Clinical
Practice Guideline
For
DYSMENORRHEA
_____________________________________________________________________________________________________________________________________________
Developed for the
Aerospace Medical Association
by their constituent organization
American Society of Aerospace Medicine Specialists
Overview:
Dysmenorrhea occurs when prostaglandin F2α (PG F2α)
causes
menstrual cramping, with or without associated symptoms of nausea headaches,
anxiety, fatigue, diarrhea, and bloating.
In varying degrees, it affects 45-95% of reproductive aged women,
causing 3 days of incapacitating symptoms and/or up to 3 lost duty days per
month in 10-15% of women with untreated dysmenorrhea. Dysmenorrhea occurs most
commonly in young nulliparous women. Smoking and psychological stress are
additional risk factors. The physical exam in primary dysmenorrhea is normal;
abnormal examination may indicate secondary dysmenorrhea from ovarian cyst,
adenomyosis, leiomyomas and, less commonly, chronic
salpingitis, copper IUD use, or acquired outflow tract obstruction. First line
management includes the use of non-steroidal anti-inflammatory drugs (NSAIDs)
and combination oral contraceptives pills (OCPs), with acetaminophen acceptable
when controlling mild symptoms. OCPs may
be used continuously for menstrual suppression. Estrogen-progesterone delivery
is also available through the vaginal ring (ethinyl estradiol; etonogetrel
ring, trade named NuvaRing®)and
estrogen patch (OrthoEvra®) in individuals who prefer
more convenient dosing. Medroxyprogesterone acetate (Depo-Provera) and
progesterone containing IUDs such as the levonorgestrel
IUD (Mirena®) may afford pain relief through
cessation of menstruation.
Other
medications such as danazol, (Danocrine ®) and medroxyprogesterone acetate
(Depo- Provera ®) as well as gonadotropin releasing hormone (GnRH) agonists such as leuprolide (Lupron ®) and goserelin
(Zoladex ®) are available and effective in treating the symptoms of
endometriosis. GnRH antagonists such as cetrorelix
(Cetrotide™), abarelix (Plenaxis™) and ganirelix (Antagon™)
are not currently approved for dysmenorrhea but may have therapeutic potential.
NSAIDS/NSAID equivalent medications such as acetaminophen, OCPs, progesterone
containing IUDs and medroxyprogesterone acetate (Depo-Provera) are more
frequently waiverable. However other treatments such as danazol (Danocrine ®) or GnRH agonists/antagonists
may be considered for waiver if well tolerated and, in the case of GnRH agonists/antagonists, used in conjunction with low-dose estrogen and progesterone continuous ‘add back’
therapy.
Non-traditional
interventions that may be beneficial include thiamine, vitamin E and fish oil
supplementation, low fat vegetarian diet, acupuncture/acupressure and TENs. (transcutaneous electric nerve stimulation) Other multi-vitamin formulations and spinal
manipulation have not been proven and cannot be recommended. Rose tea may be
effective, but lack of FDA oversight makes this a potentially unreliable
therapy. Although not studied rigorously, tobacco cessation eliminates a risk
factor for dysmenorrhea as well as a self-imposed stress for flight. Surgical
therapy is the preferred treatment for patients with endometriosis related
infertility. More definitive surgery, such as hysterectomy and bilateral salpingo-oophorectomy, may be also effective.
Aeromedical
Concerns: Dysmenorrhea usually begins as low grade discomfort and may
progress over hours or days to severe discomfort that is distracting. It is not normally acutely
incapacitating. Menorrhagia may be
associated with dysmenorrhea and can cause a gradual onset anemia. Medical therapy should consist of medications
that are aeromedically acceptable, such as NSAIDs and OCPs. Due to low impact
on clotting mechanisms, acetaminophen for control of mild symptoms is
especially acceptable in pilots operating high-risk environments such as
acrobatic instruction, urban law enforcement, search and rescue operations and
extreme environmental monitoring. Oral contraceptive pills afford additional
benefits in terms of pregnancy prevention, prevention of incapacitating
emergencies such as ovarian torsion and ectopic pregnancy, preservation of
hemoglobin and potential for menstrual suppression, However, OCPs predispose
towards clot formation, especially in long duration flights and in individuals
with hereditary thromophilias. Due to risk
for bone density loss, medroxyprogesterone acetate
and GnRH agonists/antagonists must be used with
caution in pilots subject to microgravity or who have other risk factors for
bone loss. GnRH agonists/antagonists should be used
only in conjunction with ‘add back’ therapy. Although medroxyprogesterone
acetate is convenient and reliable, it is associated with weight gain and
irregular menstrual bleeding. The estrogen-progesterone patch may be associated
with higher rates of thrombosis than OCPs and is not ideal for pilots with risk
factors such as hereditary thrombophilas or prolonged duration flights.
Potassium sparing OCPs such as drospirenone; ethinyl estradiol (Yaz®)
/Yasmin®) require potassium monitoring in order to
prevent electrolyte imbalance.
Medical
Work-up: The following consults and tests are required for proper
medical evaluation leading to an aeromedical disposition:
A) History of symptoms
B) Gynecological evaluation report
c) Report of previous
treatments used
d) Report of any
current medications or ongoing treatments
e) Hemoglobin/Hematocrit
Aeromedical
Disposition (military): U.S. Army and U.S. Air Force consider
endometriosis to be waiverable on a case-by-case basis. U.S. Navy considers
chronic pelvic pain as waiverable on a case-by-case basis. The U.S. Air Force
specifically addresses dysmenorrhea as a waiverable condition when symptoms are
controlled.
Aeromedical
Disposition (civilian): Waiver for dysmenorrhea is considered
when symptoms are controlled and will be considered on a case-by-case
basis.
Aeromedical
Disposition (NASA): Waiver for dysmenorrhea may be
considered if symptoms are controlled.
Waiver
Experience (military): The U.S. Army has reviewed 15 cases of
dysmenorrhea for formal waiver. Of these cases, 5 were disqualified, 3 were qualified
without waiver or exception with the condition cited as ‘information only.’ 5
were granted formal waiver and 2 were granted exception to policy for initial
flight training. The U.S. Air Force has reviewed 13 cases of dysmenorrhea for
formal waiver. Of these, 2 were granted waiver for class II flight duties and 5
were granted waiver for class III flight duties. 4 were disqualified from class
III flight duties and 2 cases are currently pending further review.
Waiver
Experience (civilian): Data not currently available for
waiver issuance for dysmenorrhea.
Waiver Experience (NASA): No waiver requests for primary dysmenorrhea have presented to the
medical board.
References:
ASAMS: Endometriosis. Obtained on 31 Dec
2007 from http://www.asams.org/guidelines/Completed/NEW%20Endometriosis.htm.
Bouchard, Philippe. 2005. GnRH
antagonists: Present and Future. Ann Urol (
Dawood,
M. Yusoff, 2006. Primary
Dysmenorrhea Advances in Pathogenesis and Management. Obstet Gynecol.
108 (2), 428.
Dysmenorrhea, NASA waiver guide. 2008.
Ferri,
Fred, 2007. Ferri’s Clinical Advisor: Instant
Diagnosis and Treatment, 9th Edition. Mosby Elsevier.
French, Linda, 2005. Dysmenorrhea.
Am Fam Physician. 71 (2), 285-91.
National Guideline Clearinghouse: Medical management of
endometriosis. Obtained on 19 Dec 2007
from http://www.guideline.gov/summary/summary.aspx?doc_id=3961
Proctor, Michelle, Farquhar, Cynthia, 2006. Diagnosis and management of dysmenorrhoea,
BMJ. 332, 1134-1138.
July 22, 2008