Primary dysmenorrhea

　　One, etiology

　　1, Age is an important factor in the occurrence of dysmenorrhea. In the first few months of menarche, dysmenorrhea occurs rarely, and then the incidence rate rises rapidly, reaching a peak at 16-18 years old (82%), and gradually decreasing after 30-35 years, stabilizing at about 40% in the middle of the reproductive age, and lower thereafter, maintaining at 20% at the age of 50. The beginning of sexual life can reduce the incidence of dysmenorrhea. A 5-year follow-up survey of 19-year-old Swedish women showed that by the age of 24, the incidence of dysmenorrhea had decreased from 72% to 67%, and the severity had also decreased.

　　2, Childbirth is another important factor. Women with a history of full-term pregnancy and childbirth have significantly lower incidence and severity of dysmenorrhea than those without pregnancy history or those with pregnancy but spontaneous or induced abortion. Because, near full-term, the adrenergic nerves that dominate the smooth muscle cells of the uterus almost completely disappear, and the level of norepinephrine in the uterus also decreases; after childbirth, these nerve endings regenerate only partially, and the level of norepinephrine in the uterus cannot recover to the pre-pregnancy level. This change in uterine neuro-muscular activity after full-term pregnancy can explain the reduction or disappearance of dysmenorrhea after full-term childbirth, but there are no such changes in aborters. In addition, women with early menarche or long menstrual periods and heavy menstrual flow have severe dysmenorrhea. The incidence of dysmenorrhea is significantly reduced in those who take birth control pills. Dysmenorrhea also shows a certain familial characteristic, and the mothers and sisters of dysmenorrhea patients often have dysmenorrhea as well. Smokers experience a reduction in the severity of dysmenorrhea. There is no relationship between education level, physical activity, and dysmenorrhea.

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

　　4. Mental factors: The relationship between mental factors and dysmenorrhea has been discussed over the years, with inconsistent results. Some believe that mental factors in women with dysmenorrhea are also very important, often showing poor self-regulation, being more depressed, anxious, and introverted. Severe dysmenorrhea patients are more feminine in terms of interest and emotions compared to those without dysmenorrhea. Some believe that mental factors only affect the response to pain and are not pathogenic factors.

　　Secondly, pathogenesis

　　Abnormal uterine contraction: The occurrence of primary dysmenorrhea is related to the increased uterine tension and excessive spasmodic contractions caused by the enhanced uterine muscle activity. During the normal menstrual period, the baseline tension in the uterine cavity

　　Complications such as anxiety and other mental disorders. Anxiety refers to an inner unease or unfounded fear without obvious objective reasons, which is a normal emotional response when people encounter certain events such as challenges, difficulties, or dangers. Anxiety is usually associated with mental distress and the impending threats or dangers that may cause harm, and is subjectively expressed as feeling tense, unhappy, or even painful to the point of being uncontrollable. In severe cases, it may be accompanied by changes or disorders in the vegetative nervous system function.

　　Primary dysmenorrhea often occurs in young women, starting a few months (6-12 months) after menarche, and the incidence rate begins to decline after the age of 30. Pain usually starts before or after the onset of menstruation and lasts for the first 48-72 hours of the menstrual period. The pain is often spasmodic and sometimes very severe, requiring bed rest for several hours or even days. The pain is concentrated in the middle of the lower abdomen, and sometimes accompanied by lower back pain or radiation to the inner side of the thigh. Pelvic examination shows no positive findings.

　　The assessment of dysmenorrhea degree is generally based on the pain intensity and its impact on daily activities, systemic symptoms, and the use of analgesics, and is made comprehensively. Mild: There is pain, but it does not affect daily activities, work is rarely affected, there are no systemic symptoms, and analgesics are rarely used; Moderate: Pain affects daily activities and work capacity, there are rarely systemic symptoms, analgesics are needed and effective; Severe: Pain significantly affects daily activities and work, there are obvious systemic symptoms, and the effect of analgesics is not good.

　　Dysmenorrhea refers to the pain in the lower abdomen or腰部 during menstruation and before and after it, which can even extend to the sacrum and coccyx. It occurs with each menstrual cycle, and severe cases can be accompanied by nausea and vomiting, cold sweat, cold limbs, and even fainting, affecting work and life. Currently, it is often divided into primary and secondary dysmenorrhea in clinical practice. Primary dysmenorrhea usually refers to those without obvious pathological changes in the reproductive organs, so it is also called functional dysmenorrhea, and it is more common in adolescent girls, unmarried and married childless women. This kind of dysmenorrhea can usually be relieved or disappear after normal delivery. Secondary dysmenorrhea is often caused by organic lesions in the reproductive organs. This disease is a common disease in gynecological clinical practice, and according to relevant surveys, the incidence rate of dysmenorrhea is 33.19%.

      Daily care:

　　24. Pay attention to and pay attention to menstrual hygiene, and eat less cold and spicy foods with strong stimulation before and during menstruation.

　　23. Eliminate the tension and fear of menstruation, relieve mental concerns, and keep a cheerful mood. It is appropriate to participate in labor and exercise, but attention should be paid to rest.

　　22. Strengthen physical exercise in daily life, especially for those with weak physique. It is also necessary to pay attention to improve the nutritional status and actively treat chronic diseases.

　　21. When the pain occurs,对症处理 can be taken, such as taking painkillers, or taking atropine tablets and valium tablets, which can all relieve pain. In addition, drinking some hot molasses ginger water will also have a good effect.

　　20. If the pain is unbearable, and symptoms such as fainting and cold sweat appear, go to a professional hospital for treatment, and relieve the pain under the help of a doctor, and do not take it lightly.

　　When diagnosing primary dysmenorrhea, in addition to relying on its clinical manifestations, it is also necessary to rely on auxiliary examinations. Patients need to undergo secretion examination, hormone level examination, ultrasound, laparoscopy, hysteroscopy, and uterine salpingography with iodine oil.

　　Primary dysmenorrhea therapeutic recipe

　　13. For those with cold blood stasis, who are afraid of cold during menstruation, it is advisable to warm the meridians and dispel cold.

　　Angelica sinensis and mutton pot

　　Ingredients: 6 grams of Angelica sinensis, 1.5 grams of cinnamon, 3 grams of dried tangerine peel, and 250 grams of mutton.

　　Method: Clean the mutton, cut it into pieces, and cook it with dried tangerine peel and Angelica sinensis in a pot until it is soft. Then cook it with cinnamon for 10 minutes, and season it for eating.

　　Effect: Warm the meridians and dispel cold, activate blood and nourish blood, regulate menstruation and relieve pain. Suitable for those with abdominal cold pain, fatigue, and cold limbs.

　　8. For those with Qi stagnation and blood stasis, who are under stress, depressed, and have a bad mood, it is advisable to promote Qi and resolve stagnation.

　　Amomum pork stomach soup

　　Ingredients: 10 grams of amomum, 9 grams of Panax notoginseng, and 100 grams of pork stomach.

　　Method: Rinse the pork stomach with boiling water, scrape off the inner membrane, remove the smell, and cook it with amomum and Panax notoginseng in the pot with an appropriate amount of water. Boil it over low heat for about 2 hours. Season and drink the soup and eat the meat.

　　4. For those with dampness and blood stasis, who do not like to use hot water to apply heat during dysmenorrhea, and whose pain increases with pressure, it can remove dampness and blood stasis.

　　Inula japonica and hawthorn decoction

　　Ingredients: 20 grams of Inula japonica, 10 grams of hawthorn seeds, 15 grams of lonicera, and an appropriate amount of molasses.

　　Method: Rinse the medicine and put it in the pot together, add an appropriate amount of water, decoct the medicine, add molasses and dissolve it, then take it in several doses.

　　4. For dysmenorrhea caused by insufficient liver and kidney and physical weakness, it is advisable to nourish Yin and blood.

　　Dysmenorrhea caused by insufficient liver and kidney, belonging to deficiency syndrome, can enhance physical fitness and improve the weak state of the body through food therapy, and promote recovery.

　　Braised turtle meat

　　Ingredients: 1 grass turtle, 10 jujubes, 10 grams of Yuan meat.

　　Preparation: Wash the grass turtle, remove the shell and take out the meat and cut it into pieces. Put it in a pot with jujube and Yuan meat, add soy sauce, cooking wine, sugar, vegetable oil, and appropriate amount of water, cook until tender, season and eat.

　　II. What foods are good for primary dysmenorrhea patients

　　1. During this period, patients can eat some sour foods, such as sauerkraut, vinegar, etc., which have a pain-relieving effect.

　　2. Dysmenorrhea patients should maintain smooth defecation before or after menstruation. Eat more honey, bananas, celery, sweet potatoes, etc. as much as possible. Because constipation can induce dysmenorrhea and increase pain.

　　3. Drinking a moderate amount of wine can promote the flow of Qi and blood, dilate blood vessels, relax smooth muscle, and has a preventive and therapeutic effect on dysmenorrhea. If the menstrual blood is not abundant, drinking a moderate amount of red wine can alleviate the symptoms and has a certain therapeutic effect. Red wine has an excitatory effect on the human body due to the presence of ethanol. For dysmenorrhea caused by emotional depression, drinking a little red wine at the appropriate time can help relax the mind, relieve liver depression, and make Qi flow smoothly. In addition, red wine is pungent and sweet in taste and warm in nature, pungent can disperse and promote, for dysmenorrhea due to cold and dampness, it can disperse cold and dampness, activate blood circulation and relieve pain; sweet and warm can tonify and relieve, for dysmenorrhea caused by Qi and blood deficiency, it can also play a role in warming Yang, nourishing blood, and relieving pain.

　　4. Dysmenorrhea patients should have a diversified diet in daily life, not be biased, and eat more vegetables and fruits with the function of regulating Qi and activating blood circulation, such as shepherd's purse, ranunculus, coriander, carrots, oranges, finger citron, ginger, etc.

　　5. People with weak bodies and insufficient Qi and blood should eat more foods that tonify Qi, nourish blood, and tonify the liver and kidneys, such as chicken, duck, fish, eggs, milk, animal liver and kidney, fish, beans, etc.

　　6. Eat more high-protein foods such as beans and fish.

　　7. Women should avoid salted foods before menstruation. Because salted foods can increase the amount of salt and water in the body, and with the increase of progesterone before menstruation, edema and headache may occur. Starting 10 days before menstruation, eating low-salt foods can prevent the above symptoms.

　　III. What foods are bad for primary dysmenorrhea patients

　　Avoid all cold and difficult-to-digest and irritant foods, such as chili, scallions, garlic, pepper, strong alcohol, etc.

　　I. Traditional Chinese medicine treatment for primary dysmenorrhea

　　1. Qi stagnation and blood stasis:Abdominal distension before or during menstruation, painful to the touch, restless in sitting or lying, scanty menstrual flow or irregular menstrual flow, purple menstrual blood with clots, pain decreases after clot expulsion, irritable and prone to anger in daily life, chest and breast distension, purple tongue with petechiae or ecchymosis on the edges, wiry or wiry and涩 pulse. Treatment method: regulate Qi and activate blood circulation, resolve blood stasis and relieve pain. Prescription: Acorus tangkinensis, Corydalis yanhusuo, Lignum viticis, prepared Cyperus rotundus, Angelica sinensis, Ligusticum chuanxiong, Carthamus tinctorius, Peony, fried Mylabris, each 10 grams, 15 grams of赤芍, 12 grams of peach kernel, 6 grams of prepared Liquorice. Traditional Chinese medicine: Tunjing Jiemei Wan.

　　2. Cold blood stasisBefore and during menstruation, there is cold pain or colicky pain in the lower abdomen, which is relieved by heat, with a preference for pressure, small amount of menstrual blood, purple and dark color, with blood clots, pain reduced after clotting, aversion to cold and cold limbs, purple and dark tongue with blood spots or macules, white and slippery coating, deep and wiry pulse or deep and tense pulse. Treatment method: warm the meridians and dispel cold, activate blood and relieve pain. Formula: Chao Xiaohuoxiang, Ganjiang, Rougui, Chuanxiong, Sheng蒲huang (wrapped), Wulingzhi, Yuanhu, Zhizhimao each 10 grams, Danggui, Chishao each 15 grams. Traditional Chinese medicine: Jingtong Wan.

　　3. Dampness-heat and blood stasisBefore and during menstruation, there is burning pain and distension in the lower abdomen, with a preference for pressure, or accompanied by distension and坠 pain in the lower back and sacrum, or during normal days, there is distension and pain in the lower abdomen, which worsens during menstruation. The color of menstrual blood is dark red, with thick and clotted quality, with a low fever and intermittent leukorrhea, with a thick and yellow leukorrhea, red tongue with yellow or greasy coating, and wiry and rapid pulse or slippery and rapid pulse. Treatment method: clear heat and eliminate dampness, remove blood stasis and relieve pain. Formula: Danpi, Huangbai, Chuanxiong, Taoren, Honghua, Zhizhu, Yuanhu each 10 grams, Shengdi, Chishao, Yiyu, Bajiangcao, Shengyiyiren each 15 grams. Traditional Chinese medicine: Yudai Wan.

　　4. Empty uterus with coldDuring menstruation, there is cold pain in the lower abdomen, extending to the sacrum and coccyx, with a preference for warmth and pressure. The amount of menstrual blood is small, with thin quality and light color, accompanied by soreness and coldness in the lower back and knees, clear urine, pale tongue with white and slippery coating, and deep, thin, and weak pulse. Treatment method: warm the yang and warm the uterus, regulate the menstrual cycle and relieve pain. Formula: Wuyao, Guizhi, Zhizhipian, Chao Xiaohuoxiang, Chuanxiong, Ejiao (dissolved), Zhigancao each 10 grams, Danggui, Chishao, Danpi, Maidong each 15 grams, Aiyi 6 grams. Traditional Chinese medicine: Shenrong Lutai Wan.

　　Secondly, Western medical treatment methods for primary dysmenorrhea

　　1. General treatment:Firstly, it is necessary to explain the necessary information to patients with dysmenorrhea, especially to adolescent girls. Explain the basic physiological knowledge, clarify that 'menstruation' is a normal physiological phenomenon, and help patients dispel concerns and build confidence. During dysmenorrhea, patients can rest in bed or apply heat to the lower abdomen. Pay attention to menstrual hygiene. Non-specific analgesics can also be taken, such as: salicylates, which have the effect of reducing fever and pain.

　　2. Oral contraceptives:Applicable to patients with dysmenorrhea who need to take birth control measures. Since the 1960s, a large number of studies have observed and confirmed that oral contraceptives can effectively treat primary dysmenorrhea, resulting in complete pain relief in 50% of patients and significant relief in 40%. Oral contraceptives can inhibit endometrial growth, reduce the levels of prostaglandins, vasopressin, and oxytocin (labor-inducing hormone) in the blood, and inhibit uterine activity. The enhanced uterine activity in women with primary dysmenorrhea is partly due to an imbalance of ovarian hormones, which may be caused by elevated estrogen levels during the luteal phase and the premenstrual period. Estrogen can stimulate the synthesis and release of PGF2a and vasopressin. Oral contraceptives may inhibit uterine activity by changing the imbalance of ovarian hormones. It was once believed that the activity of progesterone was an important factor in the treatment of dysmenorrhea. However, recent studies have confirmed that various combined estrogen-progesterone contraceptives can reduce the occurrence of dysmenorrhea and alleviate the severity of dysmenorrhea, with no significant differences in efficacy.

　　3. Prostaglandin synthase inhibitors:For patients with primary dysmenorrhea who do not need to seek contraception or have an ineffective response to oral contraceptives, non-steroidal anti-inflammatory drugs (NSAIDs) can be used. NSAIDs are prostaglandin synthase inhibitors that inhibit PG synthesis by blocking the cyclooxygenase pathway, reducing uterine tone and contractility, and achieving the effect of treating dysmenorrhea. Due to their good efficacy (60% to 90% effective rate), they are simple to take, require only 2-3 days of menstrual medication, have few side effects, and have been widely used for the treatment of primary dysmenorrhea since the 1970s. NSAIDs can not only alleviate pain but also alleviate related symptoms such as nausea, vomiting, headache, diarrhea, and so on. The side effects are usually very mild, uncommon, and generally well-tolerated. The main symptoms are gastrointestinal and central nervous system symptoms, such as indigestion, nausea, anorexia, heartburn, diarrhea, constipation, headache, dizziness, irritability, and drowsiness; more serious side effects include skin reactions, bronchospasm, and temporary renal dysfunction, which are very rare.

　　Generally, medication is started after the onset of menstruation and pain, and is taken continuously for 2-3 days, because prostaglandins are released the most in the first 48 hours of the menstrual period. The purpose of continuous medication is to correct the biochemical imbalance of excessive synthesis and release of PG in menstrual blood. If medication is not given continuously in the first 48 hours but is given intermittently when in pain, it is difficult to control the pain. The effects of premenstrual preventive medication and starting medication after the period are similar. If there is still a certain degree of pain within the first few hours after starting medication, it indicates that the initial dose of the next cycle should be doubled, but the maintenance dose should remain unchanged. Common drugs and dosages.

　　Among them, ibuprofen and ketoprofen (ketone ibuprofen) reach their peak blood concentration within 30-60 minutes, act quickly, and are more commonly used in the treatment of dysmenorrhea. Piroxicam (Ingesikang), indomethacin (Anti-inflammatory pain), have significant gastrointestinal reactions, can cause diarrhea and gastrointestinal bleeding, and should not be used as the first-line drug for dysmenorrhea. Contraindications: gastrointestinal ulcers, allergy to aspirin or similar drugs.

　　4. Calcium channel blockers:Experiments have shown that nifedipine (nifedipine) can significantly inhibit uterine contractions caused by oxytocin (催产素). The drug has low toxicity and few side effects, making it safe and effective. In China, a small sample size open-label clinical trial was conducted by taking the drug (5-10mg, 3 times a day, 3-7 days) before the menstrual period or using 10mg sublingual tablets during pain, with most patients achieving good results. The side effects include headache, palpitations, and attention should be paid to blood pressure.

　　5. Spinal manipulation technique:It can alleviate dysmenorrhea and reduce the concentration of the metabolites of PGF2a in the blood, which is a safe and effective non-drug method for treating dysmenorrhea. The massage technique requires the patient to lie on their side with the lower leg straight and the upper leg bent, and to repeatedly and rapidly massage the area between the 10th thoracic vertebra and the 5th lumbar vertebra, as well as the sacroiliac joint.

　　6. Transcutaneous Electrical Nerve Stimulation (TENS):It can be used for patients who are ineffective with drug treatment, or have side effects, or do not want to accept drug treatment. Studies have shown that this method of high-frequency electrical stimulation can achieve satisfactory pain relief in 42.4% of patients, which is a safe and effective non-drug treatment method. Moreover, if TENS is added with a small amount of ibuprofen, the effect can be increased to 71%. Operation method: one TENS device, plus reusable electrodes. Two cathodes are placed 4 cm beside the navel, this area is equivalent to the bilateral chest 10-11 skin areas, and the anode is placed in the central area above the pubic arch (at the level of the chest 12 skin area). These three electrodes stimulate the sensory nerves of the chest 10-12 skin areas, which are the same nerve roots as the sensory nerves of the uterus. The electrical stimulation is 100 times/s, the stimulation intensity is 40-50mA, and the pulse width is 100 microseconds. The patient adjusts the amplitude to achieve a comfortable, tingling sensation (or to the extent of satisfactory pain relief of abdominal pain). Studies have confirmed that TENS can quickly relieve pain without changing uterine activity and intracavitary pressure. Regarding the mechanism of action, it is speculated that there are two possibilities:

　　(1) Large-area continuous stimulation of sensory nerve fibers within the skin area, causing the neurons in the posterior horn to be in a saturated state, thereby blocking the conduction of pain information.

　　(2) TENS also induces these nerve cells to release endorphins, relieving pain.

　　7. Surgical treatment:For patients with refractory dysmenorrhea who have been ineffective with drug and other treatments in the past, the pre-sacral ganglionectomy is selected, which has a good effect, but the surgery has certain complications. In recent years, with the development of endoscopic examination technology, laparoscopic and hysteroscopic examinations have been adopted for the above patients, about 20% have no organic diseases, and at the same time, a partial hysteroneurectomy is performed. Sundell (1990) reported that 70% of the cases were significantly effective, 20% had no change, and 10% worsened. The degree of dysmenorrhea can be reduced by 33%. Postoperative, 60% still need NSAIDs. Attention should be paid to hemostasis and not to injure the ureter during the operation. It can be used as a second-line treatment. For those without fertility requirements, the last choice can be hysterectomy.