Dysmenorrhea (painful menses) is the most common gynecological condition among women of reproductive age and the leading risk factor for chronic pelvic pain according to the World Health Organization.1-3 Dysmenorrhea is considered primary in the absence of underlying pelvic pathology, whereas secondary dysmenorrhea results from identifiable pelvic pathology.4,5 Primary dysmenorrhea-associated symptoms may include abdominopelvic and lumbosacral pain, headache, nausea, fatigue, bloating, and general malaise, which may compromise overall quality of life and functionality.4,6 Symptoms usually precede several hours before menstruation and may continue for up to 48-72 hours, leaving some females unable to cognitively and physically function for several days each month.7
The socioeconomic burden of primary dysmenorrhea (PD) results in 600 million working hours per year of absenteeism and up to $2 billion in lost productivity per year.8-10 Moreover, non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptive pills and/or progestins are associated with adverse events and have a 20-30% failure rate for controlling myometrial pain.11-13 As such, the National Institute of Health recommends the use of complementary and alternative approaches, such as acupuncture, for treating chronic pelvic pain.14
PATHOGENESIS OF PRIMARY DYSMENORRHEA
Although PD is associated with normal ovulatory cycles, it results in abnormal uterine contractions due to hypersecretion of prostaglandins during the luteal phase.15 When progesterone declines prior to menstruation, arachidonic acid is released, causing a cascade of prostaglandin and leukotriene release in the uterus.16 The pain associated with dysmenorrhea is caused by prostaglandin F2A and prostaglandin E2, which constricts arteriole blood flow to the uterus and causes high-amplitude contractions.17 The menstrual fluid of women with PD has twice the normal amount of prostaglandin F2A.18,19 Moreover, endometrial levels of prostaglandin F2A are four times the normal amount on the first day of the menstrual cycle in women with PD.18,19 In addition, Leukotriene-C4/D4, leukocytes count, mean platelet volume, and platelet distribution width are indicators of inflammation, have been shown to be elevated in women with PD, and are considered a correlate of dysmenorrheal symptoms.20-22 New evidence further suggests differing cytokine gene expression profiles in women with PD throughout the menstrual cycle; however, the complete pathophysiology of PD continues to be a mystery.
ACUPUNCTURE, NSAIDS & ORAL CONTRACEPTIVE PILLS
Several recent systematic reviews and meta-analyses have demonstrated the effectiveness of acupuncture when compared with NSAIDs and/or oral contraceptive pill use in females with PD. In a recent systematic review and meta-analysis of 19 randomized-controlled trials that compared acupuncture to NSAIDs for the treatment of PD, 17 trials reported a superior clinical effectiveness rate, 6 trials reported symptom score improvements, and 4 trials demonstrated a reduction in plasma PGF2A concentration levels in peripheral blood following needling procedures.23Another systematic review and meta-analysis24 concluded that acupuncture reduced menstrual pain more effectively than the use of NSAIDs in women with PD.
The most commonly used acupoints in both reviews included: SP6, followed by CV4, SP8, BL32, ST36, SP10, LV3, CV3, EX-B8, and BL23.23,24 Needle retention times ranged from 15-60 minutes and were performed once per day, 2-7 days prior to menstruation for up to 3 to 6 cycles. Most studies reviewed included either manual or electric stimulation until deqi was attained. The efficacy of needle manipulation on patients with PD was systematically reviewed, and deep needling with strong stimulation was superior to superficial needling with weak or no stimulation.25-27 In addition to pain control, acupuncture has been reported to improve overall quality of life and disuse of NSAIDs with regular treatments for 3 to 6 months.28,29
When acupuncture—i.e., CV6, CV3, SP8 and SP6 (bilaterally) for 20 minutes, at a frequency of 3 sessions per week for the 2 weeks prior to menstruation—was compared to a combined-oral contraceptive (COC) group for PD,30 the COC group was more efficacious than acupuncture at reducing maximal pain scores. However, both the acupuncture and COC interventions were comparable with respect to the number of painful days per cycle, the amount of rescue analgesics for pain relief, and the overall quality of life. Notably, the side effects of the group that received acupuncture were significantly less than the group that received COC. Moreover, given the variability of medical and surgical treatments for PD, it is recommended that healthcare providers utilize a more holistic and multidisciplinary approach whenever possible.31
TRIGGER POINT DRY NEEDLING
Given that menstrual pain is referred to the abdomen in 70-90%32 and lower back in 40%33 of women, somatovisceral convergence seems commonplace in PD.34 More specifically, lamina I of the spinal cord is the first site in the central nervous system where somatic and visceral C-fibers pathways converge onto individual projection and local circuit neurons. It is this mechanism of convergence that may explain the causation of referred pain. Since referred pain is well documented for the uterus and because it shares common pain fiber pathways with the rectus abdominis, needling procedures directed to the abdomen can limit nociceptive stimuli to the uterus, thereby decreasing the severity of pain associated with PD.34 Given that high levels of prostaglandins may activate latent trigger points in abdominal muscles, trigger point dry needling may be a useful technique in women with PD. However, the relevance of the localized twitch response continues to be debated in the literature, and trigger point dry needling has primarily been associated with short-term outcomes.3536
Although Huang and Liu37 injected lidocaine into trigger points of the rectus abdominis and reported 63% improvement in pain intensity levels for one year after just a single treatment, the authors did not include a control or comparison group. Nevertheless, and similarly, a single session of trigger point dry needling targeting abdominal trigger points at 2 weeks prior to menstruation was found to reduce pain intensity better than placebo in patients with PD; however, no significant difference in quality of life was found between the two groups.48 Furthermore, in a recent case series,38 11 of 12 patients with chronic abdominal wall pain with uncertain origin that received trigger point dry needling targeting the rectus abdominis and external oblique muscles reported significant improvements in pain at the 4-month follow-up. While the patients in this 2019 study were not specifically diagnosed with PD, the findings certainly highlight the potential value of targeting trigger points in the abdominal muscles with dry needling.38
Spinal manipulation has also been recommended for patients with PD. One of the earliest pilot studies that investigated the use spinal manipulation in women with PD was conducted in 1992.39 The investigators performed side-lying high-velocity, low-amplitude thrust manipulation targeting the lumbosacral region on the first day of menstruation. While SMT did not alter prostaglandins in the blood, it did lead to significant improvements in pain intensity (VAS) and perceived menstrual distress (Menstrual Distress Questionnaire) compared to the sham manipulation group.
A recent systematic review40 found spinal manipulative therapy is effective for pain relief in women with PD, particularly when used as an adjunct treatment. In a separate trial, osteopathic spinal manipulation led to significant reductions in pain intensity and quality of life when performed the first five days of each menstrual cycle for 5 consecutive cycles.41 Moreover, women treated with spinal manipulation experienced a significant decrease in NSAID use, absenteeism from work/school, and menstrual-related symptoms. Similarly, when compared with sham manipulation, bilateral sacroiliac joint manipulation has been found to significantly decrease self-perceived pelvic pain and improve pressure pain thresholds over the sacroiliac joint.42
There is a moderate level of evidence in the literature supporting the use of acupuncture, trigger point dry needling, and spinal manipulation in patients with PD. If initiated within the week prior to menstruation, several studies have found needling (without injectate) and high-velocity thrust spinal manipulation to be effective in managing the symptoms associated with PD.
Kristina Koroyan, DPT, FAAOMPT, Dip. Osteopractic
Physical Therapist, Sanger Physical Therapy, Sanger, CA
Fellow, American Academy of Orthopaedic Manual Physical Therapists
Raymond Butts, PhD, DPT, MSc (Neurosci), Dip. Osteopractic
Senior Instructor, American Academy of Manipulative Therapy
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
James Dunning, PhD, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Owner, Montgomery Osteopractic Physical Therapy & Acupuncture, Montgomery, AL
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
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