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Dysmenorrhoeaby

A.J. Yates

What is dysmenorrhoea (anddoes it matter…?)

• Dysmenorrhoea is painful cramping, usually in the

lower abdomen, occurring shortly before or during

menstruation, or both

• Primary dysmenorrhoea occurs in the absence of any

identifiable underlying pelvic pathology

• Secondary dysmenorrhoea is associated with

underlying pelvic pathology (such as endometriosis,

fibroids, or endometrial polyps).

Some facts and figures

• Dysmenorrhoea is the most common gynaecological symptomreported by women

• It affects between 50% and 90% of menstruating women. Thewide variation in reported prevalence rates is probably due todifferences in definition

• It can lead to absence from school or work; 13–51% of womenreport ever having been absent and 5–14% report beingfrequently absent because of dysmenorrhoea

• Despite the high prevalence of dysmenorrhoea and the impactit has on quality of life and general well-being, few womenseek medical treatment for dysmenorrhoea.

Aims and objectives

• Consider the underlying causes of primary

dysmenorrhoea

• Look at common orthodox treatments for

dysmenorrhoea

• Look at herbs and supplements that can help

alleviate the symptom of dysmenorrhoea

• Consider our differential diagnosis

• Review some case studies.

What can cause primary

dysmenorrhoea?

• Strong, frequent uterine contractions lead toischaemia of the uterine muscle

• Can be caused by in imbalance of prostaglandins and endogenous hormones

• Other factors may contribute:

– Poor diet

– Digestive problems

– Lack of exercise

– Stress.

The orthodox approach

• Lifestyle changes• NSAID’s

• Oral contraception

• Medroxyprogesterone acetate • Mirena IUD

• Laparoscopic uterine nerve ablation

• Hysterectomy.



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Eicosanoids

• A family of hormone-like substances which regulateovulation, menstruation, and labour

• Include prostaglandins, leukotrienes andthromboxane

• Identified by different series:

– Series 1 are derived from linoleic acid and γ-linolenic acid,and are anti-inflammatory

– Series 2 are derived from arachidonic acid and are largely pro-inflammatory

– Series 3 are derived from eicosapentaenoic acid and reduceabnormal blood clotting.

Prostaglandins

• A number of different eicosanoids have a role to play

the menstrual cycle

• Some prostaglandins are pro-inflammatory, and their

levels are elevated in women that suffer from

dysmenorrhoea

• PGE1 is also known as the ‘good’ prostaglandin, and

is anti-inflammatory

• At the end of the day, getting the balance right is key

• But how are these substances formed…?

Okay… So what do we need to know…?

• Changing the amounts of source materials for

the different eicosanoids can change the ratios

of series 1 and series 2 prostaglandins

• These source materials are derived from our

diet

• Increasing sources of linoleic acid and α-linolenic acid relative to arachidonic acid will

have an anti-inflammtory effect.

Which are the sources?

• Examples of sources to encourage: – Dark green leafy vegetables

– Pumpkin seeds, linseeds

– EPO, soya bean oil, star flower oil

– Fish oils (especially good for omega 3)

• Examples of sources to discourage:

– Meat

– Eggs.

Aims of phytotherapy

• Consider the use of: – Anodynes

– Uterine tonics

– Emmenagogues

– Relaxants

– Circulatory stimulants

– Hormone regulation

– Digestive support.



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Anemone pulsatilla Alchemilla vulgaris

Artemisia vulgaris Valeriana officinalis

Viburnum spp. Zingiber officinale



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Achillea millefolium Vitex agnus-castus

Taraxacum officinale Supplementation

• Number one priority is to get the diet right

• Some nutrients are thought to regulate prostaglandin levels and/or reduce pain:

– EFA’s from EPO or fish oils

– Magnesium

– Calcium

– Zinc

– Vitamin B6

– Vitamin E.

Differential diagnosis

• The following can involve secondarydysmenorrhoea:

– Endometriosis

– Chronic PID

– IUD

– Pelvic congestion syndrome

• If in doubt, refer.

Case study 1

• Female, aged 29 years• PC – dysmenorrhoea & menorrhagia

• PMH – been on the contraceptive pill since aged 16

years due to above symptoms. Treated for

endometriosis aged 20 years – laparoscopy two years

later showed NAD. Miscarriage aged 26 years.

Symptoms worsened six months ago – GP has just

prescribe analgesics and advised her to “keep a

diary”.



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Case study 1 (cont)

• NS – suffers with insomnia; usually onlymanages five or six hours sleep a night.

• DS – weight stable; 2 x BM/day. Has had IBS but asymptomatic for past two years. Has atendency to eat lots of wheat and chocolate at

present due to stress.

• P/E – some tenderness in suprapubic regionand left iliac fossa. Patient complained of feeling bloated. No lymphadenopathy.

Case study 1 (cont)

• Rx 1 main mix:Alchemilla vulgaris 1:5 – 20

Anemone pulsatilla (specific) 1:1 – 15

Centella asiatica 1:4 – 20

Cimicifuga racemosa 1:1 – 15

Taraxacum officinale (radix) 1:3 – 10

Viburnum prunifolium 1:1 – 20

Zingiber officinale 1:2 – 5

TOTAL = 105 ml x 3

Sig – 5 ml tds ac caq

Case study 1 (cont)

• Rx 2Vitex agnus-castus 1:1 – 20

TOTAL = 20 ml

Sig – 20 gtt od mane

• Rx 3 (not to be taken with main mix)Anemone pulsatilla (specific) 1:1 – 20

Valeriana officinalis 1:1 – 40Viburnum prunifolium 1:1 – 40

TOTAL = 100 ml

Sig – 5 ml every two hours prn

Case study 1 (cont)

• Second consultation:

• GRS – Had just had a period; bleeding had beenlighter. Pain mix had worked really well – hadn’tneeded to take any analgesics.

• NS – sleep improved (patient felt that pain had beencontributing to her insomnia). Mood has been up &down (is still feeling stressed).

• DS – NAD. Advised to increase fruit & veg, and tryto cut down protein intake. Had started taking amulti-vitamin & mineral plus hemp seed oil.

• Rx – repeated all Rx, but added a calming tea.

Case study 1 (cont)

• Third consultation• Generally patient is happy with the treatment.

All symptoms are still improved, although

period is still longer than usual (14 days), and

needs the pain mix regularly.

• GP has arranged for a laparoscopy.

• Repeated Rx.

Case study 1 (cont)

• Fourth consultation• Telephone conversation with patient.

Laparoscopy had shown patient to be suffering

from PID.

• Referred to a consultant, so patient decided to

suspend herbal treatment.



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Case Study 2

• Female, aged 39 years

• PC – PMS: mainly dysmenorrhoea about fivedays before period until two days after. Alsosuffers from nausea, mood swings, andmastalgia about the same time, and suffersfrom some menorrhagia during the period.

• PMH – treated for GU & PU aged 26 years.History of depression; currently been on SSRIfor the past two years.

Case stud 2 (cont)

• DH – currently taking an SSRI & omeprazole. Was

given a medroxyprogesterone acetate injection

fourteen months ago due to her dysmenorrhoea, but

then bled continuously for nine months. Due a

hysterectomy, but did not have it due to bleeding.

• DS – generally okay with the omeprazole.

• NS – mood stable; some insomnia.

• P/E – tenderness in epigastric, umbilical, suprapubic

regions, and right iliac fossa. No lymphadenopathy.

Case study 2 (cont)

• Rx 1 main mix:

Anemone pulsatilla (specific) 1:1 – 15

Cimicifuga racemosa 1:1 – 15

Glycyrrhiza glabra 1:1 – 10

Taraxacum officinale (folia) 1:1 – 20

Taraxacum officinale (radix) 1:1 – 15

Viburnum prunifolium 1:4 – 20


TOTAL = 100 ml x 2

Sig – 5 ml tds ac caq

Case study 2 (cont)

• Rx 2Vitex agnus-castus 1:1 – 20

TOTAL = 20 ml

Sig – 20 gtt od mane

• Rx 3 (not to be taken with main mix)Anemone pulsatilla (specific) 1:1 – 20

Valeriana officinalis 1:1 – 40Viburnum prunifolium 1:1 – 40


TOTAL = 105 ml

Sig – 5 ml every two hours prn

Case study 2 (cont)

• Second consultation:• GRS – not had any PMS symptoms (would normally

have had them by now). Is due a hysterectomy next

month but is going to postpone.

• DS – diet improved (is taking hemp seed oil).

Asymptomatic (but is still taking omeprazole).

• NS – mood stable; will talk to GP about reducing

amount of SSRI.

• Rx – repeated x5 (except pain mix as not needed yet).

Case study 2 (cont)

• Third consultation• GRS – still no PMS symptoms. Dysmenorrhoea is

less, and is relieved by pain mix. Menorrhagia isreduced.

• SH – friend recently died.

• DS – diet poor at the moment, but generallyimproved.

• NS – sleep disturbed at the moment, but is generallyokay.

• Rx – repeated Rx x5, but added another calming tea.



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Case study 2 (cont)

• Fourth consultation.

• GRS – all symptoms improved. Only needed pain mix on one day. Bleeding lighter.

• DS – diet has improved. Has gained four kgand feels better for it.

• NS – mood stable, sleep improved. Has nowweaned herself off of the SSRI.

• SH – started doing yoga and meditation.

• Repeated Rx x5.

Case study 2 (cont)

• Fifth consultation.

• GRS – symptoms unchanged. Feels that shecan manage them and does not feel the needfor a hysterectomy.

• All other symptoms fine.

• Is due to move from the area – will take astock of herbs, but will try without them oncesettled. Will contact me if she requires further treatment or details of a herbalist in the area.

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