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By Adriane Fugh-Berman, MD, and Anthony Scialli, MD
A variety of cam treatments, including diet, exercise, acupuncture, chiropractic, transcutaneous electrical nerve stimulation (TENS), herbs, and dietary supplements, are used to treat dysmenorrhea. This article will discuss therapies commonly prescribed by complementary and alternative medicine (CAM) practitioners and will review the few controlled trials that exist.
The belief that avoiding fat or heavy meals lessens dysmenorrhea has been explored in several studies, and there may be some relationship between fat intake—or the type of fat eaten—and menstrual cramps. The effect of a low-fat diet on dysmenorrhea and water retention was tested in a recent crossover study of 33 women (21 completed the trial).1 Baseline data were gathered in the first month, after which women were assigned to a low-fat vegetarian diet or their regular diet plus a placebo pill; after two months the groups were crossed over. There was a substantial dropout rate. The duration of dysmenorrhea significantly decreased from baseline (3.9 days) to diet (2.7 days); there was no significant change from baseline to placebo supplement (3.6 days). However, differences in pain intensity between the placebo supplement phase and diet phase were significant for only one of three days with pain.
Fish and Fish Oil
The type of fat consumed also may make a difference in dysmenorrhea. Fish oil, high in omega-3 fatty acids, modulates prostaglandin production and may have an effect on menstrual cramps. A Danish survey of 181 women ages 20-45 utilized food intake diaries and found that menstrual pain was significantly correlated with a low intake of animal and fish products and a low omega-3 to omega-6 dietary ratio.2
In a placebo-controlled, crossover study, 42 adolescents with dysmenorrhea were randomized to placebo or fish oil supplements (containing 1,080 mg eicosapentaenoic acid, 720 mg docosahexaenoic acid, and 1.5 mg vitamin E); after two months the groups were crossed over. As assessed by the Cox Menstrual Symptom scale, dysmenorrhea symptom scores decreased significantly (from 69.9 to 44.0) after fish oil treatment; there was no difference between placebo and baseline.3
Women who exercise appear to have fewer menstrual symptoms than women who do not exercise. A review of studies on dysmenorrhea and exercise identified seven trials on the subject (three observational studies and four randomized controlled trials).4 Of the four randomized, controlled trials (two compared different types of exercise and two compared exercise to no exercise), all found a significant reduction in dysmenorrhea among exercisers. Two observational studies found a lower prevalence of dysmenorrhea in regular exercisers; the third (which adjusted scores for disposition, medication, stress, and mood) found that regular exercisers had more menstrual symptoms than non-exercisers. The reviewers point out that these studies were inadequately blinded (difficult to imagine an adequate blind for exercise) and that better studies are needed.
Chiropractic uses manual techniques to adjust spinal vertebrae. Although this treatment is more accepted for back pain or musculoskeletal disorders, chiropractic is used commonly to treat excessive bleeding or dysmenorrhea. A small dysmenorrhea trial compared chiropractic manipulation (at least twice a week) in eight women with three controls.5 Seven of the eight women treated with chiropractic experienced decreased pain and disability, compared with none of the controls.
In a randomized controlled trial of 45 women with primary dysmenorrhea, 24 women received spinal manipulative therapy (SMT) and 21 women received "sham" manipulation.6 A Menstrual Distress Questionnaire (MDQ) and a visual analog pain scale were administered 15 minutes before and 60 minutes after treatment, and blood was drawn. Compared with pretreatment values, the SMT group had less abdominal pain than the sham-treated group and lower scores on the MDQ. Both groups experienced significantly decreased levels of the prostaglandin F2a metabolite 15 keto-13,14-dihydroprostaglandin (prostaglandin F2a is increased in women with dysmenorrhea), but there was no significant difference between groups.
One study of dysmenorrhea compared two acupuncture groups with two control groups. Eleven women received real acupuncture at "real" acupuncture points, 11 received "placebo" acupuncture at non-acupuncture points, 10 women continued prior treatment ("standard" controls), and 11 continued prior methods but also received extra office visits (visit control).7 Both acupuncture groups were treated for three weeks of each month (every week except during menses) for three menstrual cycles. Mean monthly pain scores were not significantly different between groups. However, the proportion of women whose average pain scores were halved after treatment was significantly higher in the real acupuncture group compared to each of the other groups.
Transcutaneous Electrical Nerve Stimulation
TENS has become an accepted treatment for various kinds of pain, and although not commonly prescribed for dysmenorrhea, there is evidence that TENS is effective for this condition. In a randomized, crossover study, 32 women with severe primary dysmenorrhea were treated with TENS for two cycles, sham TENS for one cycle, and ibuprofen for one cycle.8 During the ibuprofen cycle, the subjects received 400 mg ibuprofen at the onset of dysmenorrhea and continued treatment (400 mg qid) for up to three days. During the TENS cycle, negative electrodes were placed bilaterally about 4 cm lateral to the umbilicus with the positive electrode positioned over the suprapubic area. This placement was meant to stimulate sensory nerves in the thoracic 10-12 dermatomes. One hundred pulses per second with a 100-microsecond pulse width were used; the patient adjusted stimulation individually. TENS stimulation was used continuously during the first eight hours of the cycle and then as needed. During the TENS and placebo TENS cycles, up to 1,600 mg/d ibuprofen was allowed.
Compared to the other two groups, significantly more subjects receiving TENS did not require ibuprofen or required less ibuprofen during the first 24 hours after the onset of dysmenorrhea and for the duration of menstruation. TENS also significantly delayed the need for ibuprofen (by an average of 5.9 hours). The use of TENS alone resulted in good to excellent pain relief in 42.4% of subjects (pain included cramps, backache, leg cramps, continuous abdominal pain, headache, and general body aches), while placebo TENS resulted in relief in only 3.2%. TENS also significantly reduced diarrhea, menstrual flow, clot formation, and fatigue compared with placebo TENS.
An open, randomized crossover study in 12 women compared the use of TENS stimulation and oral naproxen (500 mg) on dysmenorrhea and intrauterine pressure.9 Pain scores were significantly reduced within 30-60 minutes following treatment with TENS and within 19-120 minutes after naproxen administration. Naproxen significantly suppresses uterine activity (measured by an intrauterine microtransducer catheter) while TENS treatment caused no significant change in uterine activity.
Other CAM Treatments
Herbs, dietary supplements, or yoga may be recommended by CAM practitioners, but no clinical trials were identified on these therapies. Magnesium, calcium, or vitamin E are some of the dietary supplements that may be recommended by CAM practitioners. Herbs used to treat dysmenorrhea include cramp bark (Viburnum opulus), black haw (Viburnum prunifolium), raspberry leaf (Rubus idaeus), root or flower of dandelion (Taraxacum officinale), nettle (Urtica dioica), chamomile (Matricaria recutita), yarrow (Achillea millefolium), and catnip (Nepeta cataria), usually in the form of hot tea or infusions (which are essentially over-steeped teas). None of these benign herbs has been associated with significant adverse effects. Black haw (but not the closely related cramp bark) contains oxalates and should be avoided by those on a low-oxalate diet.
Yoga teachers often prescribe relaxing, supine poses for menstruating women, and instruct women to avoid upside-down poses (shoulderstand, headstand, and handstand) during the menses. The basis for this proscription apparently is fear of retrograde menstruation and subsequent endometriosis. However, almost all women experience retrograde menstruation to some extent, and its relationship to endometriosis is unclear.
A variety of herbs and dietary supplements are used to treat dysmenorrhea. The most popular, listed in this article, have a good safety profile and require no warnings. Most of these trials of CAM treatments for premenstrual syndrome used inappropriate statistical testing (parametric tests are not appropriate for analyzing ranked scores of symptoms) that could affect conclusions (see Alternative Therapies in Women’s Health, February 2001, pp. 9-12).
There is limited evidence to support the use of exercise, TENS, chiropractic, or fish oil for the treatment of dysmenorrhea. Results were equivocal in the single trial that examined the effect of acupuncture and the single trial that examined a low-fat vegetarian diet.
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8. Dawood MY, Ramos J. Transcutaneous electrical nerve stimulation (TENS) for the treatment of primary dysmenorrhea: A randomized crossover comparison with placebo TENS and ibuprofen. Obstet Gynecol 1990;75:656-660.
9. Milsom I, et al. A comparative study of the effect of high-intensity transcutaneous nerve stimulation and oral naproxen on intrauterine pressure and menstrual pain in patients with primary dysmenorrhea. Am J Obstet Gynecol 1994;170(1 Pt 1):123-129.