Treatment of pubertal dysmenorrhea

Treatment goals for pubertal dysmenorrhea

• Relief of pain.
• Correction of vegetative tone and mental status.
• Restoration and correction of menstrual cycle disorders, normalization of hormonal parameters.
• Elimination or relief of symptoms of the main organic causes of dysmenorrhea (genital endometriosis, acute and chronic inflammatory processes in the pelvic organs).

Indications for hospitalization

Hospitalization is necessary in the following cases:

• the need for surgical examination and treatment;
• severe forms of dysmenorrhea with a predominance of pronounced vegetative and psychopathic reactions.

Non-drug treatment

Important conditions for successful treatment are:

• compliance with the work and wakefulness regime;
• regulation of diet with increased consumption of easily digestible and vitamin-rich foods during perimenstrual days and exclusion of milk-based and coffee-based products;
• increasing overall tone through therapeutic exercise;
• It is possible to use individual or collective psychotherapy.

A good effect of the impact on trigger points (acupuncture, acupuncture, magnetic therapy) has been proven. Reflexotherapy is more effective in combination with exercise therapy, diet, and psychotherapy.

In the treatment of dysmenorrhea, the use of preformed therapeutic and physical factors remains relevant: diadynamic therapy, fluctuation, amplipulse therapy.

Drug treatment of dysmenorrhea in puberty

Basic treatment for any form of dysmenorrhea should include a combination of antioxidants and magnesium salt-containing medications.

It has been proven that vitamin E, along with reducing the intensity of peroxidation of unsaturated fatty acids, from which prostaglandin is formed, participates in the process of mobilizing endorphins from the hypothalamic-pituitary structures and intestinal walls. Vitamin E is used continuously in a dose of 200 to 400 mg/day.

Magnesium activates more than three hundred enzymatic reactions, inhibits prostaglandin synthetase, and participates in the synthesis of all known neuropeptides in the brain. It has a general tonic and calming effect, has a positive effect on vascular tone, has a diuretic effect, promotes active excretion of bile, has antimicrobial properties, reduces cholesterol in the blood and tissues, and prevents the formation of kidney stones. Magnesium is necessary for the normal functioning of B vitamins.

Among magnesium-containing drugs, the drug of choice for patients with dysmenorrhea is the magnesium B6 complex _. The pyridoxine hydrochloride it contains ensures better penetration and retention of magnesium inside the cell. A prophylactic dose (1 tablet 3 times a day) should be prescribed to patients with clinical symptoms of chronic magnesium deficiency, but with its normal content in the blood plasma. In patients with hypomagnesemia and pronounced manifestations of magnesium deficiency, it is necessary to prescribe the drug in a therapeutic dose (2 tablets 3 times a day). The drug is taken continuously for 4 months in courses 2 times a year, long-term.

In patients with mild dysmenorrhea, a normal menstrual rhythm, and an undisturbed estradiol-to-progesterone ratio at the end of the menstrual cycle, it is justified to prescribe NSAIDs at 1 dose of the drug 1-2 times a day on the first day of painful menstruation.

For moderate functional dysmenorrhea combined with manifestations of premenstrual syndrome, it is advisable to start taking the drug 1-3 days before menstruation, 1 tablet 2-3 times a day.

Patients with severe manifestations of dysmenorrhea should take 3 tablets per day during all days of painful menstruation.

Currently, a wide range of NSAIDs is available: acetylsalicylic acid, indomethacin, ibuprofen, rofecoxib, naproxen, paracetamol, ketoprofen, diclofenac and many others. These drugs are the means of choice for young girls who do not want to use COCs to treat dysmenorrhea, as well as in cases where these drugs are contraindicated.

In patients with mild to moderate dysmenorrhea with clinical manifestations of vagotomy, NLF with normal estradiol levels, gestagens are included in the treatment. As is known, under the influence of progesterone, the production of prostaglandins decreases not only in the endometrium, but also in the neuromuscular structures, the central nervous system and other tissues. The addition of progesterone to the treatment of dysmenorrhea leads to the disappearance of not only pain, but also many other symptoms, helping to restore the normal ratio of progesterone and estradiol in the luteal phase of the cycle. The inhibitory effect of progesterone on the contractile activity of myofibrils causes a significant decrease or disappearance of painful uterine contractions. Of the gestagens, the most optimal is the use of natural progesterone.

Dydrogesterone, unlike other synthetic progestogens, is completely devoid of estrogenic, androgenic, anabolic effects, mineralocorticoid and glucocorticoid activity, does not affect the lipid spectrum of the blood and the hemostasis system.

According to literature, the effectiveness of treatment depends on the daily dose of progesterone. In patients taking the drug at 10-15 mg/day, dysmenorrhea was relieved in 60-80% of cases, at a dose of 20 mg/day - in more than 90% of patients.

Patients with severe dysmenorrhea with high estradiol levels and predominant parasympathetic tone are prescribed monophasic COCs containing 20 mcg of ethinyl estradiol as a mandatory component of the therapeutic effect. Such drugs help reduce ovarian hyperactivity and balance prostaglandin-dependent reactions in the body of patients with dysmenorrhea on the eve and during menstruation.

In inflammatory processes, first of all, it is necessary to exclude tuberculosis etiology, and then comprehensively treat the inflammation, taking into account the causative agent of the infectious process and using physiotherapy.

Treatment of external genital endometriosis in girls is a more complex task, often requiring surgical treatment. Internal endometriosis in girls is quite rare. When this disease is detected, effective treatment is carried out with GnRH agonists COC (depot forms of triptorelin, buserelin, goserelin) for 3-4 months with the addition of low-dose monophasic COC in the last month of treatment with GnRH agonists. COC intake is continued until the patient wants to become pregnant.

Treatment of dysmenorrhea during puberty in a hospital setting

Surgical treatment of girls with dysmenorrhea should be carried out in hospitals with an endoscopic surgical unit. Laparoscopy is indicated for patients with the following pathology:

• persistent dysmenorrhea that does not respond to conservative treatment (to clarify the cause of the disease);
• external genital endometriosis, including endometriotic ovarian cysts;
• malformations of the uterus and vagina (additional rudimentary horn of the uterus, doubling of the uterus with aplasia of one of the vaginas).

Indications for consultation with other specialists

It is necessary to consult a therapist, endocrinologist; if indicated, contact a psychologist, exercise therapy specialist.

Evaluation of treatment effectiveness

Treatment is considered effective if it has achieved the established goals.

Further management

During the first year, dynamic observation once every 3 months is advisable. Later, if the disease progresses favorably, it is advisable to conduct a control examination of the patient once every 6 months until she reaches adulthood (18 years), after which the girl, with a detailed statement on the results of the dynamic examination and treatment, is transferred to the supervision of doctors providing obstetric and gynecological care to adult women.

Forecast

If the etiology of dysmenorrhea is clarified and treatment of the disorder is started in a timely manner, the prognosis for further reproductive function is favorable.