Background & Aims
Dysmenorrhea, pain with menstruation, affects over half of women who menstruate[1, 2]. Many women have severe dysmenorrhea symptoms that interfere with functioning for up to a week each month[3]. Despite widespread prevalence, there is little guidance to predict development of severe dysmenorrhea as underlying pain mechanisms are heterogeneous[1, 4]. The age of menarche is a risk factor for chronic pain development[5]; However, very little is known about pre-pubertal risk factors. In our previous work, we have shown that non-painful somatic symptoms, dysregulated sleep, and attentional issues at age 9-10 are associated with the appearance of multisite pain one year later[6]. Based on this, our hypothesis was that CNS vulnerabilities for pain are apparent in girls prior to menarche and will be significant predictors for future dysmenorrhea. Our secondary hypothesis was that age of menarche is a significant predictor for development of dysmenorrhea, independent of severity.
Methods
Symptom assessments were completed by parents of pre-menstrual girls aged 9-10 who participated in the Adolescent Brain and Cognitive Development (ABCD) study and who subsequently answered questions on the presence and severity of dysmenorrhea at ages 12-13. At baseline data collection (ages 9-10), participants (parents) completed the medical history questionnaire, Sleep Disturbance Scale for Children, Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5), and NIH ToolBox Tasks. At the three-year follow-up (ages 12-13), participants completed the Pubertal Development Scale and Menstrual Cycle survey. Using multivariate logistic regression, we tested the association between the presence of pain at age 9-10 (no pain, one pain complaint, two or more pain complaints) and dysmenorrhea at age 12-13. We then tested the association between somatic symptoms, sleep, and attentional issues at age 9-10 with subsequent dysmenorrhea at age 12-13.
Results
In girls with no pain at age 9-10, more non-painful somatic complaints are associated with the dysmenorrhea at ages 12-13 (OR: 1.24, 95% CI: 1.03, 1.49, p=0.025), while attentional issues and sleep problems were not (both p>0.05). Furthermore, two or more pain complaints at age 9-10 were robustly associated with the future occurrence of any dysmenorrhea (OR:1.36; 95% CI: 1.11, 1.65) and severe dysmenorrhea (intensity ? 8/10; OR: 1.84; 95% CI: 1.35, 2.51; p < 0.01)). To test the hypothesis that earlier-developing girls would be at greater risk of dysmenorrhea, we calculated the OR associated with the incidence of dysmenorrhea by age at mid-puberty (n= 2259). Each one-year increase in age was associated with a roughly 25% lower odds of reporting dysmenorrhea at age 12-13 (OR: 0.74; 95% CI: 0.71, 0.91), and with a 37% lower odds of reporting severe dysmenorrhea (OR: 0.63; 95% CI: 0.53, 0.74).
Conclusions
These analyses demonstrate that pre-pubertal somatic sensitivity and pain predict both the incidence and severity of dysmenorrhea. The fact that having two or more pain complaints was a robust predictor of dysmenorrhea points toward a central sensitization process, as independent pain complaints suggest the development of a broad vulnerability to pain. The age of menarche was also a robust predictor dysmenorrhea, with age of menarche negatively correlating with dysmenorrhea sensitivity. Pubertal hormones are thought to be the primary cause behind increased prevalence of chronic pain among women[7,8,9]; however, these analyses demonstrate that risk factors for the development of chronic pain are established before puberty. Increased understanding on biological risk factors for development of dysmenorrhea and chronic pain in young girls will help to identify contributing mechanisms and lead to improved patient outcomes.
References
1.Ferries-Rowe, E., E. Corey, and J.S. Archer, Primary Dysmenorrhea: Diagnosis and Therapy. Obstet Gynecol, 2020. 136(5): p. 1047-1058.
2.Ju, H., M. Jones, and G. Mishra, The prevalence and risk factors of dysmenorrhea. Epidemiol Rev, 2014. 36: p. 104-13.
3.Zondervan, K.T., et al., Chronic pelvic pain in the community–symptoms, investigations, and diagnoses. Am J Obstet Gynecol, 2001. 184(6): p. 1149-55.
4.Martire, F.G., et al., Endometriosis and Adolescence: The Impact of Dysmenorrhea. J Clin Med, 2023. 12(17).
5.Lund, C.I., et al., The association between age at menarche and chronic pain outcomes in women: the Tromsø Study, 2007 to 2016. PAIN, 2022. 163(9): p. 1790-1799.
6.Kaplan, C.M., et al., Risk Factors for the Development of Multisite Pain in Children. The Clinical Journal of Pain, 2023. 39(11): p. 588-594.
7.De Sanctis, V., et al., Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge. Pediatr Endocrinol Rev, 2015. 13(2): p. 512-20.
8.Bartley, E.J. and R.B. Fillingim, Sex differences in pain: a brief review of clinical and experimental findings. BJA: British Journal of Anaesthesia, 2013. 111(1): p. 52-58.
9.Bimpong, K., et al., The Gender Pain Gap: gender inequalities in pain across 19 European countries. Scandinavian Journal of Public Health, 2022. 50(2): p. 287-294.
Presenting Author
Melissa Lenert
Poster Authors
Topics
- Specific Pain conditions/Pain in Specific Populations: Gynecological Pain