Dysmenorrhea Symptom-Based Phenotypes: A Replication and Extension Study

Social Determinants of Health and Dysmenorrhea: A Systematic Review

Social determinants of health play a key role in health disparities. Dysmenorrhea is a highly prevalent and impactful public health problem affecting reproductive-age females. Systematically examining social determinants of health (SDoH) in dysmenorrhea is important for identifying gaps in the literature and informing research, policy, and clinical practice to reduce the public health burden associated with dysmenorrhea. The purpose of this systematic review was to synthesize the literature on SDoH and dysmenorrhea. The review protocol was prospectively registered. We searched Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Google Scholar through February 2024 using search strategies informed by the literature. Screening of the articles, data extraction, and risk-of-bias (RoB) assessment were conducted independently by at least 2 reviewers on the Covidence platform. Among 2,594 unique records screened, 166 met eligibility criteria and were included for data extraction and RoB assessment. Evidence suggests traumatic experiences, toxic environmental exposures, female genital mutilation, job-related stress, lack of menstrual education, and low social support were associated with worse dysmenorrhea outcomes. However, evidence was equivocal regarding the relationships between dysmenorrhea outcomes and SDoH factors, including socioeconomic status, geographical location, race/ethnicity, employment, and religion. Nearly all articles (99.4%) had a high or very high overall RoB. The relationships between SDoH and dysmenorrhea outcomes were often inconsistent and complicated by heterogeneous study populations and methodologies. More rigorous research examining SDoH in dysmenorrhea is needed to inform policy and clinical practice. PERSPECTIVE: This systematic review synthesizes evidence linking SDoH and dysmenorrhea. The relationships between SDoH and dysmenorrhea were often equivocal and complicated by heterogeneous study populations and methodologies. We identify directions for future research and SDoH factors that could be addressed clinically (eg, trauma, menstrual education, and occupational stress).

Efficacy and Safety of Sanjie Analgesic Capsule in Patients with Endometriosis-Associated Pain: A Multicenter, 3:1 Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To assess the efficacy and safety of Sanjie Analgesic Capsule (SAC) in Chinese patients with endometriosis-associated pain.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled trial conducted at 15 centers between November 2013 and July 2017 in China. Eligible 323 patients with endometriosis were randomized at a 3:1 ratio to the SAC group (241 cases) and placebo group (82 cases) by stratified block randomization. Patients in the SAC or placebo groups were given SAC or placebo 1.6 g 3 times per day, orally, respectively since the first day of menstruation for 3 consecutive menstrual cycles. The primary endpoint was clinical response to dysmenorrhea evaluated using a 10-point Visual Analogue Scale at 3 and 6 months. The secondary endpoint was the pain score evaluated by VAS (chronic pelvic pain, defecation pain, and dyspareunia) at 3 and 6 months, and the pain recurrence rate at 6 months. Adverse events (AEs) were recorded during the study.

RESULTS

A total of 241 women were included in the SAC group, and 82 were in the placebo group. Among these women, 217 (90.0%) and 71 (86.6%) completed the intervention, respectively. At 3 months, overall response rate (ORR) was significantly higher in women administered SAC (80.1%) compared with those who received a placebo (30.5%, P<0.01). Six months after treatment, the ORR for dysmenorrhea was 62.7% in the SAC group and 31.7% in the placebo group (P<0.01). Chronic pelvic pain and defecation pain were significantly improved by SAC compared with placebo (both P<0.05). The incidence rates of total AEs events in the SAC and placebo groups were 6.6% and 9.8%, respectively, and no significant difference was shown between the two groups (P=0.339).

CONCLUSION

SAC is well-tolerated and may improve dysmenorrhea in women with endometriosis-associated pain. (Trial registration: ClinicalTrials.gov, No. NCT02031523).

Dysmenorrhea and psychological distress: a meta-analysis

Dysmenorrhea is characterized by pelvic pain associated with menstruation. Similar to people with other pain conditions, females who experience dysmenorrhea report increased psychological distress. However, the pooled magnitude of this association has not been quantified across studies. Accordingly, this meta-analytic review quantifies the magnitude of the associations between dysmenorrhea severity and psychological distress. We conducted a systematic search of the literature using PsycINFO, PubMed, CINHAL, Embase, and Web of Science. Analyzed studies provided observational data on dysmenorrhea severity and anxiety symptoms, depressive symptoms, and/or global psychological distress. A total of 44 studies were included, and three random-effects meta-analyses were conducted, with average pooled effect sizes calculated using Person's r. We found significant, positive associations between measures of dysmenorrhea severity and measures of depressive symptoms (r = 0.216), anxiety symptoms (r = 0.207), and global psychological distress (r = 0.311). Our review suggests that females with greater dysmenorrhea severity experience greater psychological distress. Future directions include defining a clinically meaningful dysmenorrhea severity threshold, understanding the mechanisms and directionality underlying the dysmenorrhea-psychological distress relationship, and designing and testing interventions to jointly address dysmenorrhea and psychological distress.

Gastrointestinal functioning and menstrual cycle phase in emerging young adult women: a cross-sectional study

BACKGROUND

Women experience more severe gastrointestinal (GI) symptoms compared to men. The onset of puberty and the menstrual cycle may influence these differences. Additionally, health anxiety is an important construct that has been shown to play a role in increased symptomatology across many medical conditions. Using standardized clinical measures often employed to assess disorders of gut-brain interaction (DGBI) we aimed to identify differences of GI functioning across menstrual cycle phases and to evaluate the role of health anxiety in this relationship.

METHODS

Six hundred three participants completed a survey including functional GI assessment scales (PROMIS-GI®), an abdominal pain scale and map, and a health anxiety measure. They were grouped by menstrual cycle phases (Menses, Follicular, Early-Luteal, and Premenstrual) based on self-reported start date of most recent period. Multivariate analyses of covariance were conducted to identify differences between menstrual cycle phase and scores on the symptom scales. Heath anxiety was included as a covariate in all analyses.

RESULTS

No significant differences were found between menstrual cycle group and PROMIS-GI scores. Higher GI-symptom and pain levels were found as health anxiety increased. Pain in the hypogastric region of the abdomen was significantly higher during the Menses phase when compared to Early-Luteal and Premenstrual phases. A subset of participants with DGBI diagnoses demonstrated significantly higher GI-symptom severity on several PROMIS-GI scales when compared to matched controls who did not have those diagnoses. In addition, participants with DGBI diagnoses reported significantly greater pain across multiple abdominal regions than their non-diagnosed counterparts.

CONCLUSIONS

GI symptom levels as measured by the PROMIS-GI scales in otherwise healthy women were not dependent on menstrual cycle phase. Yet, the PROMIS-GI scales were sensitive to symptom differences in women with DGBI diagnoses. Overall, this study demonstrated that the PROMIS-GI measures are unlikely to be affected by gynecological functioning in healthy young women. We argue that the abdominal pain map is an essential addition to classification and diagnosis.

Menstrual disturbances and its association with sleep disturbances: a systematic review

BACKGROUND

Menstrual disturbances harm women's health, and general well-being. As growing evidence highlights the relationship between sleep and menstrual disturbances, it is imperative to comprehensively examine the association between sleep and menstrual disturbance considering the multiple dimensions of sleep. This systematic review aims to identify the association between sleep and menstrual disturbances by evaluating using Buysse's sleep health framework.

METHODS

A comprehensive search of the literature was conducted in PubMed, EMBASE, psychINFO, and CINAHL to identify publications describing any types of menstrual disturbances, and their associations with sleep published between January 1, 1988 to June 2, 2022. Quality assessment was conducted using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. The findings were iteratively evaluated menstrual disturbances and their association with sleep using Buysse's sleep health framework. This framework understands sleep as multidimensional concept and provides a holistic framing of sleep including Satisfaction, Alertness during waking hours, Timing of sleep, Efficiency, and Sleep duration. Menstrual disturbances were grouped into three categories: premenstrual syndrome, dysmenorrhea, and abnormal menstrual cycle/heavy bleeding during periods.

RESULTS

Thirty-five studies were reviewed to examine the association between sleep and menstrual disturbances. Premenstrual syndrome and dysmenorrhea were associated with sleep disturbances in sleep health domains of Satisfaction (e.g., poor sleep quality), Alertness during waking hours (e.g., daytime sleepiness), Efficiency (e.g., difficulty initiating/maintaining sleep), and Duration (e.g., short sleep duration). Abnormal menstrual cycle and heavy bleeding during the period were related to Satisfaction, Efficiency, and Duration. There were no studies which investigated the timing of sleep.

CONCLUSIONS/IMPLICATIONS

Sleep disturbances within most dimensions of the sleep health framework negatively impact on menstrual disturbances. Future research should longitudinally examine the effects of sleep disturbances in all dimensions of sleep health with the additional objective sleep measure on menstrual disturbances. This review gives insight in that it can be recommended to provide interventions for improving sleep disturbances in women with menstrual disturbance.

Efficacy of psychological interventions for dysmenorrhea: a meta-analysis

Dysmenorrhea is pelvic pain associated with menstruation and is one of the most common pain conditions among reproductive-age women. It is commonly treated with medications, complementary and alternative medicine, and self-management techniques. However, there is increased focus on psychological interventions which modify thoughts, beliefs, emotions, and behavioral responses to dysmenorrhea. This review examined the efficacy of psychological interventions on dysmenorrhea pain severity and interference. We conducted a systematic search of the literature using PsycINFO, PubMed, CINHAL, and Embase. A total of 22 studies were included; 21 examined within-group improvement (ie, within-group analysis) and 14 examined between-group improvement (ie, between-group analysis). Random-effects meta-analyses were conducted on pain severity and interference, with average effect sizes calculated using Hedges's g. Within-group analyses showed decreased pain severity and interference at post-treatment (g = 0.986 and 0.949, respectively) and first follow-up (g = 1.239 and 0.842, respectively). Between-group analyses showed decreased pain severity at post-treatment (g = 0.909) and decreased pain severity and interference at first follow-up (g = 0.964 and 0.884, respectively) compared to control groups. This review supports the efficacy of psychological interventions for dysmenorrhea, but conclusions are tempered by suboptimal methodological quality of the included studies and high heterogeneity across studies. Additional, rigorous research is needed to determine the clinical utility of psychological interventions for dysmenorrhea.

Electroacupuncture treatment of primary dysmenorrhea: A randomized, participant-blinded, sham-controlled clinical trial protocol

BACKGROUND

Primary dysmenorrhea in women is a common and serious public health problem with psychological and physical effects. Painkillers have adverse effects, such as tolerance, addiction, irritation of the digestive tract, and liver and kidney damage. Electroacupuncture has been used as alternative therapy, although with no (non-anecdotal) evidence of effectiveness.

OBJECTIVE

This study aims to provide evidence for the feasibility and efficacy of electroacupuncture in the treatment of primary dysmenorrhea. Moreover, by observing changes in serum and urine metabolites, we will evaluate the putative mechanisms mediating electroacupuncture effects in primary dysmenorrhea.

METHODS

This multicenter, randomized, participant-blinded, sham-controlled clinical trial including 336 women with primary dysmenorrhea is being conducted at three hospital centers in China and consists of a 12-week treatment and a 3-month follow-up. Women will undergo electroacupuncture (n = 168) or sham acupuncture (n = 168), beginning 7 days before their menstruation, once per day, until menstruation. Each menstrual cycle equals one course of treatment, and we will evaluate a total of three courses of treatment. The primary outcome of interest is the change in visual analogue scale scores before and after treatment. The secondary outcomes include changes in the numeric rating scale, Cox Menstrual Symptom Scale, traditional Chinese medicine symptoms, the Self-Rating Anxiety Scale, Self-Rating Depression Scale, and 36-Item Short Form questionnaire scores, and a safety evaluation. Moreover, we will preliminarily investigate the metabolomics mechanism as a potential mediator of the association between electroacupuncture and primary dysmenorrhea symptomology.

DISCUSSION

We aim to find a suitable non-medicinal alternative for primary dysmenorrhea treatment to reduce reliance on non-steroidal anti-inflammatory drugs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2100054234; http://www.chictr.org.cn/.

Symptom patterns and health service use of women in early adulthood: a latent class analysis from the Australian Longitudinal Study on Women's Health

BACKGROUND

Symptoms can be strong drivers for initiating interaction with the health system, especially when they are frequent, severe or impact on daily activities. Research on symptoms often use counts of symptoms as a proxy for symptom burden, however simple counts don't provide information on whether groups of symptoms are likely to occur together or whether such groups are associated with different types and levels of healthcare use. Women have a higher symptom burden than men; however studies of symptom patterns in young women are lacking. We aimed to characterise subgroups of women in early adulthood who experienced different symptom patterns and to compare women's use of different types of health care across the different symptom subgroups.

METHODS

Survey and linked administrative data from 7 797 women aged 22-27 years in 2017 from the 1989-95 cohort of the Australian Longitudinal Study on Women's Health were analysed. A latent class analysis was conducted to identify subgroups of women based on the frequency of 16 symptom variables. To estimate the associations between the latent classes and health service use, we used the "Bolck, Croon and Hagenaars" (BCH) approach that takes account of classification error in the assignment of women to latent classes.

RESULTS

Four latent classes were identified, characterised by 1) low prevalence of most symptoms (36.6%), 2) high prevalence of menstrual symptoms but low prevalence of mood symptoms (21.9%), 3) high prevalence of mood symptoms but low prevalence of menstrual symptoms, (26.2%), and high prevalence of many symptoms (15.3%). Compared to the other three classes, women in the high prevalence of many symptoms class were more likely to visit general practitioners and specialists, use more medications, and more likely to have had a hospital admission.

CONCLUSIONS

Women in young adulthood experience substantially different symptom burdens. A sizeable proportion of women experience many co-occurring symptoms across both physical and psychological domains and this high symptom burden is associated with a high level of health service use. Further follow-up of the women in our study as they enter their late 20 s and early 30 s will allow us to examine the stability of the classes of symptoms and their associations with general health and health service use. Similar studies in other populations are needed to assess the generalisability of the findings.

The role of catastrophizing in chronic cyclical pelvic pain: A systematic review and meta-analysis

BACKGROUND

Dysmenorrhea (painful menstrual cramps) is one of the most common gynecological complaints in women and girls. Dysmenorrhea may be a condition itself or a result of another medical condition, including endometriosis and chronic pelvic pain. Research examining the relationship between menstrual pain ratings and catastrophizing has produced mixed results.

OBJECTIVE

To review and meta-analyze the relationship between catastrophizing and pain ratings of chronic cyclical pelvic pain.

DESIGN

Cross-sectional, longitudinal, and intervention studies that reported the relationship between menstrual/pelvic pain and catastrophizing were included. Study populations had to include healthy menstruating persons or persons with a condition associated with cyclical pelvic pain including primary dysmenorrhea, endometriosis, and/or chronic pelvic pain.

DATA SOURCES AND METHODS

A systematic search of articles published since 2012 on PubMed, PsychInfo, CINHAL, and Medline was conducted in January and rerun in November of 2022. Search terms included cyclical pelvic pain, dysmenorrhea, endometriosis, pelvic pain, and catastrophizing. Data extraction was completed independently by two extractors and cross-checked for errors. A random-effects meta-regression was used to synthesize the data using restricted maximum likelihood.

RESULTS

Twenty-five studies examining 4,540 participants were included. A random effects model found a meta-correlation between catastrophizing and pain of r = .31 (95% confidence interval: .23-.40) p < .001. Heterogeneity was large and significant (I2 = 84.5%, Q(24) = 155.16, p < .001). Studies that measured general pelvic pain rather than cyclical pelvic pain specifically and those that used multi-item rather than single-item measures of pain had significantly higher correlations. Age and depression did not moderate the relationship between catastrophizing and pain.

CONCLUSION

A systematic review and meta-analysis found that catastrophizing had a small but significant positive association with pain ratings. Patients experiencing cyclical pelvic pain may benefit from interventions targeting the psychological management of pain.

REGISTRATION

This meta-analysis was registered in PROSPERO on 14 January 2022. Registration number: CRD42022295328.

Latent Profile/Class Analysis Identifying Differentiated Intervention Effects

BACKGROUND

The randomized clinical trial is generally considered the most rigorous study design for evaluating overall intervention effects. Due to patient heterogeneity, subgroup analysis is often used to identify differential intervention effects. In research of behavioral interventions, such subgroups often depend on a latent construct measured by multiple correlated observed variables.

OBJECTIVES

The purpose of this article is to illustrate latent class analysis/latent profile analysis as a helpful tool to characterize latent subgroups, conduct exploratory subgroup analysis, and identify potential differential intervention effects using clinical trial data.

METHODS

After reviewing different approaches for subgroup analysis, latent class analysis/latent profile analysis was chosen to identify heterogeneous patient groups based on multiple correlated variables. This approach is superior in this specific scenario because of its ability to control type I error, assess intersection of multiple moderators, and improve interpretability. We used a case study example to illustrate the process of identifying latent classes as potential moderators based on both clinical and perceived risk scores and then tested the differential effects of health coaching in improving health behavior for patients with elevated risk of developing coronary heart disease.

RESULTS

We identified three classes based on one clinical risk score and four perceived risk measures for individuals with high risk of developing coronary heart disease. Compared to other classes we assessed, individuals in the class with low clinical risk and low perceived risk benefit most from health coaching to improve their physical activity levels.

DISCUSSION

Latent class analysis/latent profile analysis offers a person-centered approach to identifying distinct patient profiles that can be used as moderators for subgroup analysis. This offers tremendous opportunity to identify differential intervention effects in behavioral research.

Associations Between Dysmenorrhea Symptom-Based Phenotypes and Vaginal Microbiome: A Pilot Study

BACKGROUND

Dysmenorrhea is highly prevalent; it places women at risk for other chronic pain conditions. There is a high degree of individual variability in menstrual pain severity, the number of painful sites, and co-occurring gastrointestinal symptoms. Distinct dysmenorrhea symptom-based phenotypes were previously identified, but the biological underpinnings of these phenotypes are less known. One underexplored contributor is the vaginal microbiome. The vaginal microbiota differs significantly among reproductive-age women and may modulate as well as amplify reproductive tract inflammation, which may contribute to dysmenorrhea symptoms.

OBJECTIVES

The objective of this study was to examine associations between dysmenorrhea symptom-based phenotypes and vaginal microbiome compositions on- and off-menses.

METHODS

We conducted a prospective, longitudinal, pilot study of 20 women (aged 15-24 years) grouped into three dysmenorrhea symptom-based phenotypes: "mild localized pain," "severe localized pain," and "severe multiple pain and gastrointestinal symptoms." Over one menstrual cycle, participants provided vaginal swabs when they were on- and off-menses. We assayed the vaginal microbiome using 16S rRNA gene sequencing. Permutational multivariate analysis of variance tests were used to compare microbiome compositions across phenotypes, with heat maps generated to visualize the relative abundance of bacterial taxa.

RESULTS

The vaginal microbiome compositions (n = 40) were different across the three phenotypes. After separating the on-menses (n = 20) and off-menses (n = 20) specimens, the statistically significant difference was seen on-menses, but not off-menses. Compared to the "mild localized pain" phenotype, participants in the "multiple severe symptoms" phenotype had a lower lactobacilli level and a higher abundance of Prevotella, Atopobium, and Gardnerella when on-menses. We also observed trends of differences across phenotypes in vaginal microbiome change from off- to on-menses.

DISCUSSION

The study provides proof-of-concept data to support larger studies on associations between dysmenorrhea symptom-based phenotypes and vaginal microbiome that might lead to new intervention targets and/or biomarkers for dysmenorrhea. This line of research has the potential to inform precision dysmenorrhea treatment that can improve women's quality of life.