Prevalence, risk factors, and management practices of primary dysmenorrhea among young females.

BACKGROUND: Primary dysmenorrhea (PD) is one of the most common gynecological conditions among young females, which has a significant negative impact on health-related quality of life and productivity. Despite its high prevalence, the evidence is limited regarding the management-seeking practices and its perceived effectiveness among females with PD. METHODS: This is a cross-sectional study conducted among 550 female students in six universities across Lebanon. The prevalence of PD, associated risk factors, and management-seeking practices were assessed using a self-administered questionnaire. RESULTS: The prevalence of PD was 80.9%. Most of the females with PD described their menstrual pain as moderate (56%) to severe (34.6%), which significantly affected their daily activities and studying ability (P < 0.001). The major risk factors associated with PD included heavy menstrual flow (adjusted odds ratio [AOR] = 10.28), family history of PD (AOR = 2.52), history of weight loss attempt (AOR = 2.05), and medical specialization (AOR = 1.663). Only 36.9% of females with PD sought formal medical advice. Most dysmenorrheic females (76.4%) received medications for the management of PD, and remarkably none of them took hormonal contraceptives. Drugs commonly used for PD were mefenamic acid (26.2%), ibuprofen (25%), and paracetamol (11.5%), which were administered when the pain started (58.2%). All medications were significantly effective in reducing the pain score (P = 0.001), and most NSAIDs were more potent than paracetamol in managing PD (P = 0.001). However, no significant difference in adverse effects among medications was revealed. Moreover, no superiority of any individual NSAID for pain relief was established. Nevertheless, mefenamic acid was associated with the lowest risk of abdominal pain (OR: 0.03, P = 0.005) and the highest risk of flank pain (OR = 12, P = 0.02). CONCLUSIONS: Suboptimal management of PD is practiced among university students in Lebanon. Therefore, health care providers should educate dysmenorrheic females to optimize the self-management support of PD. Furthermore, future research is required to investigate females' misconceptions about hormonal contraceptives in the management of PD, aiming to raise awareness and correct misconceptions.

Experiências das mulheres quanto às suas trajetórias até o diagnóstico de endometriose / Experiencias de mujeres en cuanto a sus trayectorias hasta el diagnóstico de endometriosis / Experiences of women regarding their pathways to the diagnosis of endometriosis

Resumo Objetivo descrever as experiências das mulheres sobre as suas trajetórias desde o início dos sintomas até o diagnóstico da endometriose. Método pesquisa descritiva, qualitativa, realizada com dez mulheres com diagnóstico de endometriose no município do Rio de Janeiro (RJ), Brasil. Coletaram-se entrevistas semiestruturadas áudio gravadas e posteriormente submetidas à Análise de Conteúdo por meio do software Atlas.ti 8. Resultados sem o diagnóstico de endometriose, as mulheres vivenciam sintomas fortes desde a menarca. Essa situação repercute negativamente em diferentes esferas da vida, inclusive pela desvalorização de suas queixas em seus círculos de convivência. Assim, entende-se a importância da rede de apoio perante essa situação. Diante desse contexto, as mulheres peregrinam por diversos profissionais até o diagnóstico definitivo. Considerações finais e implicações para a prática as trajetórias dessas mulheres são marcadas pela desvalorização de suas queixas por profissionais de saúde e pessoas próximas, pela naturalização da dor feminina e pela dificuldade em estabelecer um diagnóstico diferencial. No entanto, a capacidade individual de reconhecer a presença de uma patologia, o conhecimento sobre a endometriose e a experiência do profissional facilitaram o diagnóstico. No contexto da assistência de enfermagem, entender essa trajetória pode promover a escuta ativa, melhor valorização das queixas, avaliação clínica e o encaminhamento para o diagnóstico precoce.

Resumen Objetivo describir las vivencias de las mujeres en sus trayectorias desde el inicio de los síntomas hasta el diagnóstico de endometriosis. Método investigación descriptiva cualitativa realizada con diez mujeres diagnosticadas con endometriosis en la ciudad de Río de Janeiro (RJ), Brasil. Se recogieron entrevistas semiestructuradas grabadas en audio y posteriormente se sometieron a Análisis de Contenido utilizando el software Atlas.ti 8. Resultados sin el diagnóstico de endometriosis, las mujeres experimentan síntomas fuertes desde la menarquia. Esta situación tiene un impacto negativo en diferentes ámbitos de la vida, incluso por la devaluación de sus quejas en sus círculos de convivencia. Así, se comprende la importancia de la red de apoyo en esta situación. Ante este contexto, las mujeres deambulan por diferentes profesionales hasta el diagnóstico definitivo. Consideraciones finales e implicaciones para la práctica las trayectorias de estas mujeres están marcadas por la devaluación de sus quejas por parte de los profesionales de la salud y personas cercanas, por la naturalización del dolor femenino y por la dificultad para establecer un diagnóstico diferencial. Sin embargo, la capacidad del individuo para reconocer la presencia de una patología, el conocimiento sobre la endometriosis y la experiencia del profesional facilitaron el diagnóstico. En el contexto del cuidado de enfermería, comprender esta trayectoria puede promover la escucha activa, mejor valoración de las quejas, evaluación clínica y la derivación para diagnóstico precoz.

Abstract Objectives to describe the experiences of women on their trajectories from the beginning of symptoms to the diagnosis of endometriosis. Method descriptive, qualitative research, conducted with ten women diagnosed with endometriosis in the city of Rio de Janeiro (RJ), Brazil. Audio recorded semi-structured interviews were collected and later submitted to Content Analysis using Atlas.ti 8 software. Results without the diagnosis of endometriosis, women experience strong symptoms from the menarche. This situation has a negative impact on different spheres of life, including the devaluation of their complaints in their circles of coexistence. Thus, the importance of the support network in this situation is understood. Faced with this context, women wander through various professionals until the definitive diagnosis. Final considerations and implications for practice the trajectories of these women are marked by the devaluation of their complaints by health professionals and people close to them, by the naturalization of female pain and by the difficulty in establishing a differential diagnosis. However, the individual's ability to recognize the presence of a pathology, the knowledge about endometriosis and the professional's experience facilitated the diagnosis. In the context of nursing care, understanding this trajectory can promote active listening, better appreciation of complaints, clinical assessment and referral to early diagnosis.

Long-Acting Reversible Contraception: Specific Issues for Adolescents.

Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.

Leonurus cardiaca L. as a Source of Bioactive Compounds: An Update of the European Medicines Agency Assessment Report (2010).

Leonurus cardiaca L. (motherwort) is a perennial herb, native to Asia and southeastern Europe, with widespread global occurrence in present days. The plant was historically used as cardiotonic and for treating gynaecological afflictions (such as amenorrhea, dysmenorrhea, menopausal anxiety, or postpartum depression). Although its use in oriental and occidental medicine is relatively well documented, the recent progress registered raises the need for an update of the Medicines Agency assessment report on Leonurus cardiaca L., herba (2010). The current study presents the progress made within the 2010-2018 timeframe regarding the potential applications and scientific evidences supporting the traditional use of motherwort, in the same time suggesting future research opportunities.

Model-free tests of equality in binary data under an incomplete block design.

Using Prescott's model-free approach, we develop an asymptotic procedure and an exact procedure for testing equality between treatments with binary responses under an incomplete block crossover design. We employ Monte Carlo simulation and note that these test procedures can not only perform well in small-sample cases but also outperform the corresponding test procedures accounting for only patients with discordant responses published elsewhere. We use the data taken as a part of the crossover trial comparing two different doses of an analgesic with placebo for the relief of primary dysmenorrhea to illustrate the use of test procedures discussed here.

Exact tests in binary data under an incomplete block crossover design.

To improve the power of a parallel groups design and reduce the time length of a crossover trial, we may consider an incomplete block crossover design. Under a distribution-free random effects logistic regression model, we derive an exact test and a Mantel-Haenszel Type of summary test procedure for testing non-equality in binary data when comparing three treatments. We employ Monte Carlo simulation to evaluate the performance of these test procedures. We find that both test procedures developed here can perform well in a variety of situations. We use the data taken as a part of the crossover trial comparing the low and high doses of an analgesic with a placebo for the relief of pain in primary dysmenorrhea to illustrate the use of the proposed test procedures.

Testing equality and interval estimation of the generalized odds ratio in ordinal data under a three-period crossover design.

The crossover design can be of use to save the number of patients or improve power of a parallel groups design in studying treatments to noncurable chronic diseases. We propose using the generalized odds ratio for paired sample data to measure the relative effects in ordinal data between treatments and between periods. We show that one can apply the commonly used asymptotic and exact test procedures for stratified analysis in epidemiology to test non-equality of treatments in ordinal data, as well as obtain asymptotic and exact interval estimators for the generalized odds ratio under a three-period crossover design. We further show that one can apply procedures for testing the homogeneity of the odds ratio under stratified sampling to examine whether there are treatment-by-period interactions. We use the data taken from a three-period crossover trial studying the effects of low and high doses of an analgesic versus a placebo for the relief of pain in primary dysmenorrhea to illustrate the use of these test procedures and estimators proposed here.

Prescott tests of equality in binary data under a three-treatment three-period crossover design.

Three test procedures accounting for patients with tied responses based on Prescott's ideas are developed for comparing three treatments under a three-period crossover trial in binary data. Monte Carlo simulation is employed to evaluate the performance of these test procedures in a variety of situations. The test procedures proposed here are noted to have power larger than those procedures, which utilize only those patients with un-tied responses. The data taken from a three-period crossover trial comparing two different doses of an analgesic with placebo for the relief of primary dysmenorrhea are used to illustrate the use of the test procedures developed here.

Continuous Norethisterone Acetate versus Cyclical Drospirenone 3 mg/Ethinyl Estradiol 20 µg for the Management of Primary Dysmenorrhea in Young Adult Women.

STUDY OBJECTIVE: To evaluate the efficacy of continuous norethisterone acetate (NET-A), 5 mg (group N) vs cyclical combined oral contraceptive pill (COC) consisting of drospirenone 3 mg/ethinyl estradiol 20 µg pills (group P) in treating dysmenorrhea in young adult women. DESIGN, SETTING, AND PARTICIPANTS: This prospective, open-label, nonrandomized study included 38 Jordanian patients: 20 patients in group N and 18 patients in group P. INTERVENTIONS: Continuous NET-A 5 mg daily or cyclical COC. MAIN OUTCOME MEASURES: Pain scores, adverse effects, analgesic use, school absence, and cost. RESULTS: Thirty-eight patients used NET-A or COC for 6 months. All participants had almost the same starting levels of visual analogue scale (VAS) scores. Both drugs were similar in suppressing dysmenorrhea at the 3-month follow-up visit; VAS score mean (±SD) in group N and P were 1.30 ± 1.22 and 1.28 ± 0.83 (P = .22), respectively, and after 6 months, with mean VAS scores (±SD) of 1.30 ± 1.22 and 1.28 ± 0.83, respectively (P = .95). The cost of the treatment in the N group was much less than in the P group. Participants in the N group were less likely to use pain killers: 20% and 44% in the N and P groups, respectively (P = .006) in the first month and only 5% and 17% (P = .019) in the N and P groups, respectively, at the 3-month follow-up, and none of them used any analgesics at the 6-month follow-up. CONCLUSION: A continuous NET-A regimen is a well tolerated, effective, and inexpensive option for dysmenorrhea treatment and was as good as COC.

Testing equality and interval estimation in binary responses when high dose cannot be used first under a three-period crossover design.

When comparing two doses of a new drug with a placebo, we may consider using a crossover design subject to the condition that the high dose cannot be administered before the low dose. Under a random-effects logistic regression model, we focus our attention on dichotomous responses when the high dose cannot be used first under a three-period crossover trial. We derive asymptotic test procedures for testing equality between treatments. We further derive interval estimators to assess the magnitude of the relative treatment effects. We employ Monte Carlo simulation to evaluate the performance of these test procedures and interval estimators in a variety of situations. We use the data taken as a part of trial comparing two different doses of an analgesic with a placebo for the relief of primary dysmenorrhea to illustrate the use of the proposed test procedures and estimators.

[Assessment on analgesic and anti-inflammatory effects of Tongjingbao optimal formula and analysis on its active components].

OBJECTIVE: To assess the analgesic and anti-inflammatory effects of Tongjingbao optimal formula and analyze its active components. METHOD: Animals were divided into the model group, the Tongjingbao granule group and the Tongjingbao optimal formula group. The mice dysmenorrhea model was induced by oxytocin, and their content of blood calcium and MDA, NO, PGE2 in uterus were determined to assess the analgesic and anti-inflammatory effects of different components in Tongjingbao optimal formula and their impacts. RESULT: All components of Tongjingbao optimal formula could extend the dysmenorrhea incubation period of mice with dysmenorrhea, reduce their average writhing time, increase the writhing inhibition rate, lessen the content of blood calcium and MDA, PGE2 in uterus, and enhance the content of NO in uterus. CONCLUSION: All components of Tongjingbao optimal formula have the analgesic and anti-inflammatory effects, and different components show a synergistic effect in treating dysmenorrheal in many links.

Dysmenorrhea in Siriraj medical students; prevalence, quality of life, and knowledge of management.

OBJECTIVE: To determine the prevalence of dysmenorrhea, effect on daily activity, academic activities, quality of life, and knowledge of management in Siriraj medical students. MATERIAL AND METHOD: A cross-sectional descriptive study at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand that included 552 female medical students who were asked to complete two questionnaires. The first questionnaire (32 items) included demographic data, menstrual pattern, severity of dysmenorrhea, pain score, impact of dysmenorrhea on daily and academic activities, the method and knowledge of medications to treat dysmenorrhea. The second questionnaire was Short Form (SF)-36 questionnaires used to evaluate the health-related quality of life. RESULTS: The prevalence of dysmenorrhea was 77.7%. The prevalence of mild, moderate, and severe dysmenorrhea was 35.3%, 39.3%, and 3.1% respectively. Age of menarche, duration of menses, and the family history of dysmenorrhea were significantly different between two groups. Students who had moderate to severe dysmenorrhea reported the negative impact on daily and academic activities. The scores of SF-36 in moderate and severe group was significantly lower than the mild group (p < 0.001). In the moderate to severe dysmenorrhea group, 82.9% and 66.7% of participants used mefenamic acid and paracetamol for pain relief respectively. CONCLUSION: Dysmenorrhea in medical students has high prevalence and it has negative effects on daily activities, academic activities, and quality of life. Most of the subjects know that mefenamic acid and/or paracetamol can relief dysmenorrhea. Dysmenorrhea is a significant public health problem.

Menstrual patterns and gynecologic morbidity among university students in Kano, Nigeria.

OBJECTIVE: To examine menstrual patterns and effects of menstrual disorders on social and academic lives of undergraduate students in Kano, Nigeria. PARTICIPANTS: Students attending Bayero University Kano, Nigeria (n = 383). INTERVENTION: Self-administered questionnaires. MAIN OUTCOME MEASURES: Sociodemographic characteristics, menstrual patterns, and associated symptoms were elicited. Treatment-seeking behavior and effects of symptoms on academic and social activities were ascertained. RESULTS: The mean age at menarche was 13.7 ± 1.68 years. Menstrual bleeding lasted an average of 5.2 ± 1.6 days. Cycle length was 21-35 days in 92% of cases (n = 353). Approximately 72% of respondents reported dysmenorrhea. After adjusting for confounding, age at menarche, menstrual cycle length, duration of menstrual bleeding and use of contraceptive pills remained significant predictors of dysmenorrhea. Menstrual disorders interfered with social and academic life of 91% and 84% of respondents respectively. CONCLUSIONS: Gynecologic morbidity related to menstruation is common among adolescent Nigerians and is associated with detrimental effects on academic and social activities. Student health services should prioritize measures to mitigate the social and physical impact of menstrual disorders in young women.

Dysmenorrhea among Siriraj nurses; prevalence, quality of life, and knowledge of management.

OBJECTIVE: To determine the prevalence of dysmenorrhea, impact on daily activity, quality of life, and knowledge of management among Siriraj nurses. SUBJECTS: Four hundred ninety three female nurses in the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand MATERIAL AND METHOD: A cross-sectional descriptive study was done at Siriraj Hospital, Bangkok, Thailand Subjects were asked to complete a questionnaire (32 items) and a Short form-36. The questionnaire included demographic data, menstrual pattern, age at dysmenorrhea, severity of dysmenorrhea, pain score, impact of dysmenorrhea on daily activity, and method and knowledge of medications to treat dysmenorrhea. Evaluation of the quality of life using short form-36 questionnaire was also asked. RESULTS: The prevalence of dysmenorrhea was 70.2%. The prevalence of mild, moderate, and severe dysmenorrhea was 29.6%, 38.9%, and 1.6% respectively. Dysmenorrhea was significantly associated with age of participants, amount of menses, and the family history of dysmenorrhea. Nurses who had moderate to severe dysmenorrhea reported the impact on daily activities as limited sport activity (93%), limited social activity (66%), affected their concentration (81%), and absenteeism from work (16.5%). The mean total score of short form-36 in moderate and severe dysmenorrhea group was 69.9, significantly lower than mild and no dysmenorrhea group (75.2). Eighty-one percent and 68% of nurses with moderate and severe dysmenorrhea used paracetamol and mefenamic acid for pain relief respectively. CONCLUSION: The prevalence of dysmenorrhea among nurses was high and it had a negative impact on daily activities and quality of life. Most of the subjects knew that paracetamol and mefenamic acid can relieve dysmenorrhea. The hospital administrators should be concerned with this problem in nurses working in their hospital.

The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers.

OBJECTIVE: The aim of this study was to: (1) establish the typical experience of menstruation for senior high school girls and (2) determine how many experience considerable menstrual disturbance that could require further investigation and management of underlying pathology. DESIGN: Cross-sectional study. SETTING: Senior High Schools in the Australian Capital Territory (ACT), Australia. POPULATION: A total of 1051 girls aged between 15 and 19 years. METHODS: Data based on a quantitative survey. MAIN OUTCOME MEASURES: Self-reports of menstrual bleeding patterns, typical and atypical symptoms and morbidities. RESULTS: Typical menstruation in adolescence includes pain (93%), cramping (71%), premenstrual symptoms (96%) and mood disturbance (73%). Highly significant associations were found between increasing severity of menstrual pain, number of menstrual-related symptoms, interference with life activities and school absence. These associations indicate that approximately 25% of the sample had marked menstrual disturbance: 21% experienced severe pain; 26% school absence; 26% suffering five or more symptoms; > or =24% reporting moderate to high interference with four out of nine life activities. Approximately 10% reported atypical symptoms associated with menstruation. Diagnosis of menstrual pathology in the sample was low, even though 33% had seen a GP and 9% had been referred to a specialist. CONCLUSIONS: Menstrual pain and symptoms are common in teenagers. Girls indicating moderate to severe pain in association with a high number of menstrual symptoms, school absence and interference with life activities should be effectively managed to minimise menstrual morbidity. Those girls who do not respond to medical management should be considered for further investigation for possible underlying pathology, such as endometriosis.

Letrozole combined with norethisterone acetate compared with norethisterone acetate alone in the treatment of pain symptoms caused by endometriosis.

BACKGROUND: The available data on effectiveness of aromatase inhibitors in treating pain symptoms related to endometriosis is limited. We compared the efficacy and tolerability of the aromatase inhibitor letrozole combined with norethisterone acetate versus norethisterone acetate alone in treating pain symptoms. METHODS: This prospective, open-label, non-randomized trial included 82 women with pain symptoms caused by rectovaginal endometriosis. Patients received either a combination of letrozole and norethisterone acetate (group L) or norethisterone acetate alone (group N) for 6 months. Changes in pain symptoms during treatment and in the 12 months of follow-up were evaluated. Side effects of each treatment protocol were recorded. RESULTS: Intensity of chronic pelvic pain and deep dyspareunia significantly decreased during treatment (P < 0.001 versus baseline by 3 months) in both study groups. At both 3- and 6-month assessment, the intensity of chronic pelvic pain (P < 0.001, P = 0.002, respectively) and deep dyspareunia (P < 0.001, P = 0.005, respectively) was significantly lower in group L than group N. At completion of treatment, 63.4% of women in group N were satisfied with treatment compared with 56.1% in group L (P = 0.49). Pain symptoms recurred after the completion of treatment; at 6-month follow-up no difference was observed in the intensity of pain symptoms between the groups. Adverse effects were more frequent in group L than in group N (P = 0.02). CONCLUSIONS: The combination drug regimen was more effective in reducing pain and deep dyspareunia than norethisterone acetate; however, letrozole caused a higher incidence of adverse effects, cost more and did not improve patients' satisfaction or influence recurrence of pain.

The effect of oral contraceptives on uterine contractility and menstrual pain: an assessment with cine MR imaging.

BACKGROUND: Low-dose oral contraceptives (OC) have been reported to control primary dysmenorrhea. Furthermore, a close relationship between dysmenorrhea and uterine contractions has been visualized with magnetic resonance imaging (MRI). This study aimed to use cine MR to demonstrate the effects of OC on myometrial contractility during menstruation and to associate the findings with dysmenorrhea. METHODS: MR studies were obtained of 21 healthy female volunteers (22-47 years old) taking OC, and 20 control women (24-39 years old) not taking OC. Cine- and static MR images were obtained with a 1.5 T magnet during menstruation. Uterine contractility was assessed by the presence of endometrial distortion on cine MR, the area of the mid-sagittal uterine myometrium, and the thickness of the subendometrial low-intensity area on static images. Dysmenorrhea were assessed via a questionnaire. RESULTS: A total of 21 OC users and 20 controls were included in the analysis. Endometrial distortion was significantly less prominent and the subendometrial low-intensity area was significantly thinner in the OC group. Furthermore in the OC group, the uterine myometrial area was larger (although not significantly) and the degree of assessed pain was significantly lower. CONCLUSIONS: Both cine- and static MR images demonstrate that myometrial contractility was relatively suppressed in OC users, which may represent one of the reasons explaining the reduced menstrual pain experienced by OC users.

Patterns of prescription and self-medication for treating primary dysmenorrhea in a Mexican population.

Dysmenorrhea is defined as cramping pain in the lower abdomen occurring just before or during menstruation. Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment, with the addition of oral contraceptive pills when necessary. With the widespread availability of over-the-counter NSAIDs, it is often assumed that women are treating themselves adequately. Unfortunately, this is not always the case. Therefore we evaluated the use of drugs for treating primary dysmenorrhea in Mexican students. A multiple-choice questionnaire was administered to 285 psychology students (20.6 +/- 2.4 yrs; range, 17-33 yrs), to assess the prevalence of dysmenorrhea and medications employed. The reported prevalence of dysmenorrhea among these women was 67%. Dysmenorrhea was mild in 34% moderate in 43% and severe in 21%. Of the dysmenorrheic sample, only 33.5% consulted physician in 2.6 +/- 0.2 cycles per year for their problem and the most common prescriptions were an over-the-counter medication with paracetamol pamabrom and pyrilamine maleate (Syncol; 22.4%) naproxen (18.4%), metamizole plus butylhyoscine bromide (10.2%), ibuprofen (6.1%) and butylhyoscine bromide (6.1%). On the other hand, self-medication was practiced by 64.9% of the women with dysmenorrhea in 6.1 +/- 3.8 cycles per year and the most common drugs by self-medication were Syncol (35.5%), naproxen (16.9%), metamizole plus naproxen butylhyoscine bromide (13.7%), an over-the-counter medication with adiphenine and propyphenazon (Espasmo-cibalgina; 10.5%), paracetamol (5.6%) butylhyoscine alone (4%) and ibuprofen (4%). Our data suggest that dysmenorrheic women use numerous drugs by self-medication for pain but infrequently accessed formal medical care.

Primary dysmenorrhea: assessment and management update.

Many women are familiar with the experience of dysmenorrhea, which can contribute to significant physical and emotional distress and life disruption. However, women may not seek professional expertise in their attempt to alleviate this condition. It is important to assess the beliefs and experiences of all women with dysmenorrhea, including adolescents, as early in gynecologic care as possible. This article reviews the management of primary dysmenorrhea. Midwives can provide valuable assistance to women in their explorations of the variety of treatment options available for the relief of dysmenorrhea, including lifestyle changes, complementary and alternative approaches, analgesics, and hormones.