Clinical and social aspects of dysmenorrhea development

OR = 3.84, CI = 1.67–8.83, P = 0.002). Gynecological pathology in anamnesis had only 46.67 % of controls and 74.19 % of basic group patients (χ 2 = 7.77, P = 0.005; OR = 3.29, CI = 1.47–7.33, P = 0.004). High rate of gynecological diseases among patients with dysmenorrhea frequency of this in the women of the II group. the same rate of primagravida and multigravida among persons in the groups. pain I group of group menses I of group. women of groups of pain (67.27 % persons in the I group and 73.00 % the II). premenstrual menstrual in the persons with dysmenorrhea. of 36-Item Short Form Health Survey in basic group patients compared to controls. Index of “Bodily pain” by 25.56 % in persons with dysmenorrhea compared with healthy individuals (P < 0.001). Score “Vitality” the lowest among other indices of psychological component – by 27.27 % (P < 0.001) compared to controls. We determined decrease of “Social Functioning” and “Role-Emotional Functioning” in women with secondary dysmenorrhea more than in patients with primary one (P = 0.049). pathology (OR = 3.84, CI = 1.67–8.83, P = 0.002). Chronic pelvic pain, dyspareunia, pain which is not related to menstrual cycle, are more common symptoms associated with secondary dysmenorrhea compared to primary one (P < 0.05). But there is no difference in intensity of pain between women with primary and secondary forms of pathology. Decreased quality of life is typical for women with dysmenorrhea.


Introduction
Dysmenorrhea is one of the most spread diseases in gynecological practice. A lot of women suffer from pain during menstruation. Rate of the pathology is about 45-95 % of menstruated women [1]. Dysmenorrhea is classified into primary and secondary forms. Primary dysmenorrhea is related to increase in secretion of prostaglandins, leukotrienes, disorders of uterine contractility and so on [2]. Secondary dysmenorrhea usually occurs on the background of pelvic organs inflammatory diseases, endometriosis, adenomyosis and uterine myoma [3]. Pain syndrome is very often accompanied by psychological disorders. Tendency to aggressive behavior, depression, increased anxiety are typical for such patients [4,5]. Besides this, reduced daily activities and decreased quality of life are associated with dysmenorrhea [6][7][8].
Diagnosis of dysmenorrhea is based on patients' complains of menstrual pain and results of examinations. First of all, clinical management of women with dysmenorrhea includes complete examination using general and gyneco-logical ones, ultrasonography and Doppler ultrasonography of pelvic organs. Other underlying gynecological pathology must be included or excluded for differentiation of dysmenorrhea primary or secondary form [3]. Treatment of patients depends on form and cause of disease. Usually it includes hormonal therapy, non-steroidal anti-inflammatory drugs, treatment of underlying pathology [9]. There are publications showing effectiveness of physical exercises, nutrition supplements with vitamin D and omega-3 fatty acids for menses pain relief [3].
It is worth mentioning, that usually menstrual pain syndrome is not a reason to visit a gynecologist. Self-treatment using medicines which are advertised on TV or in fashion magazines is more popular among women than consultation by a doctor on this particular pathology [10,11]. Unfortunately, such patients do not realize all the problems that may be associated with pain syndrome. Today, the rate of gynecological diseases differs from that several decades ago when most women were screened by the government-controlled periodic health examination. So, it is important today to determine the clinical and social aspects of this problem.

The aim
Aim of the research was to determine clinical and social aspects of women with dysmenorrhea.

Materials and methods
The study involved 155 women with diagnosis dysmenorrhea who formed the basic group. 55 persons had primary form of disease (the I group), 100 patients -secondary one (the II group). Control group included 30 women without pathology. The research was carried out in female dispensary No. 2 of Ivano-Frankivsk City Clinical Perinatal Centre.
Inclusion criteria: presence of dysmenorrhea, reproductive age, written consent from patient. Exclusion criteria: pregnancy, lactation, acute inflammatory diseases of pelvic organs, tumors of the uterus and ovaries of unknown etiology, organic pathology of the central nervous system, mental illness, malignant tumors in the present or in anamnesis, trauma of pelvic organs in anamnesis, severe form of extragenital diseases, dysmenorrhea after operations on pelvic organs, having taken psychotropic drugs in the previous three months.
All women underwent general and gynecological examination, and ultrasound echography of pelvic organs. Visual Analogue Scale (VAS) was used to determine intensity of pain (mild pain -1-4 points, moderate -5-6 points, severe -7-10 points). Premenstrual syndrome was diagnosed with the help of anamnestic data and R. Moos Menstrual Distress Questionnaire. 36-Item Short Form Health Survey (SF-36) was used to assess quality of life.
For statistical analysis we used program Stаtistica 6.0. Descriptive statistics (mean, standard error of mean), nonparametric statistic (Mann-Whitney test was used to compare two independent samples), criterion χ 2 , odds ratio (OR), confidence interval (CI) were calculated. A P-value ≤ 0.05 was considered as statistically significant.

Results
The average age in the control group was 27.97 ± 0.87 years, in the basic one -30.78 ± 0.44 years (28.75 ± 0.78 years in the I group, 31.90 ± 0.50 years -in the II (P < 0.01 in comparison with the controls and I group)). There was no significant difference in age at menarche between women with dysmenorrhea (13.03 ± 0.17 years) and without it (12.90 ± 0.07 years). We did not find any association between employment and development of dysmenorrhea. Most of persons in the control and basic groups had intellectual work (students, teachers, doctors, managers and so on) -19 (63.33 %) and 88 (56.77 %) persons, respectively. 11 (36.67 %) and 67 (43.23 %) individuals, respectively, were workers and housewives. Also no significant difference was found between body mass index (BMI) and pathology. Women with normal BMI predominated in both groups -21 (70.00 %) healthy individuals and 104 (67.09 %) patients with dysmenorrhea. 8 (26.67 %) controls were overweight or had obesity, 1 (3.33 %) person was underweight. In the basic group these parameters were, respectively, 46 (29.68 %) and 5 (3.23 %) patients.
So, among social factors we found only importance of physical activity for dysmenorrhea development. Adequate physical activity indicated 20 (66.67 %) persons in the con-trol group and 59 (38.06 %) -in the basic one. The number of persons with low level of physical activity was 1.86 times more in the group with dysmenorrhea (96 (61.94 %)) than among healthy (10 (33.33 %) women; χ 2 = 7.28, P = 0.007; OR = 3.84, CI = 1.67-8.83, P = 0.002). There was no difference in above mentioned indices between patients of the I and II groups. The onset of dysmenorrhea was different between women of the I and II groups -16.04 ± 0.24 and 22.67 ± 0.45 years, respectively (P < 0.001). The common complaints in women with dysmenorrhea were related to menstrual pain syndrome. Usually duration of pain syndrome was 1-2 days in women of the I group. Persons of the II group indicated prolonged pain syndrome during menses lasting 2-4 days. Besides this, chronic pelvic pain was typical only for the II group persons (31 (31.00 %) women) (χ 2 = 19.42, P < 0.001 in comparison with the I group) as well as other types of pain. Dyspareunia and dyschezia had only 11 (11.00 %) patients with secondary dysmenorrhea (χ 2 = 5.95, P = 0.03 compared to the I group). Also 28 (28.00 %) women in the II group had non-menstrual pain (χ 2 = 16.95, P < 0.001, compared with the I group).
We did not find any significant difference in pain syndrome severity according to VAS scale between persons of the I and II groups. Moderate pain intensity was indicated by most patients of both groups: (37 (67.27 %) women in the I group and 73 (73.00 %) -in II). 9 (16.36 %) individuals with primary dysmenorrhea had mild and severe intensity of pain each. 4 (4.00 %) patients with secondary form of disease suffered from mild pain, 23 (23.00 %) -from severe one.
We determined difference in dynamics of pain intensity after childbirth between women with primary and secondary form of pathology. After childbirth 27 (49.09 %) persons in I the group noted pain syndrome reduction, 11 (20.00 %) patients indicated no changes. But the number of persons with pain relief after childbirth in the II group (22 (22.00 %) was 2.23 times less than in the I group; χ 2 = 10.83, P = 0.001). Besides this 37 (37.00 %) women reported increase of pain intensity last months.
Self-management for dysmenorrhea was typical among persons of both groups. Only 12 (21.82 %) patients with primary form of disease consulted gynecologist about treatment. 19 (34.55 %) women with primary dysmenorrhea did not use medicines, 24 (43.63 %) -used self-medications (spasmolytics, analgetics, non-steroidal anti-inflammatory drugs). The number of persons with secondary dysmenorrhea who visited gynecologist was 2.52 times higher than patients with primary one (55 (55.00 %) individuals; χ 2 = 14.59, P < 0.001). They consulted doctor mostly not because of pain during menstruation. The main reasons for such visits were related to underlying gynecological diseases.
All the scores of 36-Item Short Form Health Survey were significantly decreased in women of the basic group compared to controls ( Table 1). Among physical component attention should be paid to "Bodily pain" which was less in persons with dysmenorrhea by 25.56 % compared to healthy individuals (P < 0.001). Score "Vitality" was the lowest among other indices of psychological component -by 27.27 % (P < 0.001) compared to controls. There was no significant difference between patients with primary and secondary dysmenorrhea in physical component indices. But scores of psychological component were lower in women of the II group than of the I group. Thus, we determined more severe reduction of "Social Functioning" and "Role-Emotional Functioning" in women with secondary dysmenorrhea as compared to women with primary one (P = 0.049) ( Table 1).
The underlying pathology is often resulting in secondary dysmenorrhea. The main causes of it are endometriosis, chronic pelvic inflammatory diseases. Various types of pain as dyspareunia, noncyclic pain, different forms of intensity and duration are typical for such gynecological diseases [3]. It has been well determined that pain syndrome is associated with the influence on activity of life reduction [12]. That is why decrease in scores of physical component that was demonstrated in our research is representative for both primary and secondary forms of pathology. Besides the pain syndrome influence on physical part of quality of life, some publications indicate that patients with dysmenorrhea are very often in the risk group of mental health problems development such as depression, sleep disorders, aggressive mood, anxiety [4,5]. We believe that underlying pathology of secondary dysmenorrhea has a profound impact on the psychological condition of patients.

Conclusions
1. Among social factors that can lead to dysmenorrhea we found association of reduced physical activity with the development of pathology (OR = 3.84, CI = 1.67-8.83, P = 0.002). There are no associations between body mass index, type of employment and dysmenorrhea.
2. Type of pain and its duration depend on form of dysmenorrhea. Chronic pelvic pain, dyspareunia, pain which is not related to menstrual cycle are more common symptoms associated with secondary dysmenorrhea compared to primary one (P < 0.05). But there is no difference in intensity of pain between women with primary and secondary forms of pathology.
3. The quality of life is decreased in women with dysmenorrhea. Scores of physical components of SF-36 are similarly decreased in patients with primary and secondary dysmenorrhea. Reduction in psychological scores is more significant in secondary form of the disease.
Prospects for further research in this direction. In the future, we expect to study different types of treatment for patients with dysmenorrhea.