Blooming Beyond the Pain: A Case Report on Homoeopathic management of Dysmenorrhoea

Dr Anupama Kumari

Abstract
Dysmenorrhea, a frequent gynaecological issue, is characterized by painful periods that considerably impact the well-being of numerous women globally. As reported in a systematic review and meta-analysis, dysmenorrhea affects up to 71.1% of young women. This article delves into various aspects of dysmenorrhea, including its definition, prevalence, underlying mechanisms, causes, signs and symptoms, diagnosis, differentiation from similar conditions, and common management approaches.

Keyword  : Individualised homoeopathy, Dysmenorrhea, MONARCH inventory, VAS Score

Abbreviations
PD- Primary dysmenorrhea, QOL- Quality of life, PGF2ALPHA &PGE2-Prostaglandins, CPP- Chronic pelvic pain, VAS-Visual Analog Scale, PID-Pelvic inflammatory disease

Introduction
Dysmenorrhea is characterized by intense menstrual cramps typically arising shortly before or during a woman’s period. This pain can be debilitating, significantly disrupting daily activities and productivity, as reported in studies.¹ Understanding the underlying causes and implementing effective management strategies are crucial to alleviate symptoms and improve the quality of life for women battling this condition.

Derived from Greek for “painful monthly bleeding,” dysmenorrhea is a frequent concern among women experiencing menstruation during their reproductive years. This condition can be linked to significant negative consequences on emotional, psychological, and functional health, as documented in research.²

Signs and Symptoms

Pain: Primary dysmenorrhea is characterized by recurrent, crampy lower abdominal or pelvic pain that typically begins before or at the onset of menstruation. This pain is often described as intense and throbbing, and it may radiate to the lower back or thighs.^7,8

Timing: The pain typically starts 1-2 days before menstruation and can last for 1-3 days into the menstrual period. It follows a cyclic pattern, recurring with each menstrual cycle .⁷

Pattern: The pain may vary in intensity but tends to be most severe at the onset of menstruation, gradually improving as the period progresses.⁹

Associated Symptoms:

• Nausea and Vomiting: Some individuals with primary dysmenorrhea may experience nausea, occasionally leading to vomiting.⁷
• Gastrointestinal Symptoms: Diarrhea or loose stools are also common during menstruation for individuals with primary dysmenorrhea.⁷
• Headache and Fatigue: Headaches and fatigue are reported as associated symptoms during painful menstruation.⁹

Systemic: Such as body and joint pains, lethargy, fatigue, sleep disorders, tender breasts, and swollen legs.

Impact on Daily Life: The severity of symptoms can significantly impact daily activities, work, and social interactions, leading to decreased productivity and absenteeism.⁸

Primary dysmenorrhea significantly impacts the Quality of life (QOL) in India, where:

• 4% of women reported that menstrual pain affected their daily activities (Journal of Midwifery and Women’s Health, 2018).
• 5% of women experienced severe pain that interfered with their daily routine (Indian Journal of Medical Research, 2018).
• 6% of women reported absenteeism from school or work due to menstrual pain (Journal of Obstetrics and Gynecology of India, 2019).
• 4% of women experienced anxiety and depression due to menstrual pain (Journal of Mental Health and Human Behavior, 2018).
• 4% of women reported reduced social and recreational activities due to menstrual pain (Journal of Women’s Health Issues, 2019).

Primary dysmenorrhea also affects the mental   and physical well-being of Indian women, leading to:

• Reduced productivity and academic performance
• Strained relationships with family and friends
• Increased stress and anxiety
• Decreased participation in social and cultural activities
• Poor sleep quality and fatigue

Overall, primary dysmenorrhea significantly impacts the quality of life in Indian women, affecting their physical, emotional, and social well-being.

Absence of Underlying Pathology: Primary dysmenorrhea occurs without identifiable pelvic pathology or structural abnormalities, distinguishing it from secondary dysmenorrhea caused by conditions like endometriosis or fibroids.⁷

Age of Onset: Symptoms typically begin shortly after menarche (the first menstrual period) and may persist throughout the reproductive years, although they may improve with age or after childbirth.⁹

Neurobiological Basis: Recent research has highlighted abnormal metabolic and structural changes in the brain of individuals with primary dysmenorrhea, suggesting a neurobiological basis for the pain sensitivity observed in these patients.^8,

Physical Examination
Pelvic Examination: Generally normal in primary dysmenorrhea. This helps to rule out conditions like endometriosis, fibroids, or pelvic.¹⁰

Imaging studies such as ultrasound may be used to identify underlying pelvic pathology in cases of secondary dysmenorrhoea.¹¹

Exclusion of Secondary Dysmenorrhea

Secondary Dysmenorrhea: Consider if there is an atypical onset of pain, such as starting after age 25, or if there are additional symptoms like irregular menstrual bleeding or non-cyclic pain.

Assessment Tools
Pain Scales: Visual Analog Scale (VAS) and the Numeric Rating Scale (NRS) or other pain assessment tools to gauge the severity of pain.¹²

Menstrual Symptom Questionnaires: To assess the impact of symptoms on daily activities^.13

Homoeopathic Management
Magnesia phosphorica: This remedy is often used for menstrual cramps characterized by pain relieved by pressure and warmth, aggravated by cold. Menstrual flow typically starts early, with dark, stringy blood. Pain is less severe before menstruation and increases as the flow begins, described as darting, shooting pain, often more pronounced on the right side and alleviated by heat and bending double.¹⁷

 Colocynthis: This remedy, indicated for severe cramps causing the person to bend over in pain, is characterized by pain relief from bending double or applying pressure. It is used for cramp-like pain in the left ovary and uterus, feeling as if the organs are squeezed in a vice. It’s also effective for ovarian cysts with acute pain episodes in the abdomen, sacrum, and hip, which are alleviated by flexing the thigh against the pelvis and prescribed for metrorrhagia, suppressed menstruation with cramping pains, or when triggered by emotional states like anger or chagrin.¹⁸

Cimicifuga racemosa: This remedy is indicated for severe cramps that cause the person to double over in pain. Relief often comes from bending double or applying pressure. It’s effective for cramp-like pain in the left ovary or uterus, feeling as if parts are squeezed in a vice. It’s also used for ovarian cysts with sharp, acute pains in the abdomen, sacrum, and hip, which are alleviated by flexing the thigh on the pelvis. It’s prescribed for metrorrhagia.¹⁸

Pulsatilla nigricans: Prescribed when the pain is shifting in nature and the menstrual flow is irregular. The person may feel better in the open air and worse in a warm room. Too late, scanty, thick, dark, clotted, changeable, intermittent. Chilliness, nausea, downward pressure, painful, flow intermits. Pain in back; tired feeling. Diarrhœa during or after menses.¹⁹

Sepia: When there is bearing down pain in the pelvis, and the woman feels worn out and irritable. Menses Too late and scanty, irregular; early and profuse; sharp clutching pains. Violent stitches upward in the vagina, from the uterus to the umbilicus. Prolapse of uterus and vagina. Morning sickness.¹⁹

Viburnum opulus: Menses too late, scanty, lasting a few hours, offensive in odour, with crampy pains, cramps extend down thighs. Bearing-down pains before. The ovarian region feels heavy and congested. Aching in sacrum and pubes, with pain in anterior muscles of thighs; spasmodic and membranous dysmenorrhoea.¹⁹

Case Report
A girl aged 16 years old, a high school student, came to Budha Homeo Medicare Clinic, Ramkrishna Nagar, Patna, Bihar on 12/06/2023 with complaints of severe pain in the lower abdomen during menstruation for 4 months. Menstrual pain was aggravated by heat, fatty food and lying on the painless side and relieved by cold food, and cold drinks. The girl was subjected to the investigation of ultrasonography of the whole abdomen. Earlier the girl was treated with a course of some analgesic (allopathic painkiller) without satisfactory improvement. On local examination, no tenderness or swelling was present in the whole abdomen. Past medical history was not significant.

Present complaint

• Severe pain in the lower abdomen during menstruation for 4 months.
• Aggravation-fatty food, lying on the painless side
• Amelioration- cold food and cold drinks
• Location- lower abdomen
• Sensation- cramping pain
• History of present complain
• Onset- complaint started from 4month ago then now the pain has been worse last 2 months
• Probable cause- nothing significant
• Treatment- allopathy
• Result- temporary relief

Family History-
Paternal side (father)- hypertension
Maternal side (mother)- diabetes mellitus

Personal History

• Addiction- tea
• Socioeconomic condition- low
• Habit & hobbies- watching TV
• Occupation- student
• Marital history- Unmarried

Physical general

• Thermal reaction- chilly patient
• Appetite- less
• Thirst- thirstless,1liter/day at small quantities of water at long intervals
• Desire- fatty rich food, cold food & drinks
• Aversion- N/S
• Intolerance- N/S
• Tongue- dry, yellow coating in middle, offensive mouth,
• Stool- watery stool,2-3times/day, sticking pain in anus, flatulence
• Urine- burning micturition more at night, 4-5times/day
• Perspiration- moderate
• Sleep- disturbed during menses
• Dream- Not such
• Menses-LMP-02/06/2023, Cycle-28days, duration-4-5days, regular scanty, character of discharge-thick, color-dark clotted, painful flows.

Mental general

• Always wants to be with someone
• Weeping tendency
• Fear of dark

Physical Examination

• Appearance- Ectomorphic (lean, thin)
• Height- 5ft2inch
• Weight- 47kg
• Pulse- 78beats/min
• Tongue- dry, yellow coating in the middle
• Pallor- absent
• Anaemia- absent
• Jaundice- absent
• Clubbing- absent
• Lymph Nodes- not palpable
• Neck veins- no engorgement

Pelvic Examination
No abnormal findings that could account for other than primary dysmenorrhea.

Systemic Examination
No abnormalities were seen. Tenderness and swelling were absent in the whole abdomen.

 Table 2 – Totality of Symptom

1.	Weeping tendency
2.	Always wants to be with someone
3.	Fear of dark
4.	Thirstlessness
5.	Desire to fatty rich food, cold food & drinks,
6.	Stool watery during menses, flatulence
7.	Urine burning micturition more on night
8.	Thermal reaction chilly patient
9.	Tongue yellow coated
10.	Painful menstruation during menses
11.	Pain in the lower abdomen during menses More on lying on the painless side   and better by cold food & drink

Provisional Diagnosis– Primary dysmenorrhoea

ICD 11code-GA34.3

Miasmatic Background– Mixed Miasms

Analysis and Evaluation of Symptoms

Table 3- Analysis of Symptoms
Mental Generals	Physical Generals	Particular Symptoms
Weeping tendency, Always want to be with someone, Fear of dark	Desire- Fatty rich food, Cold food & drinks	Pain in the lower abdomen during menstruation Painful menses during menstruation < lying on painful side > cold food & drink   Thick discharge Dark clotted, scanty LMP-02/07/23, 4-5days, Regular
	Thirst-Thirstlessness
	Stool-Watery stool during menses
	Urine-burning micturition at night
	Tongue-Yellow coating While in the middle, the offensive mouth
	Thermal reaction- chilly patient

 

Table 4- Evaluation of Symptoms
Sl.no.	Symptoms	Grading	Miasm
1.	Weeping tendency	3+	Pseudo-psora
2.	Always wants to be with someone	1+	Sycosis
3.	Fear of dark	2+	Syphilitic
4.	Desire- Cold food & drinks, fatty food	3+	Syphilitic or syco-tubercular
5.	Thirst-Thirstlessness	2+
6.	Stool-Watery stool during menses	2+	Psora-sycotic
7.	Urine-burning micturition at night	1+	Psora-syco-syphilitic
8.	Tongue-Yellow coating While in the middle, the offensive mouth	3+	Sycosis
9.	Thermal reaction- chilly patient	3+	Psora
10.	Painful menstruation during menses	3+	Sycosis
11.	Pain in the lower abdomen during menses	3+	Sycosis

Conversion of Symptoms into Rubric

Table 5

Sl.no	Symptoms	Rubrics
1.	Always wants to be with someone	MIND-COMPANY-desire for
2.	Fear of dark	MIND-FEAR-dark; of
3.	Weeping tendency	MIND-WEEPING-agg
4.	Tongue-Yellow coating While in the middle, the offensive mouth	MOUTH-DISCOLORATION-Tongue-yellow
5.	Thirst-Thirstlessness	STOMACH-THIRSTLESS
6.	Pain in the lower abdomen during menses	ABDOMEN-PAIN-menses-during
7.	Stool-Watery stool during menses	STOOL-WATERY
8.	Urine-burning micturition at night	URINE-BURNING
9.	Painful menstruation during menses	FEMALE GENITALIA/SEX-MENSES-painful
10	Desire- Cold food & drinks, fatty food	GENERALS-FOOD and DRINKS-cold drinks, cold water-desire
11.	Thermal reaction- chilly patient	GENERALS-HEAT-lack of vital heat

Repertorial Selection
Pulsatilla nigricans was selected for the case as it covered all the symptoms and obtained the highest marks based on RADAR Repertory Software using Synthesis repertory.²⁰

Prescription
Considering the whole case and after consulting with materia medica, the medicine is Pulsatilla nigricans. Pulsatilla 200/1 dose was prescribed to the patient and to be taken on an empty stomach in the early morning. She was also assessed on VAS and had a 9 score.

Table-6- Follow up  

Date	Sign and symptoms	Prescription	VAS	Justification
12 June 2023	Pain in the lower abdomen during menstruation	Pulsatilla 200C/1Dose	9	As per the totality of symptoms and repertorisation
08 July 2023	Pain intensity was slightly reduced	Placebo	8	Complaints relieved
14 Aug 2023	Pain with weeping tendency reduced	Placebo	4	Improvement seen than before
20 Sept 2023	Burning micturition	Placebo		Improved
26 Oct 2023	Most of the symptoms disappeared	Placebo		Complaints decreased
30 Nov 2023	Symptoms aggravate than before	Pulsatilla 200C/1Dose	7	The action of the first dose exhausted, hence repeated
02 Feb 2024	No complaints	Rubrum		Amelioration of complaints
08 April 2024	No complaints	Rubrum		Symptoms disappeared
13 May 2024	No complaints	Rubrum		Symptoms disappeared
02 July 2024	No complaints	Rubrum	1	Symptoms disappeared

 

Table 7- Visual analogue scale
Before treatment	After treatment (02.07.2024)
9	1

 

Table 8- MONARCH Inventory (Improved Version of the Modified Naranjo Criteria for Homoeopathy Case Report)
S.No	Domains	Yes	No	Not sure or N/A	Justification
1.	Was there any improvement in the main symptom or condition for which homoeopathic medicine was prescribed?	Yes			Pain reduced after the medicine
2.	Did the clinical improvement occur within a plausible timeframe relative to the drug intake?	yes			Symptoms improved after 1month of treatment
3.	Was there an initial aggravation of symptoms?		No
4.	Did the effect encompass more than the main symptom or condition (i.e. were other symptoms, not related to the main presenting complaint, improved or changed)?	Yes			Along with pain during menses, watery stool is also relived
5.	Did overall well-being improve? (suggest using a validated scale or mention about changes in physical, emotional and behavioural elements)	Yes			Improvement in painful menstruation which can be noticed in the VAS score
6.	Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease?	yes
7.	Direction of cure: did at least one of the following aspects apply to the order of improvement in symptoms? -from organs of more importance to those of less importance? -from deeper to more superficial aspects of the individual? -from the top downward?			N/A	Not sure
8.	Did ‘old symptoms’ (defined as non-seasonal and non-cyclical symptoms previously thought to be resolved) reappear temporarily during improvement?			N/A	Not observed
9.	Are there alternative causes (i.e. other than the medicine) that, with a high probability, could, have produced the improvement? (consider the course of disease, other forms of treatment and other clinically relevant interventions)		No		Not identifiable
10.	Was the health improvement confirmed by any objective evidence? (e.g. investigations, clinical examination, etc.)	Yes			Confirmed by VAS score
11.	Did repeat dosing, if conducted, create similar clinical improvement?		No		Not done

Conclusion
Dysmenorrhoea is a common and often debilitating condition affecting many women worldwide. Understanding its pathophysiology and appropriate management options is essential in providing effective relief and improving the quality of life for individuals suffering from this condition. This article highlights the effectiveness of Individualized homoeopathic Medicine in cases of primary dysmenorrhea with improving the quality of life. Furthermore more clinical trials are warranted to increase the scope of homeopathy and contribute more towards Evidence-Based Medicine.

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Dr Anupama Kumari
P.G Scholar, Dept of Homoeopathic Materia Medica, RBTS Govt Homoeopathic Medical College & Hospital, Muzaffarpur, Bihar, India
Email : anupamanih@gmail.com

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