April 19, 2018
A BACKGROUND ON DYSMENORRHEA:
Dysmenorrhea is pain and cramping in the lower abdominal region during a woman’s menstrual cycle. There are two types of dysmenorrhea: primary or secondary. In primary dysmenorrhea there is pain with no organic disease present and this form starts six months to two years after menarche (a woman’s first period). Secondary dysmenorrhea is pain with menses that is associated to a disease process. This form starts typically when women are in their twenties and becomes increasingly worse with age. Secondary dysmenorrhea can be associated to a range of different disorders, including endometriosis, uterine polyps, leiomyoma (fibroids), ovarian cysts, and many more. Although dysmenorrhea is not a life threatening disorder in and of itself, it impacts a woman’s quality of life greatly and is the most common gynecological problem among menstruating women. Numerous studies have also shown that women who suffer from dysmenorrhea have higher rates of absenteeism from school or work, which can be correlated to lost societal productivity.
The standard first-line allopathic treatment of dysmenorrhea is the use of NSAIDs. Another common course of treatment is the use of oral contraceptives. If neither of these treatment protocols work there is additional inquiry required to rule out secondary dysmenorrhea. Even if secondary dysmenorrhea is identified, NSAIDs and oral contraceptives are commonly prescribed. Like any medication, these two are not without their associated risks. Of particular concern is peptic ulcers and thus internal bleeding in relation to the use of NSAIDs. A low but serious risk factor associated with the use of oral contraceptives that contain estrogen is the development of blood clots. This risk further increases among women who smoke cigarettes.
While conventional medicine uses anti-inflammatory medication, an ND may look at reducing overall inflammation in the patient’s body through diet. Often this begins with an elimination diet, to try and identify whether there is any food that aggravates the patient. This may extend into more permanent elimination of common triggers, such as dairy or gluten. Encouraging the patient to avoid sugar, alcohol and smoking would also be critical to decrease an inflammatory state. Other dietary approaches with varying levels of evidence that may help with dysmenorrhea include regular breakfast habits, aspartame ingestion and low fat vegan diets. Nutritional supplements that also have research to back up their efficacy in treating dysmenorrhea include magnesium, thiamine, vitamin E, iron, niacin, flavonoids, ginger root and of course omega-3 fatty acids. According to a 2001 Cochrane Review on herbal and dietary therapies for dysmenorrhea, the authors concluded that based on all available evidence, vitamin B1 and magnesium both may have benefits in the reduction of pain with dysmenorrhea.
An ND may also use some or all of the following modalities: hydrotherapy, homeopathy, lifestyle change counseling, botanical medicine and acupuncture.
For example, with hydrotherapy, an ND may recommend the use of hot compresses to relax the muscles, hot sitz bath as an analgesic and constitutional hydrotherapy for increased circulation and cellular metabolism.
Many different botanicals could also be used to help with dysmenorrhea. Desirable actions for these herbs would be antispasmodics, nervines, diuretics, uterine tonics and hormonal normalizers. For example, a common tincture prescription for people suffering from dysmenorrhea is Viburnum prunifolium (antispasmodic), Scutellaria lateriflora (nervine and antispasmodic) and Cimicifuga racemosa (anispasmodic, anti-inflammatory, nervine).
A very big lifestyle recommendation would be for patients who suffer from dysmenorrhea to regularly exercise. Exercise can have the effect of lowering the incidence of dysmenorrhea through mediating stress and hormones.
Finally, the use of acupuncture can help to decrease dysmenorrhea. For example, from a Traditional Chinese Medicine perspective, dysmenorrhea is a common symptom in patients who present with liver blood stasis. Causes of this are Qi stagnation, cold and heat. Acupuncture points that may be beneficial include, but are not limited to, stomach 36 (tonifies Qi), liver 3 and liver 4 (promotes smooth flow of liver Qi).
LET’S TALK ABOUT FATTY ACIDS:
Essential fatty acids act as precursors to prostaglandins, prostacyclins, thromboxanes and leukotrienes. These substances have critical influences on immune function, smooth muscle function, platelet aggregation and inflammation. Omega-3 fatty acids are responsible for 3-series prostaglandins while omega-6 fatty acids are responsible for 1-series prostaglandins. Generally speaking, the western diet is lacking in omega-3 fatty acids as it is not present in a lot of our common dietary oils and cold water fish and linseed oil are not a part of the typical diet. On the other hand, it is common to find omega-6 fatty acids in dietary oils. If the body receives a higher amount of one of these, it inhibits the metabolism of the other.
Before a woman menstruates, she has a progesterone withdrawal. At this time there is a cascade of prostaglandins and leukotrienes in the uterus. The ensuing inflammatory response is responsible for cramps, nausea, vomiting, bloating and headache. The prostaglandins that are produced could be 3-series or 1-series prostaglandins. Omega-3 prostaglandins (3-series) are less potent than the ones produced by omega-6 fatty acids (1-series). If a woman produces less potent prostaglandins the result could be less myometrial contraction, vasoconstriction, ischemia and pain. Thus, if a woman is taking an omega-3 fatty acid supplement, there is a higher likelihood that she will experience less dysmenorrhea based on the above information. This may be more applicable to women with primary dysmenorrhea, but could potentially play at least a partial role for women with secondary dysmenorrhea, depending on the cause.
FISH OIL TO HELP WITH MENSTRUAL PAIN:
The author of this article examined studies that compared fish oils to placebo and other oils in the treatment of dysmenorrhea. Papers that looked at surveys and case reports were also included. The overarching theme was that, at least to some degree, supplementation with omega-3 fatty acids does decrease symptoms associated with dysmenorrhea. For example, in a 2011 research paper 120 women with dysmenorrhea were randomly divided into two groups. One group received 100mg/day of fish oil and the other group received ibuprofen. Both fish oil and ibuprofen provided pain relief among these women. In another study it was identified that fish oil with B12 appeared to have the greatest effect in pain reduction. Surveys that examined dietary habits among women of reproductive age also found that those who consume less fish appeared to be more likely to have dysmenorrhea. More studies that compare the intake of omega-3 fatty acids to standards first line conventional treatment of dysmenorrhea (ie NSAIDs or oral contraceptives) should be done in order to determine whether omega-3 fatty acids are in fact a comparable treatment.
FISH OILS CAN HAVE BENEFIT BEYOND DYSMENORRHEA:
Naturopathic Doctors will commonly prescribe fish oil to patients for a variety of conditions. Research has demonstrated its efficacy in relation to a variety of mental health conditions, alzheimer’s disease, autism, skin conditions such as eczema, coronary artery disease and rheumatoid arthritis. Outside of patients with fish allergies, the intake of omega-3 fatty acids is considered safe when taken up to 3.5 years. A common concern regarding the intake of fish oil is that it may increase one’s chance of bleeding. A 1992 study followed 365 patients over seven-years who took a daily fish oil supplement. These patients had ischemic heart disease, hyperlilipedmia or a strong family history of ischemic heart disease. The research found that there were no adverse effects. Of course, an ND must look at each patient as an individual and decide based on their entire picture whether fish oil is warranted and safe. However, based on the overarching lack of harms associated with the intake of fish oil, fairly accessible prices and significant potential overall health benefits, relating to dysmenorrhea and beyond, it appears that omega-3 fatty acid supplements, commonly in the form of fish oil, are an excellent supplement to prescribe to patients. Alternatively, encouraging patients to increase their intake of fish in the diet would also be advisable and patients could budget this into their weekly groceries spending as opposed to having to buy a supplement separately.
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