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

Combined oral contraceptive pill for primary dysmenorrhoea

BACKGROUND

Dysmenorrhoea (painful menstrual cramps) is common and a major cause of pain in women. Combined oral contraceptives (OCPs) are often used in the management of primary dysmenorrhoea, but there is a need for reporting the benefits and harms. Primary dysmenorrhoea is defined as painful menstrual cramps without pelvic pathology.

OBJECTIVES

To evaluate the benefits and harms of combined oral contraceptive pills for the management of primary dysmenorrhoea.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date 28 March 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing all combined OCPs with other combined OCPs, placebo, or management with non-steroidal anti-inflammatory drugs (NSAIDs). Participants had to have primary dysmenorrhoea, diagnosed by ruling out pelvic pathology through pelvic examination or ultrasound.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary outcomes were pain score after treatment, improvement in pain, and adverse events.

MAIN RESULTS

We included 21 RCTs (3723 women). Eleven RCTs compared combined OCP with placebo, eight compared different dosages of combined OCP, one compared two OCP regimens with placebo, and one compared OCP with NSAIDs. OCP versus placebo or no treatment OCPs reduce pain in women with dysmenorrhoea more effectively than placebo. Six studies reported treatment effects on different scales; the result can be interpreted as a moderate reduction in pain (standardised mean difference (SMD) -0.58, 95% confidence interval (CI) -0.74 to -0.41; I² = 28%; 6 RCTs, 588 women; high-quality evidence). Six studies also reported pain improvement as a dichotomous outcome (risk ratio (RR) 1.65, 95% CI 1.29 to 2.10; I² = 69%; 6 RCTs, 717 women; low-quality evidence). The data suggest that in women with a 28% chance of improvement in pain with placebo or no treatment, the improvement in women using combined OCP will be between 37% and 60%. Compared to placebo or no treatment, OCPs probably increase the risk of any adverse events (RR 1.31, 95% CI 1.20 to 1.43; I² = 79%; 7 RCTs, 1025 women; moderate-quality evidence), and may also increase the risk of serious adverse events (RR 1.77, 95% CI 0.49 to 6.43; I² = 22%; 4 RCTs, 512 women; low-quality evidence). Women who received OCPs had an increased risk of irregular bleeding compared to women who received placebo or no treatment (RR 2.63, 95% CI 2.11 to 3.28; I² = 29%; 7 RCTs, 1025 women; high-quality evidence). In women with a risk of irregular bleeding of 18% if using placebo or no treatment, the risk would be between 39% and 60% if using combined OCP. OCPs probably increase the risk of headaches (RR 1.51, 95% CI 1.11 to 2.04; I² = 44%; 5 RCTs, 656 women; moderate-quality evidence), and nausea (RR 1.64, 95% CI 1.17 to 2.30; I² = 39%; 8 RCTs, 948 women; moderate-quality evidence). We are uncertain of the effect of OCP on weight gain (RR 1.83, 95% CI 0.75 to 4.45; 1 RCT, 76 women; low-quality evidence). OCPs may slightly reduce requirements for additional medication (RR 0.63, 95% CI 0.40 to 0.98; I² = 0%; 2 RCTs, 163 women; low-quality evidence), and absence from work (RR 0.63, 95% CI 0.41 to 0.97; I² = 0%; 2 RCTs, 148 women; low-quality evidence). One OCP versus another OCP Continuous use of OCPs (no pause or inactive tablets after the usual 21 days of hormone pills) may reduce pain in women with dysmenorrhoea more effectively than the standard regimen (SMD -0.73, 95% CI -1.13 to 0.34; 2 RCTs, 106 women; low-quality evidence). There was insufficient evidence to determine if there was a difference in pain improvement between ethinylestradiol 20 μg and ethinylestradiol 30 μg OCPs (RR 1.06, 95% CI 0.65 to 1.74; 1 RCT, 326 women; moderate-quality evidence). There is probably little or no difference between third- and fourth-generation and first- and second-generation OCPs (RR 0.99, 95% CI 0.93 to 1.05; 1 RCT, 178 women; moderate-quality evidence). The standard regimen of OCPs may slightly increase the risk of any adverse events over the continuous regimen (RR 1.11, 95% CI 1.01 to 1.22; I² = 76%; 3 RCTs, 602 women; low-quality evidence), and probably increases the risk of irregular bleeding (RR 1.38, 95% CI 1.14 to 1.69; 2 RCTs, 379 women; moderate-quality evidence). Due to lack of studies, it is uncertain if there is a difference between continuous and standard regimen OCPs in serious adverse events (RR 0.34, 95% CI 0.01 to 8.24; 1 RCT, 212 women), headaches (RR 0.94, 95% CI 0.50 to 1.76; I² = 0%; 2 RCTs, 435 women), or nausea (RR 1.08, 95% CI 0.51 to 2.30; I² = 23%; 2 RCTs, 435 women) (all very low-quality evidence). We are uncertain if one type of OCP reduces absence from work more than the other (RR 1.12, 95% CI 0.64 to 1.99; 1 RCT, 445 women; very low-quality evidence). OCPs versus NSAIDs There were insufficient data to determine whether OCPs were more effective than NSAIDs for pain (mean difference -0.30, 95% CI -5.43 to 4.83; 1 RCT, 91 women; low-quality evidence). The study did not report on adverse events.

AUTHORS' CONCLUSIONS

OCPs are effective for treating dysmenorrhoea, but they cause irregular bleeding, and probably headache and nausea. Long-term effects were not covered in this review. Continuous use of OCPs was probably more effective than the standard regimen but safety should be ensured with long-term data. Due to lack of data, we are uncertain whether NSAIDs are better than OCPs for treating dysmenorrhoea.

Pharmacokinetics-derived absorbed components responsible for Guizhi-Fuling capsule target PI3K/Akt-Erk to exert an anti-dysmenorrhea effect

ETHNOPHARMACOLOGICAL RELEVANCE

Guizhi-Fuling capsule (GZFL), a well-known herbal remedy, has been widely used to treat primary dysmenorrhea (PD). Hence, systematic identifying multiple active ingredients and the involved mechanism is essential and urgently needed for GZFL.

AIM OF THE STUDY

This study was planned to assess the pharmacokinetics of GZFL in rats, and identify whether these GZFL-derived absorbed components (ACs) contribute to the efficacy of source herbs and relevant mechanism.

MATERIALS AND METHODS

The in vivo pharmacokinetic profile of 11 phytochemicals and 13 metabolites in healthy and PD rats were evaluated using liquid chromatography with mass spectrometry (LC-MS/MS). Whereafter, the introduced contribution strategy assessed ACs' effect (doses = their contents in GZFL) in PD rats with the mechanism.

RESULT

The pharmacokinetic profiles of prototypes and metabolites differed in healthy and PD rats. As a main proxy of GZFL, 11ACs exerted an anti-PD effect (improvement of indexes for writhing latency, writhing time, PGF_2α/PGE₂, TXB₂/6-keto-PGF_1α and β-EP) by regulating PI3K-Akt/ERK pathway.

CONCLUSION

As a paradigmatic example, 11ACs contributed an average of 113.55% to GZFL in terms of anti-PD efficacy, providing an approach to rapidly, accurately and consistently identify the bioactive components and their pathway from herbs.

Long-term treatment of endometriosis-related pain among women seeking hormonal contraception

OBJECTIVE

To evaluate the different effects of a progestin-only contraceptive with desogestrel (DSG) vs combined oral contraceptives (COCs) for a first line long-term treatment of endometriosis-related pain among patients seeking hormonal contraception.

METHODS

An observational retrospective cohort study was conducted in collaboration with a local outpatient clinic for endometriosis among a group of nulliparous young women (n = 216) with endometriosis-related pain and seeking contraception. The cohort was subdivided into a group (n = 73) treated as first line by DSG and another group (n = 75) treated by a COC. During the study, clinical symptoms, side effects and possible changes in OC type use were recorded.

RESULTS

No significant difference was found between the two groups in terms of clinical characteristics and pain scores before treatment. After 6 months both treatments were effective in reducing endometriosis-related pain, and those treated with DSG showed lower levels of dysmenorrhea, dyspareunia and nonmenstrual pelvic pain than COCs group (p < .01). After 12 months, in DSG Group some patients (15%) switched from DSG to a COC for breakthrough bleeding, whereas in COC Group 48% of patients switched to another type of COC for reduced efficacy on pain and/or for side effects. After 3 years of OC treatment, in DSG Group 79% of patients maintained the same therapy, whereas in COC Group only 14% continued the same COC type, 37% switched to another COC and 47% to DSG.

CONCLUSIONS

A progestin-only contraceptive with DSG is a valid option for long term management of endometriosis-related pain in patients seeking hormonal contraception.

Self-care strategies and sources of knowledge on menstruation in 12,526 young women with dysmenorrhea: A systematic review and meta-analysis

Introduction: Dysmenorrhea (period pain) is common and affects around three quarters of all young women under the age of 25. The majority of young women, for a variety of reasons, think of period pain as ‘normal’ and something to be managed or endured. This normalisation of pain often is reinforced by family and friends and results in young women using self-care strategies to manage their pain rather than seeking medical advice. This systematic review and meta-analysis examined observational studies reporting on the prevalence of different types of self-care, both pharmaceutical and non-pharmaceutical, self-rated effectiveness of self-care and the sources of information on menstruation in young women under 25 Methods: A search of Medline, PsychINFO, EMBASE and CINAHL in English was carried out from 1980 to December 2018. Studies that reported on menstrual self-care strategies in young women were included. Results: Nine hundred and forty-seven articles were screened. Twenty-four studies including 12,526 young women were eligible and included in the meta-analysis. Fifteen studies were from low, lower-middle or upper-middle-income countries (LMIC) and nine studies were from high income countries (HIC). Self-care was used by over half of all young women (55%, 95%CI 34.1–74.3) with both pharmaceutical (48%, 95%CI 40.0–57.0) and non-pharmaceutical (51.8%, 95%CI 31.3–71.7) options used. Paracetamol was the most common analgesic used (28.7%, 95%CI 19.6–39.9) but did not always provide sufficient pain relief in almost half of those using it. Contraceptive use was significantly higher (P<0.001) in HIC (22%) compared to LMIC (1%). Only 11% (95%CI 8.4–15.2) of young women reported seeing a medical doctor for their period pain. Conclusions: Self-care usage, both pharmaceutical and non-pharmaceutical, was common, but young women were not necessarily choosing the most effective options for pain management. High-quality information on self-care for period pain is urgently needed.

No. 345-Primary Dysmenorrhea Consensus Guideline

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

INTENDED USERS

Health care providers.

TARGET POPULATION

Women and adolescents experiencing menstrual pain for which no underlying cause has been identified.

EVIDENCE

Published clinical trials, population studies, and review articles cited in PubMed or the Cochrane database from January 2005 to March 2016.

VALIDATION METHODS

Seven clinical questions were generated by the authors and reviewed by the SOGC Clinical Practice-Gynaecology Committee. The available literature was searched. Guideline No. 169 was reviewed and rewritten in order to incorporate current evidence. Recommendations addressing the identified clinical questions were formulated and evaluated using the ranking of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated. Effective therapy is widely available at minimal cost. Treatment has the potential to improve quality of life and to decrease time lost from school or work.

GUIDELINE UPDATE

This guideline is a revision and update of No. 169, December 2005.

SPONSORS

SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Overview of perimenopausal contraception

The perimenopause is accompanied by important biological and psychosocial changes. The choice of contraceptive methods for women in the perimenopause, none of which is limited by age alone, will depend on the efficacy, safety, tolerability, and potential benefit of each method in relation to the biopsychosocial profile of the individual woman. Copper intrauterine devices are highly effective in the typical user and are a very safe method with, in general, good tolerability but are of limited use in women with heavy menstrual bleeding and subserous myomata. An additional benefit of copper intrauterine devices is protection against endometrial cancer. All progestogen-based methods share a favorable cardiovascular profile, making their use safe in most perimenopausal women. Long-acting implants and intrauterine systems are user independent and highly effective. Injectables and pills depend on user compliance. There is no evidence of a significant impact on breast cancer. Their impact on the endometrium can be either a negative side-effect (irregularity) or a benefit regarding reduction of heavy menstrual bleeding. Combined hormonal contraceptives have the highest cardiovascular risk. They can act as a promoting factor for breast cancer and cervical cancer, but they have the strongest potential regarding benefits (protection against endometrial and ovarian cancer, positive effect on bone mineral density, menstrual complaints, hyperandrogenic symptoms, hot flushes, and reduced risk regarding benign ovarian cysts and benign breast tumors).

Vitamin E and fish oil, separately or in combination, on treatment of primary dysmenorrhea: a double-blind, randomized clinical trial

Primary dysmenorrhea is one of the most common complaints of women. The aim of this study was to investigate the adjuvant effect of vitamin E and omega-3 fatty acids, separately or in combination, supplements on pain in the treatment of primary dysmenorrhea. This clinical trial conducted on students of university. Qualified girls completed the VAS before randomization. Arrangement was determined according to the severity of the pain (mild 0-3; moderate 3.1-6; severe 6.1-10). One hundred patients were randomly assigned to four groups receiving omega-3 (n = 25), vitamin E (n = 25), vitamin E- omega-3 (n = 25), or placebo (n = 25). Three hundred milligrams of omega-3 capsules (180 mg EPA and 120 mg DHA) and 200 international units (IU) vitamin E were administered daily. Severity of the pain measured in the beginning and the end of the study. Omega-3 and vitamin E supplements effectively relieved menstrual pain compared with the placebo. But in group with combination of vitamin E + omega-3 has a considerable effect on menstrual pain when compared with other groups (p < .05). Using of Nonsteroidal anti-inflammatory drug has high complication; however, Fish oil and vitamin E are helpful in reducing of dysmenorrhea pain and can be replaced with them.

A Systematic Review and Meta-Analysis of the Efficacy of Manipulative Therapy in Women with Primary Dysmenorrhea

OBJECTIVE

To assess the robustness of evidence for the efficacy of manipulative therapy in women with primary dysmenorrhea.

METHOD

Seven electronic databases were searched for studies reporting data on manipulative therapy for women with primary dysmenorrhea. The primary and secondary outcomes were pain relief and quality of life, respectively. Quality of eligible studies was assessed using the Physiotherapy Evidence Database (PEDro) guideline.

RESULTS

The search yielded 19 citations of which four were systematically reviewed and three eligible for meta-analysis. The systematic review showed above moderate methodological quality with a mean of 6.7 out of 10 on the PEDro quality scale. Manipulative therapy showed evidence of pain reduction in primary dysmenorrhea.

CONCLUSION

Manipulative therapy could be considered as adjunct therapy in the relief of pain in primary dysmenorrhea. More high-quality research is needed before the evidence for their utilization can be ascertained. Particularly, items related to assessor blinding should be considered in future studies.

The essential oil from the twigs of Cinnamomum cassia Presl inhibits oxytocin-induced uterine contraction in vitro and in vivo

ETHNOPHARMACOLOGICAL RELEVANCE

The twigs and bark of Cinnamomum cassia Presl (Lauraceae) are widely used in traditional Chinese medicine in the treatment of tumor, abdominal pain, dysmenorrhea, digestive system disease and inflammatory diseases. The aim of this study was to determine the inhibitory effect of the essential oil from the twigs of Cinnamomum cassia Presl (EOCC) on uterine contraction in vitro and in vivo.

MATERIALS AND METHODS

The Institute of Cancer Research (ICR) mouse uterine contraction was induced by oxytocin (OT) exposure following estradiol benzoate pretreatment. Mice were given the EOCC (60, 30, and 15mg/kg) by gavage. The level of prostaglandin F_2α (PGF_2α) in uterine tissue were determined according to specification of enzyme linked immunosorbent assay (ELISA) kit. Uterine tissue was collected for histopathological analysis (H&E). Myosin light chain 20 (MLC20), phosphorylation of myosin light chain 20 (p-MLC20) and cyclooxygenase-2 (COX-2) proteins in uterine tissue were assessed by Western Blot. Mouse isolated uterus strips were mounted in tissue organ baths containing Locke's solution. The contractile responses were recorded with Power Lab recording system. The effect of the EOCC on uterine contraction induced by OT, PGF_2α, and acetylcholine (Ach) was observed. Myometrial cells were exposed to OT (7μM) to induce Ca²⁺ release, and the effect of the EOCC (100, 50, and 25μg/ml) on intracellular Ca²⁺ was analysed with fluorometry imaging.

RESULTS

In vivo study demonstrated that the EOCC significantly reduced OT-induced writhing responses with a maximal inhibition of 66.5%. It also decreased the level of PGF_2α in OT-induced mice uterine tissue. Moreover, Western blot analysis showed that COX-2 and p-MLC20 expressions in uterine tissue of dysmenorrhea mice were significantly reduced. EOCC inhibited spontaneous uterus contractions in a dose-dependent manner, and the concentration of the EOCC giving 50% of maximal contraction (IC₅₀) value was 61.3μg/ml. The IC₅₀ values of the EOCC on OT, PGF_2α, and Ach-induced contractions were 113.0μg/ml, 94.7μg/ml, and 61.5μg/ml, respectively. Further in vitro studies indicated that the EOCC could restrain intracellular Ca²⁺ levels in favour of uterine relaxation.

CONCLUSION

Both in vivo and in vitro results suggest that the EOCC possesses significant spasmolytic effect on uterine contraction. Thus, the EOCC yields a possible therapeutic choice for the prevention and treatment of primary dysmenorrhea.

Effect of yoga on the menstrual pain, physical fitness, and quality of life of young women with primary dysmenorrhea

The aim of the present study was to investigate effect of specially designed yoga program on the menstrual pain, physical fitness, and quality of life (QOL) of non-athlete women with primary dysmenorrhea (PD) aged 18-22 years. Thirty-four volunteers were randomly assigned into control and yoga groups. Menstrual pain, physical fitness, and QOL were evaluated at baseline and at the end of the 12-week study period. The yoga group was asked to practice yoga for 30 min per day, twice a week, for 12 weeks at home, while the control group did not receive any form of exercise over the study period. There were significant improve in menstrual pain, physical fitness, and QOL in the yoga group more than the control group. Therefore, this specially designed yoga program may be a possible complementary treatment for PD.

Menstrual Disorders and Its Determinants Among Married Women of Rural Haryana

INTRODUCTION

Disorders of menstruation are common problems among women. They have several psychological effects on women's health.

AIM

This study aimed to estimate prevalence of menstrual disorders, usage of sanitary pads and their determinants among married women in selected villages of rural Haryana.

MATERIALS AND METHODS

A cross-sectional study was conducted during September 2011 in 10 villages of PHC (Primary Health Centre) Mandi, Haryana, using a systematic random sampling technique. Currently married women in the age group of 18-45 years living in study area for more than 1 year were included in the study while those who were pregnant and unable to understand questions were excluded. Informed verbal consent was obtained from all participants.

RESULTS

A total of 344 women were interviewed. The mean (SD) age of participants was 28.0 (5.4) years. Majority of women were housewives (78.8%) and most had education up to middle school (22.7%). Mean (SD) age at menarche was 14.3 (1.2) years. Nearly one-tenth of women had married before 18 years of age. Prevalence of all menstrual disorders was 20.3% and most common disorder was excessive pain. About one fifth reported irregularity of menstrual cycles. Almost half were not using sanitary pads during menses. Menstrual disorders were more common among non-users of contraception (OR=1.7, p = 0.04) and housewives (OR = 2.4, p= 0.03).

CONCLUSION

Disorders of menstruation were fairly common among women surveyed. Usage of sanitary pads was quiet low. Awareness generation among women regarding menstrual problems and Behaviour Change Communication to promote usage of sanitary pads are important measures to reduce related morbidity.

Efficacy of Acupuncture versus Combined Oral Contraceptive Pill in Treatment of Moderate-to-Severe Dysmenorrhea: A Randomized Controlled Trial

This open-label randomized controlled trial was designed to compare the efficacy of acupuncture and combined oral contraceptive (COC) pill in treating moderate-to-severe primary dysmenorrhea. Fifty-two participants were randomly assigned to receive either acupuncture (n = 27) or COC (n = 25) for three menstrual cycles. Mefenamic acid was prescribed as a recue analgesic drug with both groups. The statistical approach used for efficacy and safety assessments was intention-to-treat analysis. By the end of the study, both treatments had resulted in significant improvement over baselines in all outcomes, that is, maximal dysmenorrhea pain scores, days suffering from dysmenorrhea, amount of rescue analgesic used, and quality of life assessed by SF-36 questionnaire. Over the three treatment cycles, COC caused greater reduction in maximal pain scores than acupuncture, while improvements in the remaining outcomes were comparable. Responders were defined as participants whose maximal dysmenorrhea pain scores decreased at least 33% below their baseline. Response rates following both interventions at the end of the study were not statistically different. Acupuncture commonly caused minimal local side effects but did not cause any hormone-related side effects as did COC. In conclusion, acupuncture is an alternative option for relieving dysmenorrhea, especially when COC is not a favorable choice.

A review of in vitro and in vivo studies on the efficacy of herbal medicines for primary dysmenorrhea

Purpose. Primary dysmenorrhea (PD) is a common gynecological complaint among adolescent girls and women of reproductive age. This study aims to review the findings of published articles on the in vitro and in vivo efficacy of herbal medicines for PD. Methods. In vitro and in vivo studies of herbal compounds, individual herbal extracts, or herbal formula decoctions published from their inception to April 2014 were included in this review. Results. A total of 18 studies involving herbal medicines exhibited their inhibitory effect on PD. The majority of in vitro studies investigated the inhibition of uterine contractions. In vivo studies suggest that herbal medicines exert a peripheral analgesic effect and a possible anti-inflammatory activity via the inhibition of prostaglandin (PG) synthesis. The mechanisms of herbal medicines for PD are associated with PG level reduction, suppression of cyclooxygenase-2 expression, superoxide dismutase activation and malondialdehyde reduction, nitric oxide, inducible nitric oxide synthase, and nuclear factor-kappa B reduction, stimulation of somatostatin receptor, intracellular Ca(2+) reduction, and recovery of phospholipid metabolism. Conclusions. Herbal medicines are thought to be promising sources for the development of effective therapeutic agents for PD. Further investigations on the appropriate herbal formula and their constituents are recommended.

Traditional Chinese medicine for the treatment of primary dysmenorrhea: how do Yuanhu painkillers effectively treat dysmenorrhea?

AIM

To examine the efficacy of YuanHu painkillers (YHP) as a treatment for primary dysmenorrhea and to reveal YHP's principle formula.

METHODS

A Wistar rat uterine contraction model was utilized in this study. Rats were given 0.698g/kg YHP, 0.07g/kg tetrahydropalmatine (THP; YHP's main component), 0.02g/kg imperatorin (IMP), or THP+IMP (0.07+0.02g/kg) as polypharmacy (PG) by gavage. H&E staining and histopathological examination of the uteri tissue samples were performed. We then detected superoxide dismutase (SOD) and malondialdehyde (MDA), nitric oxide (NO), as well as inducible nitric oxide synthase (iNOS), i-κB, nuclear factor-κB (NF-κB), and cyclooxygenase-2 (COX-2) indices.

RESULTS

PG significantly inhibited the uterine contraction of the primary dysmenorrhea rat model (p<0.05), and was significantly different than single-agent therapy (p<0.05). Histopathological examination showed inflammation in the uteri of the control group which YHP and its main constitutes alleviated. THP significantly inhibited the contraction of isolated uteri caused by Ach, PGF2α and oxytocin in a concentration-dependent fashion. THP and IMP both significantly affected the levels of NO, activation of NF-κB, up-regulated the expression of i-κB and down-regulated the expression of both iNOS and COX-2. IMP obviously decreased the level of MDA and increased the activation of SOD (p<0.05). PG obviously improved all the parameters mentioned above (p<0.05).

CONCLUSIONS

YHP exerted protective effects on primary dysmenorrhea in rats and remarkably alleviated the severity of experimental primary dysmenorrhea. The combined strategy proved to be more effective than either THP or IMP alone and may have synergistic effects in combination in primary dysmenorrhea. Mechanisms that might account for the beneficial effects include abating oxidative stress, inhibiting over-inflammatory reaction, and alleviating the contraction of isolated rat uteri by inhibiting the influx of extracellular Ca(2+). Broad potential for future clinical practice is foreseeable.

Dysmenorrhea in women with Crohn's disease: a case-control study

BACKGROUND

Dysmenorrhea and Crohn's disease (CD) have overlapping symptoms; however, their relationship is poorly understood. The aims of this study were to examine (1) the impact of dysmenorrhea on pain severity and pain medication use in CD and (2) the relationships between dysmenorrhea, CD activity, and health-related quality of life (HRQOL).

METHODS

This was a case-control study of menstruating women with and without CD. Subjects were assessed for dysmenorrhea, pain severity, medication use, menstrual distress, and HRQOL. CD activity scores were calculated. The correlation between menstrual distress and CD activity was assessed. Linear regression analysis was performed to determine the effects of dysmenorrhea and CD on pain severity.

RESULTS

A total of 110 subjects were studied and 40% of cases had dysmenorrhea. Dysmenorrhea was associated with higher pain scores among cases. Compared with controls, cases with dysmenorrhea reported similar pain severity but lower nonsteroidal anti-inflammatory drug use. After adjusting for medication use, cases had significantly greater distress due to menstrual pain. CD activity scores were not higher in women with dysmenorrhea; however, menstrual distress scores correlated positively with disease activity. HRQOL was significantly lower in cases with dysmenorrhea by some measures.

CONCLUSIONS

Dysmenorrhea is common in women with CD and has an additive effect on overall pain severity. It is not, however, associated with greater nonsteroidal anti-inflammatory drug use. Menstrual distress is positively correlated with CD activity scores and associated with lower HRQOL by some measures. Treatment of dysmenorrhea may improve the pain experienced by women with CD, the perception of CD activity, and the quality of life in women with CD.

Beta2-adrenoceptor agonists for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological complaint that can affect as many as 50% of premenopausal women, 10% of whom suffer severely enough to be rendered incapacitated for one to three days during each menstrual cycle. Primary dysmenorrhoea is where women suffer from menstrual pain but lack any pathology in their pelvic anatomy. Beta2-adrenoceptor agonists have been used in the treatment of women with primary dysmenorrhoea but their effects are unclear.

OBJECTIVES

To determine the effectiveness and safety of beta2-adrenoceptor agonists in the treatment of primary dysmenorrhoea.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register; CENTRAL (The Cochrane Library 2011, Issue 8); MEDLINE; EMBASE; PsycINFO and the EBM Reviews databases. The last search was on 22 August 2011.

SELECTION CRITERIA

Randomised controlled trials comparing beta2-adrenoceptor agonists with placebo or no treatment, each other or any other conventional treatment in women of reproductive age with primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data.

MAIN RESULTS

Five trials involving 187 women with an age range of 15 to 40 years were included. Oral isoxsuprine was compared with placebo in two trials; terbutaline oral spray, ritodrine chloride and oral hydroxyphenyl-orciprenalin were compared with placebo in a further three trials. Clinical diversity in the studies in terms of the interventions being evaluated, assessments at different time points and the use of different assessment tools mitigated against pooling of outcome data across studies in order to provide a summary estimate of effect for any of the comparisons. Only one study, with unclear risk of bias, reported pain relief with a combination of isoxsuprine, acetaminophen and caffeine. None of the other studies reported any significant clinical difference in effectiveness between the intervention and placebo. Adverse effects were reported with all of these medications in up to a quarter of the total number of participants. They included nausea, vomiting, dizziness, quivering, tremor and palpitations.

AUTHORS' CONCLUSIONS

The evidence presented in this review was based on a few relatively small-sized studies that were categorised to have unclear to high risk of bias, which does not allow confident decision-making at present about the use of beta2-adrenoceptor agonists for dysmenorrhoea. The benefits as reported in one study should be balanced against the wide array of unacceptable side effects documented with this class of medication. We have emphasised the lack of precision and limitations in the reported data where appropriate.

Bak Foong Pills induce an analgesic effect by inhibiting nociception via the somatostatin pathway in mice

Dysmenorrhoea, defined as cramping pain in the lower abdomen occurring before or during menstruation, affects, to varying degrees, up to 90% of women of child-bearing age. We investigated whether BFP (Bak Foong Pills), a traditional Chinese medicine treatment for dysmenorrhoea, possesses analgesic properties. Results showed that BFP was able to significantly reduce pain responses following subchronic treatment for 3 days, but not following acute (1 h) treatment in response to acetic acid-induced writhing in C57/B6 mice. The analgesic effect was not due to inhibition of COX (cyclo-oxygenase) activity, evidenced by the lack of inhibition of prostacyclin and PGE2 (prostaglandin E2) production. Molecular analysis revealed that BFP treatment modulated the expression of a number of genes in the spinal cord of mice subjected to acetic acid writhing. RT-PCR (reverse transcription-PCR) analysis of spinal cord samples showed that both sst4 (somatostatin receptor 4) and sst2 receptor mRNA, but not μOR (μ-opiate receptor) and NK1 (neurokinin-1) receptor mRNA, were down-regulated following BFP treatment, thus implicating somatostatin involvement in BFP-induced analgesia. Administration of c-som (cyclo-somatostatin), a somatostatin antagonist, prior to acetic acid-induced writhing inhibited the analgesic effect. Thus subchronic treatment with BFP has anti-nociceptive qualities mediated via the somatostatin pathway.

Effect of three yoga poses (cobra, cat and fish poses) in women with primary dysmenorrhea: a randomized clinical trial

OBJECTIVE

We have evaluated the clinical efficacy of yoga for primary dysmenorrhea. Primary dysmenorrhea occurs in 50% of female adolescents and is a common problem in women of reproductive age. We have assessed whether three yoga poses (Cobra, Cat, and Fish Poses) are able to reduce severity and duration of primary dysmenorrhea.

METHODS

To determine the effectiveness of yoga in adolescents with primary dysmenorrhea, 92 girl students,18-22 years old, were randomly assigned to an experimental group (n = 50) and a control group (n = 42). The Visual Analog Scale for Pain was used to assess intensity of pain and the pain duration was calculated in terms of hours. Each group was evaluated for three menstrual cycles. At first cycle no method was presented; the participants only were asked to complete the questionnaire of menstrual characteristics during their menstrual. Then the participants were asked by the experimental group to do yoga poses at luteal phase, and also to complete the menstrual characteristics questionnaire in during of menstruation. The control group did not receive any intervention except to complete menstrual characteristics questionnaire in during of menstruation.

RESULTS

There was a significant difference in the pain intensity and pain duration in the post-tests compared with the pretest in yoga group (P < 0.05). The results showed that compared with the Control group, there was a significant difference in the pain intensity and pain duration in the experimental group (P < 0.05).

CONCLUSION

Yoga reduced the severity and duration of primary dysmenorrhea. The findings suggest that yoga poses are safe and simple treatment for primary dysmenorrhea.

Hormonal contraception--what kind, when, and for whom?

BACKGROUND

In Germany today, one-third of the 20 million women of child-bearing age use combined oral contraceptives (COCs). In this article, we summarize the current knowledge of the mode of action, wanted and unwanted side effects, and long-term risks of COCs. The levonorgestrel intrauterine device (IUD) and long-acting injectable or implantable monophasic progestogen preparations offer comparable contraceptive efficacy to COCs. Nonetheless, they are less frequently used in Germany than COCs, because of their propensity to cause breakthrough bleeding.

METHOD

Selective review of the literature.

RESULTS

COCs suppress gonadotropin secretion and thereby inhibit follicular maturation and ovulation. Their correct use is associated with 0.3 pregnancies per 100 women per year, their typical use, with 1 pregnancy per 100 women per year (Pearl index). COCs have effects on the cardiovascular and hemostatic systems as well as on lipid and carbohydrate metabolism. When given in the presence of specific risk factors, they significantly increase the likelihood of cardiovascular disease and thromboembolism. Women with persistent human papilloma virus (HPV) infection who take COCs are at increased risk of developing invasive cervical cancer. On the other hand, COCs lower the cumulative incidence of endometrial and ovarian cancer by 30% to 50%, and that of colorectal cancer by 20% to 30%. Other malignancies seem to be unaffected by COC use.

CONCLUSION

As long as personal and familial risk factors are carefully considered, COCs constitute a safe, reversible, and well-tolerated method of contraception.

Contracepção hormonal: uma comparação entre pacientes das redes pública e privada de saúde

O objetivo deste artigo é avaliar o perfil de pacientes usuárias de contraceptivos hormonais no setor público e fazer a comparação com o serviço privado de saúde, bem como verificar a frequência de efeitos colaterais e a aderência ao tratamento. Realizou-se um estudo de corte transversal com 240 pacientes, sendo 120 da rede privada e 120 da rede pública de saúde. No grupo privado, a dosagem hormonal mais frequentemente prescrita foi a de 15 ou 20 microgramas de etinil-estradiol (EE), associados a gestodeno, desogestrel ou levonogestrel (36,7%). No grupo público, a combinação de 30 microgramas de EE associados a gestodeno, levonogestrel ou desogestrel (48,3%) foi a principal medicação contraceptiva prescrita. Não houve diferença entre a frequência dos efeitos colaterais nos dois grupos pesquisados (p>0,05). A aderência ao tratamento foi maior nas pacientes do grupo privado (p<0,05). Concluiu-se que o método contraceptivo mais utilizado foi o oral com baixa dosagem de EE, não havendo diferença entre a frequência dos efeitos colaterais. A aderência ao tratamento foi maior no grupo privado, o que pode estar associado ao fator sociocultural das pacientes estudadas.

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.

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.

Advantages and challenges of oestrogen-free hormonal contraception

BACKGROUND

Not all women tolerate hormonal contraceptives containing oestrogens.

METHODS

The authors selected and evaluated relevant publications on the advantages and challenges of oestrogen-containing and oestrogen-free oral contraceptives obtained from the MEDLINE and Google databases from January 2000 to January 2010. In addition, the reference lists from the obtained publications as well as the authors' clinical experience served as additional sources of information. Emphasis was placed on the common adverse effects and risks associated with oestrogen replacement as well as on the noncontraceptive benefits of combined oral contraceptive pills and progestogen-only pills in the management of menstrual cycle-dependent problems.

FINDINGS

Progestogen-only pills have the potential to abolish many of the common adverse effects associated with oestrogen plus progestogen oral contraceptives and can be used to treat various menstrual cycle-dependent problems. However, only a limited number of clinical comparative studies are available. Progestogen-only pills are associated with a more irregular bleeding pattern than contraceptive pills containing oestrogens, especially during the first few months of therapy. As this is not permanent, adequate counselling is essential in order to prevent unnecessary discontinuation of treatment.

CONCLUSIONS

Progestogen-only pills offer an effective, convenient, and readily reversible method of contraception that is suitable for women with contraindications for oestrogens.

The measurement of menstrual symptoms: factor structure of the menstrual symptom questionnaire in adolescent girls

This study examined the factor structure of the Menstrual Symptom Questionnaire (MSQ) in a sample of 210 adolescent girls (11-17 years). Such an examination has not been carried out with an adolescent sample. In addition, the definitions of menstrual disorders have evolved since the creation of the MSQ. Exploratory factor analysis supported a three factor structure indicating abdominal pain, negative affect/somatic complaints, and back pain. Partial correlations indicated all three MSQ factors were correlated with depressive symptoms, but only the negative affect factor was correlated with trait anxiety. Future research should explore potential associations in multiple areas of functioning as menstrual symptoms may alter healthy developmental processes during adolescence.

Dysmenorrhea

Primary dysmenorrhea is commonly a straightforward diagnosis that can be made accurately with an attentive history. In young women who have classic symptoms and no specific indication, a pelvic examination is often unnecessary in the initial evaluation. The opportunity for primary care practitioners to support women in unearthing the best approach to this chronic recurrent discomfort to minimize adverse life impact is significant and valuable. Identification of patients who are incapacitated by their symptoms or have symptoms that represent underlying pathology is a critical component of a careful history. The wide range of treatments available for primary dysmenorrhea virtually ensures that all females troubled by the symptoms can find relief with safe and inexpensive treatments while limiting negative side effects.

Celecoxib in the treatment of primary dysmenorrhea: results from two randomized, double-blind, active- and placebo-controlled, crossover studies

BACKGROUND

Celecoxib, a cyclooxygenase-2 inhibitor, has established analgesic efficacy for the treatment of acute pain resulting from a variety of causes.

OBJECTIVE

This article describes 2 studies designed to assess the efficacy and tolerability of celecoxib in patients with primary dysmenorrhea.

METHODS

Two identical, 3-day, multiple-dose, randomized, double-blind, active- and placebo-controlled, crossover studies were carried out in women aged 18 to 44 years with primary dysmenorrhea (studies 1 and 2). The studies employed a 6-sequence, 3-period, complete-block crossover design over 3 menstrual cycles. Patients received celecoxib 400 mg, followed by celecoxib 200 mg no sooner than 12 hours after first dose (day 1), then celecoxib 200 mg q12h as necessary (days 2 and 3); naproxen sodium 550 mg followed by naproxen sodium 550 mg no sooner than 12 hours after first dose (day 1), then naproxen sodium 550 mg q12h as necessary (days 2 and 3); or placebo. Primary efficacy measures were time-weighted sum of total pain relief and time-weighted sum of pain intensity difference at 8 hours after administration of the first dose of study medication (TOTPAR[8] and SPID[8], respectively). Tolerability was assessed using routine physical examination, including vital sign measurements, and clinical laboratory analyses at screening and end of study.

RESULTS

In total, 149 and 154 patients were randomized to 1 of the 6 treatment sequences in studies 1 and 2, respectively. Across treatment sequences, mean age ranges were 23.4 to 26.9 years (study 1) and 28.3 to 34.1 years (study 2). Mean weight ranges were 62.7 to 74.5 kg (study 1) and 69.2 to 86.7 kg (study 2). Most patients (96.6% in study 1, 80.5% in study 2) were white. Mean TOTPAR[8] values with celecoxib (study 1/study 2, 18.28/17.98) and naproxen sodium (20.59/21.27) were significantly greater than with placebo (12.82/12.98) (all, P < 0.001). Mean SPID[8] values were significantly greater with celecoxib (10.06/9.60) and naproxen sodium (11.48/11.71) than with placebo (5.96/6.41) (all, P < 0.001). Naproxen sodium was significantly different from celecoxib in TOTPAR[8] (study 2 only) and SPID[8] (both studies) (all, P < 0.001). In both studies, the adverse-events (AEs) profile was not significantly different between treatments, with the majority of AEs being related to primary dysmenorrhea and not medication. Less than 10% of patients experienced severe AEs in any treatment period.

CONCLUSIONS

In these 2 identically designed studies in women aged 18 to 44 years, celecoxib 400 mg (followed by 200 mg q12h) was more effective, as measured using pain scores, in the treatment of primary dysmenorrhea compared with placebo. In each study, the primary efficacy measures-TOTPAR[8] and SPID[8] scores-were significantly improved with celecoxib and naproxen sodium compared with placebo. SPID[8] in both studies and TOTPAR[8] in study 2 were significantly improved with naproxen sodium compared with celecoxib. Both celecoxib and naproxen sodium were well tolerated and provided relief from menstrual pain within 1 hour of administration.

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.

Contraception for the older woman: an update

Although fertility declines with advancing age as the woman approaches the menopause, some risk of pregnancy persists, and effective contraception needs to be offered to avoid an unintended pregnancy. An older woman may have menstrual dysfunction or climacteric symptoms and these factors would need consideration when making the choice of contraception. Low-estrogen dose combined oral contraceptives may be prescribed to healthy non-smoking women up to about 50 years of age. The progestogen-only pill may be an appropriate option in an older woman with declining fertility. The copper intrauterine device is an optimal method for parous women free of pre-existing menstrual problems. The levonorgestrel-releasing intrauterine system is considered the contraceptive method of choice for perimenopausal women with menstrual dysfunction. The woman should be provided with individualized advice so that she has a choice between the newer, effective, largely safe, reversible methods and sterilization.

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.

Non-contraceptive benefits and risks of contraception

Contraception is primarily used to prevent pregnancy. However, a user should be aware of both the possible non-contraceptive benefits she/he may experience and any potential risks to her/his health. These issues should be discussed as fully as possible, using current, evidence-based information prior to commencing a method. Some methods may be prescribed solely for their non-contraceptive benefits for a woman who does not require it for contraception. Potential risks to a woman's health may make certain methods unacceptable if concurrent medical problems or lifestyle issues exist. This chapter discusses the main non-contraceptive benefits and risks for each contraceptive method in turn.

Physiologic and psychologic symptoms associated with use of injectable contraception and 20 microg oral contraceptive pills

OBJECTIVE

The objective of the study was to compare menstrual, physiologic, and psychologic symptoms over 2 years among women initiating use of depot medroxyprogesterone acetate or an oral contraceptive pill with a reduced pill-free interval and those not using hormonal contraception.

STUDY DESIGN

A total of 608 women reported their experience regarding 17 symptoms prior to initiating contraception and every 6 months thereafter for 24 months. Longitudinal relationships between symptoms and contraceptives were assessed after adjusting for age, visits, and baseline status of symptoms.

RESULTS

Oral contraceptive pills were protective against mastalgia (odds ratio [OR], 0.7), cramping (OR, 0.5), hair loss (OR, 0.6), acne (OR, 0.4), nervousness (OR, 0.5), and mood swings (OR, 0.7). Depot medroxyprogesterone acetate (DMPA) was protective against bloating (OR, 0.5) and mood swings (OR, 0.7) but caused weight gain (OR, 2.3), bleeding episodes more than 20 days (OR, 13.4), and missed periods (OR, 96.9). Both methods caused intermenstrual bleeding.

CONCLUSION

Evidence-based data regarding beneficial and adverse symptoms associated with these methods may help clinicians counsel patients appropriately prior to contraceptive initiation.

The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: results from two studies on oestrogen-related symptoms and dysmenorrhoea

OBJECTIVES

To evaluate the effects of an oestrogen-free oral contraceptive (Cerazette; 75 mcg/day desogestrel) in women with oestrogen-related symptoms during previous combined oral contraceptive (COC) use (ERS study) and in women with dysmenorrhoea (DYS study).

METHODS

Two similarly designed prospective, non-comparative multicentre observational studies were carried out in Germany. Altogether, 403 women with oestrogen-related symptoms during previous COC use and 406 women with dysmenorrhoea took Cerazette continuously. Symptom-related assessments were made at baseline and after 3-4 months, along with bleeding pattern and treatment satisfaction.

RESULTS

In the ERS study, the four oestrogen-related symptoms studied resolved or improved in over 70% of women. Nausea improved/resolved most (92% of women), followed by breast tenderness (90%), oestrogen-related headache (84%) and oedema (74%). In the DYS study, dysmenorrhoea resolved or considerably improved in 93% of the study population. Correspondingly, use of analgesics dropped from 70% of women at baseline to 8% at study end. Adverse events were reported by 7-8% of both study populations and were mainly bleeding irregularities. Most women in both studies were satisfied with treatment (approximately 90%) and wished to continue treatment after study completion (approximately 85%).

CONCLUSIONS

Cerazette in this study set-up improved oestrogen-related symptoms and dysmenorrhoea in women affected and treatment was well accepted.

La contraception des adolescentes en France en 2007

The two main objectives of adolescence contraception are the eviction of involuntary pregnancies and the prevention of sexually transmitted infections. In France, in spite of our rich contraceptive arsenal and a widely spread information, the rate of voluntary termination of pregnancy keeps growing among the teenagers population--and this, probably because the gap between theoretical effectiveness and practice of contraception is particularly wide among the young people. Every contraceptive means can be used by teenagers; the best option being, it seems, the "double DUTCH", which consists of concomitant use of condoms and hormonal contraception. Most often, the consultation for contraception is the first gynaecological consultation. That is the reason why it is usually stressful for teenagers who dread undergoing a gynaecological examination. If this examination is not necessary for most of young patients, it is essential to create a trustful relationship and to make explicit the several contraceptive methods. During this consultation it is interesting to look for common teenage troubles like addiction to smoking and eating disorders. For any prescription of hormonal contraception, it is important to explain the benefits and the possible side effects, to stress the observance and to tell the teenager about the recommendations in case of forgetting. Concerning condom - the only efficient way of preventing sexually transmitted infections--, it is useful to talk about it in concrete and straightforward terms, to show its handling and to inform about risks of tearing. With this state of mind, an emergency contraception can be prescribed straightaway in order to make its use easier. Also, without any moralizing speech, the need for maturity must be emphasized as well as taking care of one's body with the aim of avoiding a premature pregnancy or any sexually transmitted infection. This consultation must be coupled with a close follow-up, availability and mutual confidence which are the main elements vouching for a good observance and consequently an efficient contraception.

Common traditional Chinese medicinal herbs for dysmenorrhea

Dysmenorrhea is painful menstrual cramps, which negatively impacts the quality of life of those diagnosed. The paper reviews traditional Chinese medicine's treatment of dysmenorrhea through the use of combination-herbal-formula therapeutics. These herbal treatments are effective for dysmenorrhea with minimal side effects. Pharmacological studies suggest Chinese herbal dysmenorrhea therapies likely decrease prostaglandin levels, modulate nitric oxide, increase plasma beta-endorphin (beta-EP) levels, block calcium-channels and improve microcirculation. Conventional therapy for dysmenorrhea, which usually includes non-steroidal antiinflammatory drugs (NSAIDs), provides symptomatic relief but has increasing adverse effects with long-term use. Therefore, Chinese herbal medicines, including simple herbal and combination formulas, are perhaps the ideal therapeutics of choice.

The efficacy and safety of aceclofenac versus placebo and naproxen in women with primary dysmenorrhoea

OBJECTIVE

To determine the analgesic efficacy and safety of a single oral dose of aceclofenac 100 mg and compare that with placebo and naproxen 500 mg in women with primary dysmenorrhoea.

STUDY DESIGN

In this double-blind, prospective, multicentre, randomised, three-way, crossover study, women were randomly assigned to receive one of six treatment sequences, comprising single oral doses of aceclofenac 100 mg, naproxen 500 mg or placebo, when menstrual pain reached a predetermined level of severity. A single dose of the assigned study medication was taken on three menstrual periods; a different medication was taken on each treatment day. Analgesic efficacy was determined by self-reported analgesia scoring and participants' and investigators' global evaluation of treatment effectiveness. Measurements also included physical examination and adverse events.

RESULTS

Total pain relief scores were not statistically significantly different for aceclofenac and naproxen, and both were statistically significantly more effective than placebo (p = 0.019 and 0.002, respectively). This finding was supported by secondary endpoints including sum of pain intensity differences (SPID/8), peak analgesia (peak pain intensity and peak pain relief), and participants' and investigators' overall evaluation of effectiveness. Both aceclofenac and naproxen were well tolerated.

CONCLUSIONS

Aceclofenac (100 mg) and naproxen (500 mg) effectively treated the pain associated with primary dysmenorrhoea, and both were more effective than placebo at easing menstrual pain assessed by various pain relief criteria.

Natural progression of menstrual pain in nulliparous women at reproductive age: an observational study

BACKGROUND

Menstrual pain can be alleviated after childbirth. The purpose of this observational study was to evaluate the natural progression of menstrual pain among nulliparous women at their reproductive age.

METHODS

A questionnaire-based study of perimenopausal women with a history of primary dysmenorrhea was performed. The study subjects were recruited between July 1, 2001 and June 30, 2005. Severity of menstrual pain was graded using a multidimensional scoring system.

RESULTS

A total of 247 nulliparous women with primary dysmenorrhea were enrolled, and of these, 218 patients were eligible for analysis. Patients who had more frequent intercourse (p = 0.016), fewer associated systemic symptoms (p = 0.028), and use of oral contraceptive pills (p = 0.039) tended to have a higher chance of an improvement in dysmenorrhea after age 40. Multidimensional scoring distribution over chronologic age revealed that patients had significantly improved menstrual pain after 40 years of age.

CONCLUSION

For nulliparous women with primary dysmenorrhea, the severity of menstrual pain decreased significantly after age 40. More studies are needed to explore this phenomenon from a biochemical or molecular basis.

Evidence based contraceptive choices

People who attend for contraceptive advice have usually formulated an idea of the type of contraceptive that will suit them best. They may wish to use a method that is long, short or medium acting. These are defined as follows: Long-acting method requires renewal no more frequently than every 3 months (e.g. injectable or intrauterine). Short-acting method used daily or with every act of intercourse (e.g. pills, condoms) Medium-acting method requires renewal weekly or monthly (e.g. ring, patch). For men the choice is limited to condoms or vasectomy. Some women do not wish to use hormonal preparations or have an intrauterine device (IUD) or implant inserted. There may also be cultural influences making certain methods of contraception unacceptable. Each of these factors influences the final decision of which method of contraception is decided upon. In addition to taking a full medical and sexual history to identify any risks to the individual's health, which might be increased by a particular contraceptive, time must be spent discussing the options available. It is important to ensure that there is a full understanding of the advantages and disadvantages of each method. The most successful contraceptive method is likely to be the one that the woman (or man) chooses, rather than the one the clinician chooses for them. Access for women to contraception can be improved by having convenient clinic times and service developments such as nurse prescribing and Patient Group Directions.

Primary Dysmenorrhea Consensus Guideline

METHODS

Members of this consensus group were selected based on individual expertise to represent a range of practical and academic experience both in terms of location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology backgrounds. The consensus group reviewed all available evidence through the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

RESULTS

This document provides a summary of up-to-date evidence regarding the diagnosis, investigations, and medical and surgical management of dysmenorrhea. The resulting recommendations may be adapted by individual health care workers when serving women who suffer from this condition.

CONCLUSIONS

Dysmenorrhea is an extremely common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle, medications, and allied health services should be used to limit the impact of this condition on activities of daily living. In some circumstances, surgery is required to offer the desired relief.

OUTCOMES

This guideline discusses the various options in managing dysmenorrhea. Patient information materials may be derived from these guidelines in order to educate women in terms of their options and possible risks and benefits of various treatment strategies. Women who find an acceptable management strategy for this condition may benefit from an improved quality of life.

FFPRHC Guidance (July 2005): The use of contraception outside the terms of the product licence

This Guidance provides information for clinicians and women considering the use of contraception outside the terms of the product licence. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: CEU, Clinical Effectiveness Unit; COC, combined oral contraception/contraceptive; DMPA, depot medroxyprogesterone acetate; ENG, etonogestrel; IUD, copper-bearing intrauterine contraceptive device; LNG-IUS, levonorgestrel-releasing intrauterine system; NET-EN, norethisterone enantate; PGD, Patient Group Direction; PIL, Patient Information Leaflet; POC, progestogen-only contraception/contraceptive; POEC, progestogen-only emergency contraception; POP, progestogen-only pill; RCT, randomised controlled trial; SPC, Summary of Product Characteristics; UPSI, unprotected sexual intercourse; WHO, World Health Organization; WHOMEC, WHO Medical Eligibility Criteria for Contraceptive Use; WHOSPR, WHO Selected Practice Recommendations for Contraceptive Use.