Dysmenorrhea is not among the most essential goals of Healthy People 2020. Still, women's reproductive health remains one of the top priorities in Healthy People 2020. This paper includes a detailed overview of the health condition and its relation to Healthy People 2020. The incidence, prevalence, and most essential factors of dysmenorrhea are described. The impacts of dysmenorrhea on the quality of life among women are discussed. Implications for nursing and the role of the APN in dysmenorrhea management are evaluated.
Keywords: dysmenorrhea, Healthy People 2020, nursing, reproductive health.
Dysmenorrhea Related to Healthy People 2020
Introduction/Brief Overview with Statement of Importance and Impact on Women’s Health
Dysmenorrhea is a topic of continuous medical concern. With the growing pressure to improve reproductive health and women's access to health care, dysmenorrhea remains a serious barrier to health and medical care improvements. The etiology and epidemiology of dysmenorrhea are widely documented. Still, thousands of women keep suffering from pain. The importance of the topic is justified by the major impacts, which dysmenorrhea has on women and their lives. The economic and social costs of dysmenorrhea add complexity to the problem. The focus of this paper is on the prevention of dysmenorrhea and the role, which the APN can play in comprehensive dysmenorrhea management and disease prevention.
Pathophysiology of Dysmenorrhea
The term "dysmenorrhea" is a synonymous to "menstrual pain" (Grandi et al., 2012). It is used to describe a dull, throbbing, and cramp-like pain that women feel in their abdomen before or during the menses (Grandi et al., 2012). Dysmenorrhea is divided into two types: primary and secondary. Primary dysmenorrhea is the term describing "painful menses in women with normal pelvic anatomy, usually beginning during adolescence" (Unsal et al., 2010, p.138). Secondary dysmenorrhea is always the result of some pathology, and its onset has nothing to do with menarche (Unsal et al., 2010). The causes underlying secondary dysmenorrhea can be numerous, from endometriosis to ovarian cysts and irregular cycles (Unsal et al., 2010).
The incidence and prevalence estimated for dysmenorrhea vary widely across studies. Unsal et al. (2010) state that different studies report between 28% and 72% in dysmenorrhea prevalence. Unsal et al. (2010) conducted an empirical study and found the prevalence of dysmenorrhea among young women to be 72.7%. Unsal et al. (2010) also describe the pathophysiology of the disease. The mechanism of dysmenorrhea comes into play 2-4 days before the menses and usually covers from 1 to 3 days (Unsal et al., 2010). This mechanism is associated with the changes in prostaglandin levels, which occur before the menstrual bleeding. Prostaglandins penetrate into the uterine muscle, where they accumulate and act as uterine muscle contractors (Unsal et al., 2010). They are expected to facilitate the expulsion of the endometrium during menses, but their excessive levels result in cramp pains, which millions of women experience during these days.
Common Differential Diagnosis
Making a differential diagnosis for either primary or secondary dysmenorrhea is a serious challenge for nurses (Stoelting-Gettelfinger, 2010). According to Stoelting-Gettelfinger (2010), the differential diagnosis for a young healthy woman suspected of primary dysmenorrhea should necessarily include pelvic inflammatory disease, secondary dysmenorrhea, adenomyosis and endometriosis, cervical stenosis, ovarian cyst, fibroids, and endometrial polyps. For secondary dysmenorrhea, the differential diagnosis should cover adenomyosis and endometriosis, lelomyomas, PID and intrauterine devices, cervical stenosis and adhesions, as well as endometrial and cervical polyps (Stoelting-Gettelfinger, 2010). The diagnostic plan may also include laparoscopy or laparotomy, especially when it comes to secondary dysmenorrhea.
The process of assessment must incorporate physical examination and history (Stoelting-Gettelfinger, 2010). In case of primary dysmenorrhea, physical examination is expected to be absolutely normal while the history may reveal cases of abnormal pains during menstruation. With secondary dysmenorrhea, the history confirms the onset of menstrual pains after 25 years, coupled with abnormalities detected during physical examination, irregular cycles, and other complaints, such as heavy menstrual flow and infertility (Stoelting-Gettelfinger, 2010). The assessment must include a detailed analysis of family history, possible chronic health problems, substance use, and sexual history. Laboratory tests may include complete blood count, urine analysis, cervical culture, pregnancy tests, and pelvic/vaginal ultrasound.
Healthy People 2020 Objective
Dysmenorrhea is not listed in Healthy People 2020. To be more correct, Healthy People 2020 does not include any specific goals related to dysmenorrhea. Still, eight out of 42 topics covered by Healthy People 2020 address the problems of women's reproductive health. Healthy People 2020 includes topics related to family planning and maternal health. No less important is the topic of adolescent health, given that the etiology and epidemiology of primary dysmenorrhea are invariably associated with menarche (Unsal et al., 2010). For adolescents and older populations, better management and prevention of dysmenorrhea echoes the Healthy People 2020 goal to increase the number of adolescents receiving reproductive health services and support.
Factors that May Influence Dysmenorrhea Such as Culture, Literacy, Disparity, Access, and Economics
In the past three years, scholars and practitioners have not been very active exploring the demographic and sociocultural factors of dysmenorrhea. Unsal et al. (2010) suggest that the most common risk factors responsible for the disorder include but are not limited to low body mass, younger age, early menarche and smoking, prolonged menstrual flow, pelvic infections, perimenstrual somatic complaints, genetic influences, psychological disturbances, and even the history of sexual assault. The role of racial and ethnic disparities in women's gynecologic conditions should not be disregarded: according to Jacoby, Fujimoto, Giudice, Kuppermann and Washington (2010), Black and Asian women have higher prevalence of endometriosis and related conditions, one of them being dysmenorrhea. Better educated women are more likely to seek professional medical assistance when it comes to dysmenorrhea; they are also more likely to use conventional medicine and find it effective (Tariq et al., 2009).
Unsal et al. (2010) state that the prevalence of dysmenorrhea decreases with age, with its peaks occurring mainly in late adolescence and the early 20s. Dysmenorrhea is sex-specific; in other words, it occurs only in women, which makes gender as a demographic factor of the disease absolutely irrelevant. The most essential is the finding that chronic pain, including dysmenorrhea, has distinct social patterning (Blyth, 2010). Chronic pain and material wealth are inversely related (Blyth, 2010). Those findings were also supported by Matter, Kline, Cook and Amtmann (2009), who concluded that homelessness exacerbates women's pain, including dysmenorrhea. Link, Pulliam and McKinley (2010) also write that women with a lower socioeconomic status are much more likely to face gynecologic conditions.
Evidence-Based Recommendations for Prevention
In most cases, dysmenorrhea is claimed to have profound impacts on the quality of women's lives and their productivity. Unsal et al. (2010) found that women who suffered more because of dysmenorrhea experienced greater problems with social functioning and emotional stability. In schools and other academic settings, dysmenorrhea tends to be associated with increased absenteeism and poor concentration during lessons (Wong, 2011). At present, the most valid evidence-based recommendation for dysmenorrhea prevention is the use of oral contraceptives: in 2012, Lindh, Ellstrom and Milsom published the results of their 30-years study, which confirm the efficacy of oral contraceptives in treating and preventing future primary dysmenorrhea. It is possible to suggest that preventing secondary dysmenorrhea is possible by addressing its risk factors and antecedent conditions, as well as providing better education, knowledge, and easy access to regular medical services.
Role of Advanced Practice Nurse in Dysmenorrhea Management
The most important is the role of the APN in managing and preventing dysmenorrhea. According to Mao and Anastasi (2010), "the APN plays an essential role in health promotion through disease management and infertility prevention by providing support and much needed information to the patient with endometriosis" (p.109). In a similar vein, the APN is expected to inform women about the essence and possible consequences of dysmenorrhea, as well as provide quality care and ease women's pain (Mao & Anastasi, 2010). In relation to dysmenorrhea and Healthy People 2020, the role of the APN will be to provide education and counseling to women and raise their awareness of dysmenorrhea, ensure timely and proper diagnosis, monitor and facilitate pain management, and provide support and assistance in resolving dysmenorrhea-related issues, including those which have implications for the quality of women's lives.
In most cases, and based on Stoelting-Gettelfinger (2010), the treatment plan may include hormonal therapy, especially when hormonal misbalances are at the heart dysmenorrhea. In the recent years, it has become quite common for the researchers to test the efficacy of non-traditional, alternative methods of managing dysmenorrhea. Liu et al. (2011) suggest that acupuncture provides an immediate analgesic effect in primary dysmenorrhea. Lasco, Catalano and Benvenga (2012) also recommend using a single oral dose of vitamin D to reduce women's sufferings due to dysmenorrhea. Still, non-steroidal anti-inflammatory drugs remain the chief means of treatment in women with dysmenorrhea. The use of Global Endometrial Ablation has the potential to significantly reduce the symptoms of dysmenorrhea over a 24-month period (Chapa et al., 2010).
Implications for the APN and Education
Better understanding of dysmenorrhea, its risk factors, and consequences has profound implications for the APN, who is expected to play the primary role in dysmenorrhea treatment and management. As mentioned earlier, education is one of the most essential factors impacting dysmenorrhea and its course (Tariq et al., 2009). Better educated adolescents and women are more likely to understand the abnormality of their condition and seek professional help (Tariq et al., 2009). Therefore, the APN must provide individual and group counseling/education to expand women's understanding of the problem.
Dysmenorrhea is a serious health condition. Although dysmenorrhea is not included in Healthy People 2020, it is directly related to adolescents and women's reproductive health. The most important risk factors for dysmenorrhea include but are not limited to age, social status, race and ethnicity, and even the level of education. Dysmenorrhea has profound negative impacts on women's productivity in school and workplace settings. Given the relevance of dysmenorrhea management in the context of Healthy People 2020, the APN will have to assume the roles of pain manager, infertility counselor, and major life supporter, who helps women relieve their physical pain and emotional sufferings while also educating them about the best ways to prevent and manage dysmenorrhea.