Menstrual pain

The initiation of menstruation, called menarche, usually happens between the ages of 12 and 15 [1]. Menstrual cycles typically continue to age 45 to 55, when menopause occurs. Many women fi nd themselves reluctant to discuss the existence and normality of menstruation. The word menstruation has been replaced by a variety of euphemisms, such as the curse, my period, my monthly, my friend, the red fl ag, or on the rag.


Introduction
The initiation of menstruation, called menarche, usually happens between the ages of 12 and 15 [1]. Menstrual cycles typically continue to age 45 to 55, when menopause occurs.
Many women fi nd themselves reluctant to discuss the existence and normality of menstruation. The word menstruation has been replaced by a variety of euphemisms, such as the curse, my period, my monthly, my friend, the red fl ag, or on the rag.
Most women experience deviations from the average menstrual cycle during their reproductive years. As a result, it is not uncommon for women to display certain preoccupations regarding their menstrual bleeding, not only in relation to the regularity of its occurrence, but also in regard to the characteristics of the fl ow, such as volume, duration, and associated signs and symptoms. Unfortunately, society has encouraged the notion that a woman's normalcy is based on her ability to bear children. This misperception has understandably forced women to worry over the most miniscule changes in their menstrual cycles. Indeed, changes in menstruation are one of the most frequent reasons why women visit their clinician.
Menarche is the most readily evident external event that indicates the end of one developmental stage and the beginning of a new one. It is now believed that body composition is critically important in determining the onset of puberty and menstruation in young women. The ratio of total body weight to lean body weight is probably the most relevant factor, and individuals who are moderately obese (i.e., 20-30% above their ideal body weight) tend to have an earlier onset of menarche.
Widely accepted standards for distinguishing what are regular versus irregular menses, or normal versus abnormal menses, are generally based on what is considered average and not necessarily typical for every woman. According to these standards, the normal menstrual cycle is 21 to 35 days with a menstrual fl ow lasting 4 to 6 days, although a fl ow for as few as 2 days or as many as 8 days is still considered normal.
The amount of menstrual fl ow varies, with the average being 50 mL; nevertheless, this volume may be as little as 20 mL or as much as 80 mL. Generally, women are not aware that anovulatory cycles and abnormal uterine bleeding are common after

Menstrual problems
Menstruation, the shedding of the lining of the womb, is one part of a cycle of physiological changes involving the hypothalamus, pituitary and ovaries as well as the uterus itself [2]. In western societies, most women experience menstruation for the fi rst time between 10 and 16, and will have around 400 menstrual periods before the menopause. Despite the textbook description of a 'clockwork' 28-day menstrual cycle, only one in eight cycles is exactly 28 days long. In fact, although individual women tend to have their own menstrual patterns, menstrual cycles in general vary considerably both between women and across the lifetime of an individual woman, in terms of cycle length, the number of days on which menstruation occurs and the amount of blood and fl uid lost during menstruation. This variability means that menstrual disorders are dif-fi cult to defi ne, and epidemiological studies are problematic. However, menstrual disorders are among the ten most common complaints seen in primary care settings, and since many women do not seek help from physicians it is likely that large numbers of women experience menstrual problems at some time in their life, and that most of these women develop their own ways of coping with them. Menstrual complaints are common and concerning to women [3]. In a study of women referred to hospitalbased gynecology clinics for menstrual issues, the top three complaints were pain with menstruation (33%), perimenstrual mood changes (32.8%), and increasing menstrual fl ow (29.1%); other concerns included prolonged menstruation (25.3%) and experiencing premenstrual pain (17.5%).

Siniša Franjić*
Menstrual problems present throughout the reproductive years and should be evaluated with care keeping in mind that women, especially adolescents, may present with this concern when other issues (e.g., undesired pregnancy, sexually

Dysmenorrhea
The most common menstrual problem is dysmenorrhoea, or pain before and during menstruation [2]. In studies of nonpatient populations as many as 70% of women report some pain associated with menstruation, and 5-10% regularly experience pain which is severe enough to be incapacitating for between an hour to three days each month. Other common complaints are excessive menstrual bleeding (menorrhagia), and absence of menstruation (amenorrhoea). Menorrhagia is usually defi ned as loss of over 50 ml of blood in one menstruation, a level which may put women at risk for anaemia, and approximately 5% of women between 30 and 49 will seek help from a doctor for it. There are many organic causes of menorrhagia, for example, uterine fi broids, thyroid dysfunction or intrauterine contraceptive devices. For as many as half of the women complaining of heavy periods, however, no organic cause can be found. Recent research suggests that some of these women may have inherited blood disorders. The most likely medical investigation is a D&C, followed by hormonal or surgical treatments, usually hysterectomy or endometrial ablation.
Dysmenorrhea means painful menstruation [5]. There are two types: primary dysmenorrhea, in which the pelvic organs are normal, and secondary dysmenorrhea, which results from various diseases of the pelvic organs, such as endometriosis.
Primary dysmenorrhea is the more common type. The pain is crampy, begins just prior to menstruation, and lasts for one or two days after onset of the menstrual fl ow. Usually Dysmenorrhoea is the leading cause of lost school and work time, suggesting the impact of menstrual disorders is substantial and probably largely unrecognized [6]. Some groups of menstrual cycle syndromes are termed catamenial disorders, (coming from peri or around menses) and these involve numerous bodily systems and organs associated with the menstrual cycle. Because of the diversity of systems affected, a comparable number of disciplines have been involved with referrals for treatment or assessment or both. It is surprising that little health psychological research has been carried out to delineate the impact of, for example, dysmenorrhoea on quality of life, coping and health -care -and treatment -seeking behaviours. Health -care professionals' attitudes to menstrual cycle dysfunctions traditionally attributed psychological aetiologies to these. Although treatment in the twenty -first century has improved, more can be done to acknowledge problems earlier through health education and appropriate treatments.
Different phases of the menstrual cycle can be responsible for increasing existing medical conditions such as menstrual migraine, asthma, rheumatoid arthritis, irritable bowel syndrome, epilepsy and diabetes. The rapid changes in ovarian hormones around ovulation and premenstrually may account for some of these menstrual cycle -related changes within existing medical conditions. Treatment using gonadotropin -releasing hormone agonists to suppress ovulation has been shown to be useful.

Conclusion
Moderate pain and cramps during menstruation are common occurrences. However, excessive and very severe pain that prevents everyday activities is not a normal occurrence.
The medical term for painful menstruation is dysmenorrhea.
Primary dysmenorrhea occurs in women who experience pain before and during menstruation. Women with normal menstruation that later become very painful have secondary dysmenorrhea.
Dismenorrhoea is a gynecological health condition characterized by menstrual pain that hampers daily activities.
Dismenorrhoea is often defi ned simply as menstrual pain, or intensively menstrual pain. This is also used as a synonym for menstrual cramps, but they may also relate to menstrual cervix contractions, which are usually greater in strength, duration, and frequency compared to the rest of the menstrual cycle. Dismenorrhoea may involve various types of pain, and may also precede menstruation for several days or occur during menstruation. Excessive bleeding can also occur with dismenorrhoea, known as menorrhagia.
It is believed that the pain is caused by the severe cramping of the uterine (myometrium) and ischemia -reduced oxygen