Which of the following can be used in Treatment of primary dysmenorrhea-

Ans. is 'd' All of the above * Dysmenorrhea is defined as painful menstruation so as to incapacitate day to day activities.* Typesa) Primary (spasmodic): In absence of any pelvic pathologyb) Secondary (congestive): In presence of pelvic pathology.* Primary dysmenorrhea is mostly confined to adolescent, more common among affluent society, generally with a positive family history.* The pain always occurs in ovulatory cycles and is usually cured after pregnancy and vaginal delivery.* The various theories for primary dysmenorrhea are:i) Uterine myometrial hyperactivity, junctional zone (JZ: subendometrial layer of myometrium) hyperplasia, dysperistalsis and hyperactivity of JZ.ii) Overactivity of sympathetic nerves - hypertonicity of circular fibers of isthmus.iii) PGFa - is more in ovulatory cycles which causes ischemia of myometrium.iv) Vasopressin, endothelins, leukotrienes, and platelet activating factor are all increased which cause uterine hyperactivity, hyperperistalsis, dysrhythmic contractions, ischemia, and pain.v) Psychosomatic factors, anxiety lower pain threshold.TreatmentA) Assurance, counseling, encourage normal activities.B) Drugs# NSAIDs: Given for 1 to 3 days, for 3 to 6 cycles.# Mefenamic acid 250 to 500 mg tds.# Ibuprofen (400 mg) tds or naproxen (250 mg) qds.# Indomethacin (25 mg) tds.# Newer selective COX-2 inhibitors may also be used.# Glycerin trinitrate transdermal patches are also used.# OC pills (suppresses ovulation and hence used) 3 to 6 cycles.# TENS (transcutaneous electrical nerve stimulation) has also been used to relieve the pain.C) Surgery (very rarely required)# Laparoscopy maybe very rarely needed to rule pelvic causes especially endometriosis.* Laparoscopic Uterine Nerve Ablation (LUNA) has not been found to be very beneficial* Laparoscopic Presacral Neurectomy (LPSN) to cut down sensory pathways (T11-T12) from uterus* Cervical dilatation very rarely done. May lead to incompetence in future.