Secondary dysmenorrhea

　　1. Causes of Disease

　　Secondary dysmenorrhea is often associated with organic diseases of the pelvic organs. Common secondary dysmenorrhea includes: endometriosis, adenomyosis, endometrial polyps, uterine fibroids, submucosal fibroids, uterine cavity adhesions, cervical stenosis, uterine malformations, pelvic inflammation (acute and chronic), pelvic congestion syndrome, intrauterine contraceptive devices, hymen imperforate, vaginal septum, etc.

　　Women with early menarche or long menstrual periods and heavy menstrual flow have severe dysmenorrhea. The incidence of dysmenorrhea in those taking birth control pills is significantly reduced.

　　Some other studies have shown that certain professions and work environments are also related to dysmenorrhea, and women who have long-term contact with mercury and benzene compounds (even at low concentrations) have an increased incidence of dysmenorrhea. Cold working environments are also related to dysmenorrhea.

　　2. Pathogenesis

　　Prostaglandins and secondary dysmenorrhea: Studies have shown that some patients with secondary dysmenorrhea caused by conditions such as endometriosis and adenomyosis also produce excessive PGs, which may also be one of the causes of dysmenorrhea. Antiprostaglandin synthetic agents also have the effect of alleviating dysmenorrhea. The exact relationship between PGs and the pain mechanism of endometriosis is still under study. The concentrations of 6-keto PGF1a (a metabolite of PGI2), TXB2 (a metabolite of TXA2), PGE2, and PGF2a in the culture medium of normal endometrium, normal uterine muscle layer, ectopic endometrium, uterine fibroids, normal ovaries, and affected ovarian slices were measured. The results showed that the production of PGs in ectopic endometrial tissue was significantly higher than that in other groups, especially 6-keto PGF1a, which was produced most in ectopic endometrial tissue; there were significant differences in the production of PGs between severe dysmenorrhea and non-dysmenorrhea tissues, especially in the myoadenoma tissues with severe dysmenorrhea. Another study shows that after the experimental animals are induced to develop endometriosis, the concentration of PGF2a in their peritoneal fluid significantly increases; the concentration of PGs in the peritoneal fluid of patients with endometriosis is also higher than that in the control group, suggesting that PGF1alpha can cause hyperalgesia during the menstrual period of endometriosis. In addition, adenomyosis can cause severe pain because the endometrial tissue is very close to the uterine muscle, and the localization, absorption, and activity of PGs are enhanced. Since PGs regulate inflammatory reactions in some tissues, the inflammatory reaction around the implantation site of ectopic endometrium may be regulated by PGs.

　　Cyclooxygenase (COX) is the rate-limiting enzyme for the synthesis of PGE2. The endometrial glands of humans contain high levels of COX, and detection using immunohistochemistry, RTPCR, and Western blot techniques has found that COX is highly expressed in ectopic endometrial tissue, and the high activity of COX-2 and the production of abnormal PGs play a role in the pathophysiology and progression of endometriosis. It is highly expressed in macrophages in the peritoneal fluid of patients with endometriosis, which may be related to the increase in PGE2 and plays an important role in the development of endometriosis. The level of PG in the peritoneal fluid of patients with endometriosis increases, while the level of PG in the follicular fluid is no different from the control.

　　The side effects of intrauterine devices (IUDs) include menorrhagia and secondary dysmenorrhea. The cause of dysmenorrhea may be damage to the endometrium or the possibility of leukocyte infiltration near the IUD, which may enhance the biosynthesis of PGs, causing women using IUDs to have a response to the activity of the uterine muscle. In experimental animals using IUDs, the release of PGs increases. IUDs are associated with uterine hypertrophy and increased production of PGF. In the uterine horns of mice with IUDs, the composition and concentration of uterine PGF and the level of PGF in uterine venous blood all increase. In ewes, the content of endometrial PG in the horns with IUDs also significantly increases. In human studies, there was no increase in the synthesis of PGF2a in the endometrium of volunteers wearing a shield-shaped IUD without symptoms; the use of IUDs with added medication may be related to the amount of PG produced by the endometrium. For example, wearing a metal IUD may release metal ions, thereby promoting the synthesis of PGF2a and inhibiting the synthesis of PGE2. However, there are also reports that in the 1-5 months after the IUD is placed, the endometrium of 14 women showed a significant increase in PGE rather than PGF. In women using IUDs, due to the presence of a mechanism for excessive PG release, PG inhibitors can effectively alleviate dysmenorrhea.

　　The prostaglandin theory itself cannot yet explain some other changes in primary dysmenorrhea and secondary dysmenorrhea. The increase in age and the number of deliveries, socio-economic status, and alcohol can reduce the occurrence and/or severity of dysmenorrhea; smoking, exposure to cold working environments, and stress can increase primary dysmenorrhea. Other factors that directly or indirectly affect the development and severity of the condition require further study.

　　1. Endometriosis

　　Many gynecological diseases can cause secondary dysmenorrhea, among which endometriosis is the main cause. It is mainly manifested as progressive dysmenorrhea. The pain is usually located in the lower abdomen and lumbar sacral region, which can radiate to the vagina, perineum, anus, or thigh. It usually starts 1-2 days before menstruation, reaches the most severe on the first day of menstruation, and gradually subsides after menstruation. Therefore, in patients with longer menstrual periods, the duration of pain is often longer, which is most prominent in patients with endometriosis.

　　2. Uterine adenomyosis

　　Dysmenorrhea is one of the typical symptoms of this benign lesion caused by the invasion of the endometrium into the uterine muscle layer. There may also be an increase in menstrual blood volume or prolonged menstrual periods. Gynecological examination shows that the uterus is uniformly enlarged in a spherical shape, with a harder texture, generally about the size of 2 months of pregnancy, with slight tenderness.

　　3. Uterine fibroids

　　Dysmenorrhea is not a major symptom of uterine fibroids, but submucosal fibroids can cause spasmodic pain due to uterine contraction during menstruation. Patients often have symptoms such as excessive menstrual flow, prolonged menstrual periods, or irregular vaginal bleeding. Pelvic examination may show that the uterus is of varying degrees of enlargement, with a smooth surface or nodular protuberances.

　　4. Chronic pelvic inflammatory disease

　　Lower abdominal pain and infertility are the main symptoms of chronic pelvic inflammatory disease. During the menstrual period, due to pelvic congestion or due to menstrual induction of inflammation, an acute exacerbation can cause increased pain. Patients often have a history of infertility and acute pelvic inflammatory disease. Pelvic examination shows that the uterus is often posterior, with poor mobility, and even completely fixed.

　　Secondary dysmenorrhea often has different symptoms, accompanied by abdominal distension, lower abdominal坠, and牵引 pain, which is often more obvious. Pain usually occurs before the onset of menstruation, reaching a peak in the first half of the menstrual period, then subsiding, and ending. However, dysmenorrhea in endometriosis may also occur soon after menarche, at the beginning of sexual life, which can reduce the incidence of dysmenorrhea.

　　Diagnosis can be made by combining the primary disease with symptoms.

　　Differences from primary dysmenorrhea

　　Primary dysmenorrhea, which does not involve organic lesions, is characterized by pain during the menstrual cycle. This pain can be severe or mild. However, through examination, no significant lesions are found. It is mainly related to the imbalance of certain hormones in the body, especially the imbalance of prostaglandins, which is called primary dysmenorrhea. Secondary dysmenorrhea is not caused by an imbalance in hormone secretion, but may be due to the growth of something, such as endometriosis, where the ectopic lesions also bleed during menstruation, causing pain. The pain may worsen and become more severe. There may also be poor position of the reproductive tract or a narrow cervix, leading to poor blood flow of menstrual blood, which is also called secondary dysmenorrhea. The most typical representative is endometriosis and adenomyosis.

　　Second, health care

　　1. Strengthen physical exercise in daily life, especially for those with weak physique. They should also pay attention to improving their nutritional status and actively treating chronic diseases.

　　2. Eliminate the tension and fear of menstruation, relieve mental concerns, and keep a cheerful mood. They can participate in appropriate labor and exercise, but they should pay attention to rest.

　　3. When pain attacks, symptomatic treatment can be taken, such as taking atropine tablets and valium tablets, which can alleviate pain. For those who cannot alleviate the pain for a long time, appropriate traditional Chinese medicine syndrome differentiation and adjustment can be made. In addition, drinking some hot brown sugar ginger water can also achieve a good effect.

　　4. Pay attention to and pay attention to menstrual hygiene.

　　Secondary dysmenorrhea is mainly diagnosed through medical history, physical examination, and auxiliary examinations. Gynecological internal examination can detect an enlarged and hard uterus with poor mobility, or palpable hard irregular nodules or masses in the rectouterine pouch, with marked tenderness. Auxiliary examinations mainly include pelvic ultrasound, hysterosalpingography, hysteroscopy, laparoscopy, and tissue pathological examination.

　　1. What should secondary dysmenorrhea patients eat

　　For dysmenorrhea patients, their diet should be light and easy to digest in the 3-5 days before the menstrual period. They should eat foods that are easy to digest and absorb, avoid overeating, and during the menstrual period, patients can eat some sour foods such as sauerkraut and vinegar, as sour foods have a pain-relieving effect. In addition, dysmenorrhea patients should maintain smooth defecation before and after the menstrual period. They should eat more honey, bananas, celery, sweet potatoes, etc. as constipation can induce dysmenorrhea and increase pain. Some people believe that drinking a moderate amount of alcohol can promote blood circulation, dilate blood vessels, relax smooth muscles, and has a preventive and therapeutic effect on dysmenorrhea. If the amount of menstrual blood is not much, they can drink some red wine, which can alleviate symptoms and even have a therapeutic effect. Red wine has an exciting effect on the human body due to the presence of ethanol. For those with dysmenorrhea caused by depression, drinking a little red wine can help to relieve emotions, soothe the liver, and promote the flow of Qi. In addition, red wine is acrid and sweet in taste and warm in nature. The acridness can disperse and promote, which can dispel cold and dampness for dysmenorrhea due to cold and dampness. The sweetness and warmth can tonify and relieve, which can also have the effect of warming Yang, nourishing blood, and alleviating pain for dysmenorrhea caused by Qi and blood deficiency.

　　Dysmenorrhea patients should have a diversified diet in their daily life, avoiding monotonous eating. They should frequently consume vegetables and fruits with the function of regulating qi and promoting blood circulation, such as shepherd's purse, elecampane, coriander, carrots, oranges, banyan fruit, ginger, etc. Those with weak bodies and insufficient Qi and blood should eat more foods that tonify Qi, nourish blood, and invigorate the liver and kidneys, such as chicken, duck, fish, eggs, milk, animal liver and kidneys, fish, beans, etc.

　　2. What not to eat for patients with secondary dysmenorrhea

　　Especially avoid eating cold and raw foods, as cold and raw foods can stimulate uterine and fallopian tube contraction, thereby causing or aggravating dysmenorrhea. Once menstruation has started, it is even more necessary to avoid all cold and difficult-to-digest and irritating foods, such as chili, scallions, garlic, pepper, strong alcohol, etc.

　　1. Medication Treatment

　　The treatment of dysmenorrhea caused by endometriosis can primarily choose non-steroidal anti-inflammatory drugs or oral contraceptives, with a course of treatment generally not less than six months, using the same method as primary dysmenorrhea. If the efficacy is not good, it can be changed to the treatment of gonadotropin-releasing hormone analogs, with one injection subcutaneously or intramuscularly every four weeks, and the course of treatment is six months. If the patient has no immediate desire for childbirth and is not suitable for long-term oral medication, the intrauterine placement of the levonorgestrel intrauterine release system (also known as Mirena, a type of intrauterine device) or the vaginal ring containing slow-release progestin can be chosen, which not only achieves the purpose of reducing dysmenorrhea but also significantly reduces menstrual blood volume. If the patient has the desire for childbirth and there is a large endometriotic cyst in the pelvic cavity, the minimally invasive surgical treatment under laparoscopy should be the first choice.

　　2. Surgical Treatment

　　The most thorough method of treating adenomyosis of the uterus is usually surgical resection of the uterus, but for patients with the requirement for childbirth or the requirement to retain the uterus, the treatment of gonadotropin-releasing hormone analogs should be the first choice, with the same course as before. If the patient has no immediate desire for childbirth, the intrauterine placement of the levonorgestrel intrauterine release system or the use of slow-release drugs vaginally should be the first choice. Oral contraceptives can also be chosen, but they are generally not the first choice for treatment drugs. Adenomyosis of the uterus can also be treated by uterine artery embolization to achieve the purpose of reducing dysmenorrhea and reducing menstrual blood volume. However, due to the need for very rich clinical experience of the operator and the expensive treatment cost, it is currently not widely promoted. In summary, the treatment of secondary dysmenorrhea should first distinguish the cause, and carry out both etiological and symptomatic treatment. If the refractory primary dysmenorrhea is tolerated again and again, some people may develop endometriosis in the future. The incidence of endometriosis with infertility and sterility is quite high.