial and ovarian cancer, a possible small increase in the risk for breast and cervical cancer, and an increased risk of liver cancer. Finally, many women will experience noncontraceptive health benefits with OCs that expand far beyond pregnancy prevention. Some of these benefits include reduction in menstrual-related symptoms, fewer ectopic pregnancies, a possible increase in bone density, and possible protection against pelvic inflammatory disease.

Nonsteroidal anti-inflammatory drugs for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological complaint consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs which act by blocking prostaglandin production.

OBJECTIVES

The purpose of this review is to compare all nonsteroidal anti-inflammatory drugs used in the treatment of primary dysmenorrhoea with placebo, with paracetamol and with each other to evaluate their effectiveness and safety.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (11 April 2003), Cochrane Central Register of Controlled Trials (1st quarter 2003), MEDLINE (1966-April 2003), and EMBASE (1980 - Week 15 2003). Attempts were also made to identify trials from the National Research Register and the Clinical Trials Register. Citation lists of relevant publications, review articles, abstracts of major scientific meetings and included studies were also searched.

SELECTION CRITERIA

All randomised controlled comparisons of NSAID therapies versus placebo, versus other NSAIDs or versus paracetamol when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials for quality and extracted data, calculating odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Crossover trial data were presented in additional tables and other data were summarised descriptively.

MAIN RESULTS

In women with dysmenorrhoea, NSAIDs were found significantly more effective for pain relief than placebo (OR 7.91, 95% CI 5.65 to 11.09), though overall adverse effects were also significantly more common (OR 1.52 95% CI 1.09 to 2.12). When NSAIDs were compared with each other or with paracetamol, there was little evidence of the superiority of any individual NSAID with regard to either efficacy or safety. However the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials, most of which were unsuitable for meta-analysis.

REVIEWER'S CONCLUSIONS

NSAIDs are an effective treatment for dysmenorrhoea, though women using them need to be aware of the significant risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the most safe and effective for the treatment of dysmenorrhoea.

Primary dysmenorrhea treatment with a desogestrel-containing low-dose oral contraceptive

This randomized, double-blind, placebo-controlled exploratory study examined the efficacy and safety of a low-dose oral contraceptive (Mircette), desogestrel/ethinyl estradiol [DSG/EE] and ethinyl estradiol [EE]) in relieving the symptoms of dysmenorrhea. Twenty-three clinics in the United States enrolled 77 women (age < or =32 years) with primary dysmenorrhea documented for at least four consecutive cycles. Forty participants received DSG/EE&EE and 37 received placebo for four consecutive 28-day cycles. The intensity of menstrual-related distress was measured with the Menstrual Distress Questionnaire (MDQ). Patient diaries were used to assess number of school/work days missed as well as the use of rescue medication. Participants receiving DSG/EE&EE recorded reduced menstrual pain severity, lower total MDQ scores, and significantly less menstrual cramping. No significant change in bloating, anxiety, loneliness, weight gain, or acne was reported. The DSG/EE&EE formulation shows promise for the treatment of primary dysmenorrhea and was well tolerated by the participants in this study.

A randomized clinical trial of the effectiveness of an acupressure device (relief brief) for managing symptoms of dysmenorrhea

OBJECTIVES

To develop and test the safety and effectiveness of an acupressure garment (the Relief Brief) in decreasing the pain and symptom distress associated with dysmenorrhea.

DESIGN

A randomized clinical trial applied a 2 (Relief Brief use or control group) x 3 (baseline and two treatment measurement occasions) mixed factorial design.

PARTICIPANTS

Sixty-one (61) women with moderately severe primary dysmenorrhea were randomly assigned to the standard treatment control group or the Relief Brief acupressure device group after one pretreatment menses, with 58 women reporting the effect on their pain during two post-treatment menstrual cycles. The acupressure garment: The Relief Brief is a cotton Lycra panty brief with a fixed number of lower abdominal and lower back latex foam acupads that provide pressure to dysmenorrhea-relieving Chinese acupressure points.

OUTCOME MEASURES

Menstrual pain severity (worst pain and symptom intensity), pain medication use, and adverse effects were analyzed using between-groups and repeated measures analyses of treatment effects. Statistical and clinical significance criteria were applied a priori.

RESULTS

For pain measures and pain medication use, the group main effect, time main effect and group x time interaction were statistically significant. Median pain medication use, the same for both groups at baseline (6 pills per day), dropped to 2 pills per day for the Relief Brief group but remained at 6 pills for the control group at the second treatment cycle. Predicted clinical significance criteria were surpassed: almost all (90%) women wearing the Relief Brief obtained at least a 25% reduction in menstrual pain severity (a 2-3 point drop) compared to only 8% of the control group (z = 6.07; p < 0.05). Relief Brief use was associated with at least a 50% decline in menstrual pain symptom intensity in more than two thirds of the women.

CONCLUSIONS

An acupressure device is an effective and safe nonpharmacologic strategy for the treatment of primary dysmenorrhea. With design modifications, it could serve as a main treatment modality for women who suffer from primary dysmenorrhea and do not wish to or cannot use the conventional pharmacologic agents. In addition, this acupressure device may serve as an adjuvant therapy to medication in more severe cases of dysmenorrhea.

Risks and benefits of oral contraceptive pills

In the more than 40 years since the combined oral contraceptive pill was first marketed, much information has been obtained as to its risks. Considerably less publicity has been given to the balancing benefits that have also emerged. There has been an increasing realization that the risks are focused in those women with recognised risk factors, meaning that the remainder can use the product with increasing reassurance. The doses of both hormones have also been lowered considerably since the early years. Thus, it can be a rational decision by a fully informed woman to use this form of contraception.

A comparison of the cycle control and tolerability of two ultra low-dose oral contraceptives containing 20 micrograms ethinylestradiol and either 150 micrograms desogestrel or 75 micrograms gestodene

OBJECTIVE

To compare the cycle control and tolerability of two oral contraceptives containing 20 micrograms ethinylestradiol and either 150 micrograms desogestrel or 75 micrograms gestodene.

METHODS

A randomized, multicenter study was conducted in which 1016 healthy adult women received the desogestrel (n = 509) or the gestodene (n = 507) preparation for six treatment cycles.

RESULTS

No significant differences in bleeding patterns were detected between the two treatments. The incidence and duration of irregular bleeding decreased markedly, and to a similar extent, during each treatment. The occurrence of irregular bleeding per cycle decreased from 24.6 to 9.4% in the desogestrel group and from 19.7 to 8.6% in the gestodene group. Its duration fell from 1.1 to 0.2 days and from 0.9 to 0.3 days, respectively. There was a consistently low incidence of amenorrhea (1.0-2.8%). There were no significant differences between treatments for the incidence, intensity or emergence of dysmenorrhea. During both treatments, the incidence of premenstrual syndrome and complaints such as breast tenderness, nausea and headache dropped markedly.

CONCLUSION

Ultra low-dose oral contraceptives containing desogestrel or gestodene offer equivalent, good cycle control and improvements in dysmenorrhea and premenstrual syndrome and have similar, excellent tolerability profiles.

Efficacy of minor analgesics in primary dysmenorrhoea: a systematic review

OBJECTIVE

To quantify the efficacy and safety of naproxen, ibuprofen, mefenamic acid, aspirin and acetaminophen (paracetamol) in the treatment of primary dysmenorrhoea through a systemic overview of randomised controlled trials.

METHODS

MEDLINE, EMBASE and the Science Citation Index were searched for randomised controlled trials. Efficacy was assessed by measurement of pain relief, requirement for rescue analgesics, restriction of daily life and absence from work or school. The rate ratios of side effects were used to assess safety.

RESULTS

Fifty-six trials describing 55 comparisons of analgesics with placebo and 12 direct comparisons with other analgesics met our inclusion criteria. Women taking naproxen were over three times more likely to have at least moderate pain relief than those taking placebo. Ibuprofen, mefenamic acid and aspirin were also superior to placebo but acetaminophen was not. The requirement for rescue analgesics, restriction of daily life and absence from work or school were less frequent with naproxen and ibuprofen than placebo but not with aspirin or acetaminophen. Direct comparisons did not show any difference between naproxen and ibuprofen. Side effects occurred more frequently only with naproxen when compared with placebo.

CONCLUSION

Naproxen, ibuprofen, mefenamic acid and aspirin are all effective in primary dysmenorrhoea. Ibuprofen appears to have the most favourable risk-benefit ratio. Acetaminophen appears to be less effective than nonsteroidal anti-inflammatory drugs, but there was only one trial meeting our inclusion criteria and further studies are required.

Primary dysmenorrhea and physical activity

It has been widely claimed that exercise is beneficial to dysmenorrhea, yet solid evidence is lacking. Studies investigating this relationship have been reviewed for this paper. Most showed decreased prevalence and/or improved symptomatology with exercise. However, controlled longitudinal studies involving women with confirmed primary dysmenorrhea who are sufficiently blinded to the study objectives are necessary before a definite relationship between exercise and dysmenorrhea can be established.

Reproductive disorders associated with pelvic pain

Pelvic pain is common in adolescents and can result from a number of physiological and pathological etiologies, both gynecologic and nongynecologic in origin. The evaluation, diagnosis, and management of these conditions involve both medical and surgical approaches. In this review, the authors present a comprehensive approach to the care of adolescents with pelvic pain associated with dysmenorrhea, endometriosis, and obstruction of the genital tract.

Evaluation and management of chronic pelvic pain

Evaluating patients with chronic pelvic pain is complex. A detailed medical history should be ideally supplemented by psychologic evaluation and assessment of the woman's social background. At the time of physical examination, the location and intensity of the pain should be mapped. Assessment of pain relief with the administration of a local anesthetic to trigger points or selected nerves may be useful in predicting the potential efficacy of surgical interventions such as uterosacral nerve ablation. Appropriate tests include pelvic ultrasound and magnetic resonance imaging. Ultimately, laparoscopy may provide the final diagnosis. Management should address the underlying cause(s) of pain; when this cannot be done, it should focus on treating the pain itself. When appropriate, empiric administration of antidepressants may be considered. In selected women, therapeutic goals may be achieved by electrical stimulation of nerves.