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 (Paris). Oct; 39 Supple 3:S56-8.

 

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. Philadelphia, PN.

 

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