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| REVIEW ARTICLES |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 111-119 |
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Therapeutic aspects of Kashtartava (dysmenorrhea) in Ayurveda: a review
Monika Goel1, Rohit Singh2, Unnati Bidhoodi1
1 Department of Prasuti Tantra and Stri Roga, Shri Dhanvantri Ayurvedic Medical College and Research Centre, Mathura, Uttar Pradesh, India
2 Department of Rasa Shastra and Bhaisajya Kalpana, Shri Dhanvantri Ayurvedic Medical College and Research Centre, Mathura, Uttar Pradesh, India
| Date of Submission | 15-Nov-2021 |
| Date of Decision | 22-Mar-2022 |
| Date of Acceptance | 29-Mar-2022 |
| Date of Web Publication | 28-Jun-2022 |
Correspondence Address:
Monika Goel
Department of Prasuti Tantra and Stri Roga, Shri Dhanvantri Ayurvedic Medical College and Research Centre, Mathura, Uttar Pradesh 281401
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jism.jism_90_21
Kashtartava (painful menstruation or dysmenorrhea) is one of the common gynecological disorders observed among women. It has been described as a symptom of various diseases such as Kukshishoola, Vatala yoni, Udavartini yonivyapada, etc. in Ayurvedic classics. It is characterized by a condition in which Artava (menstrual fluid) is shedded with great difficulty and pain. Acharya Charaka has specifically mentioned that none of the gynecological disorders can arise without the involvement of vitiated Vata dosha (a type of body humor). The pain produced in dysmenorrhea is due to vitiation of Vata dosha only or in combination with other Doshas, which is the result of Vatavriddhi (elevation in the Vata level) due to Apanavayu (type of Vata), margavarodha (obstruction of channel), etc. It has been reported that around 90% of adolescent females and above 50% of menstruating women worldwide reported suffering from it, with 10–20% of them describing their suffering as severe and distressing. Owing to these facts, various classical texts of Ayurveda have been reviewed and literature search was performed using the keywords “Kashtartava, Dysmenorrhea, Menstrual pain, Menstruation, Yoni vyapada (vaginal disorder)” in various online databases in order to collect the data regarding the same. It has been revealed that Dhatukshaya (depletion of body tissues), Kopa (aggravation of Doshas), and Margavarodha (obstruction of channel) are the three prime conditions which lead to the vitiation of Vata dosha resulting in dysmenorrhea. It can be managed with various Ayurvedic preparations such as Phala ghrita, Jeerakadi modak, Maharasnadi kwath, etc. Panchkarma (five therapeutic biodetoxification procedures) such as Shatavaryadi anuvasana basti and Baladi anuvasana basti is also proved to be beneficial along with Pathya ahara and Vihara (wholesome regulated diet and lifestyle). Keywords: Dysmenorrhea, gynecological disorder, Kashtartava, menstrual pain, Yoni vyapada
How to cite this article:
Goel M, Singh R, Bidhoodi U. Therapeutic aspects of Kashtartava (dysmenorrhea) in Ayurveda: a review. J Indian Sys Medicine 2022;10:111-9 |
| Introduction | |  |
Kashtartava, i.e., painful menstruation, is not separately described as a disease in Ayurvedic classics, but there are many other diseases in which pain during menstruation is mentioned. In classical literatures of Ayurveda, dysmenorrhea has been described as Kashtartava, Kukshishoola (abdominal pain), Vatala yoni, Udavartini Yonivyapad (type of vaginal disorders), etc.[1] The term Kashtartava consists of two words “Kashta” (painful) and “Artava” (menstrual flow) Thus the word Kashtartava can be expressed as “Kashthena Muchyati Iti Kashtartava,” where Kashthena refers to the condition of great difficulty[2] and Muchyati[3] means shedding or expulsion; i.e., the condition in which menstrual flow get released with great difficulty and pain is termed as “Kashtartava.” Similar etymology[4] has been mentioned in conventional medicine in which “Dys” symbolizes difficult or painful, “men” means month, and “rein” means to flow. Thus, dysmenorrhea literally refers to difficult or painful menstruation.[5] Acharya Charaka has specifically mentioned that none of the gynecological disorders can arise without the involvement of vitiated Vata Dosha,[6] thus leading to dysmenorrhea where Vata Dosha gets vitiated due to faulty lifestyle and suppression of natural urges.[7] He stated that because of Vegavarodha (suppression of natural urges), the Apana Vayu (a type of Vata) gets aggravated and moves in the reverse direction and occupies the entire Yoni (vaginal canal). This Apana Vayu forces the Raja (menstrual blood) upward and leads to pain and discomfort in menstruation. It is observed in various prevalence studies that the dysmenorrheal condition is present throughout the world. As many as 90% of adolescent females and above 50% of menstruating women worldwide reported suffering from it, with 10–20% of them describing their suffering as severe and distressing.[8] According to the study conducted in India among female medical students who reported dysmenorrhea, 31.67% and 8.68% were frequently missing college and classes, respectively. Dysmenorrhea could be a reason of recurrent short-term school absenteeism in adolescent girls and a cause of work absenteeism in women of reproductive age. An estimated 10–15% of women experience monthly menstrual pain severe enough to prevent normal daily function at school, work, or home.[9] Clinically, dysmenorrhea is of two types, i.e., primary and secondary. It affects the physical, psychological, and social status of female adolescents. Primary dysmenorrhea refers to menstrual pain without pelvic pathology. This usually appears within 1–2 years of menarche, when ovulatory cycles are established. The disorder affects younger women but may persist into 40s. The pain of primary dysmenorrhea usually begins a few hours before or just after the onset of menstrual period and lasts 48–72 h. The pain is similar to labor, with suprapubic cramping, and may be accompanied by lumbosacral backache, pain radiating down the anterior thigh, nausea, vomiting, diarrhea, and rarely syncopal episodes. The pain of dysmenorrhea is colicky in nature. Secondary dysmenorrhea is cyclic menstrual pain that occurs in association with underlying pelvic pathology. The pain of secondary dysmenorrhea often begins 1–2 weeks before menstrual flow and persists until a few days after the cessation of bleeding. The most common cause of secondary dysmenorrhea is endometriosis, followed by adenomyosis and intrauterine device.[10] Younger age, low body mass index, smoking, early menarche, prolonged or aberrant menstrual flow, premenstrual somatic complaints, pelvic infections, psychological disturbance, genetic influence, and a history of sexual abuse increase the prevalence and severity of dysmenorrhea. A study conducted in Jordan indicated that women who are underweight, having a low family income, living in a rural area, and have family history of dysmenorrhea were prone to the disease. A study conducted in Vietnam showed mean age and age at menarche, educational status, and religion were associated with incidence of dysmenorrhea.[11]
| Materials and Methods | | |
An in-depth review of various classical texts of Ayurveda has been done, and comprehensive literature search was performed using the keywords “Kashtartava, Dysmenorrhea, Menstrual pain, Menstruation, Yoni Vyapada” in PubMed, Scopus, Google Scholar, Science Direct, and Web of Science for published literature, and required data were obtained. General searches in Google were performed to assess the extent of general information on the topic.
| Results | | |
The word Kashtartava is not separately described as a disease in Ayurvedic classics. There are many other diseases in which dysmenorrhea is considered and described as a symptom. It is seen as a symptom in various diseases such as Vataja Artava Dushti (type of menstrual disorder), Vataja Yoni Vyapad, Udavartini, etc. Acharya Charaka has mentioned that none of gynecological diseases can arise without affliction of aggravated Vata.[12] It is the main responsible factor, though other Doshas (biological humor or energies) only present as Anubandh, i.e., associated factor to it. So pain is produced due to vitiation of only Vata Dosha or in combination with other biological humor or energies. The pain is the result of aggravation of Vata due to Apanavayu, Margavarodha (obstruction of body channels), or Dhatukshaya (depletion of body tissues).[13] This has been termed as dysmenorrhea. It can be found in various classical literatures mentioned as symptoms in various diseases, but the description is scattered. Various references are mentioned in [Table 1].
Pain is a very broad term, and it does not enable us to understand the exact discomfort from which the patient is suffering. The nature of pain not only signifies the intensity but also suggests the pathology behind its origin. As far as dysmenorrhea is concerned, the following types of Vataja Vedana (pain) have been reported. The words describing the characteristics are significant themselves.[28]
Varti (Vritti Inn Vaadeet)
Anything wrapped round swelling formed by internal rupture. Varti therefore means pain which resembles pain associated with internal rupture or pain arising if an organ is wrapped round itself, i.e., colicky pain. In the pathology of Vata prakopa (aggravation), obstruction to the passage has been considered as one of the major causes for the aggravation of Vata. During the process, Vata tries to push the contents of uterus outside but gets obstructed due to some pathology and hence tries to eliminate the obstruction again and again. This repetitive event of force by Apana Vayu to clear out its passage in the field of Garbhashya (uterus) is probably responsible for the Varti Vedana. Here obstruction is anatomical one.
Toda (to strike, to hit, to bruise, to pain)
Toda means striking, hitting, or bruising pain, i.e., pain of stroke, hit, or bruise which is constant and dull. In case of Vata aggravation which arises from obstruction, i.e., physiological obstruction to the passage of Apana Vayu, there is a quantitative increase in its volume which in turn raises the pain because of the striking or hitting of Vata against the boundaries of uterus. The severity of pain depends on the volume increased, but as soon as Vata gets an outlet to release, pain subsides.
Bheda (Breaking, splitting, dividing, cutting pain)
Bheda signifies pain which resembles the pain of breaking up of tissues or separation of tissues. Here the pain is constant but more severe than the Toda type of pain, i.e., excruciating pain. Vata aggravation arising from depletion of body tissues and giving rise to increased Rukshata and Kharata (dryness in body tissues) is responsible for Bheda type of pain. In this case, pain will be present till Vata is in function, i.e., throughout the menstrual cycle.
Causes/Pathophysiology of Aggravation of Vata
According to the Acharya Charaka, aggravation of Vata can be manifested through three ways as follows[29]:
Depletion of body tissues/Dhatukshaya
Consumption of Vata Prakopaka Ahara—Vihara (Vata aggravating diet and lifestyle) causes aggravation of Vata which leads to depletion of body tissues starting from the very first Dhatu, i.e., Rasa and then Rakta (Anuloma Kshaya/consecutive depletion). As menstrual blood is considered as Upadhatu (sub-body tissues),[30] there will be Alpata (decline) in Upadhatu Nirmana (formation of sub-body tissues), i.e., menstrual fluid will be produced in less quantity than normal. This will further vitiate Vata Dosha, which in turn will produce Kshobha (perturbation or constriction) in Garbhashaya, the stage resembling ischemic condition of the uterus resulting in pain. It leads to a continuous vicious cycle as aggravation of Vata causes depletion of body tissues and vice versa. Artavakshaya (deficiency of menstrual fluid) is a condition which has been described on the basis of Dhatukshaya Samprapti (pathogenesis due to depletion of body tissues), comes with the clinical features of diminished menstrual fluid and Kshaya (loss) of other body tissues. Depletion of body tissues may turn a woman to be Heena Satva (weak mental strength), whereby pain threshold gets lowered and pain is felt severe even in the case of mild pain.
Kopa/aggravation
It can occur in two ways: Svadhatu Vaishamya (vitiation of tissues) and Unmargagaman (deviation from normal physiological pathway).[31]
When a patient consumes Vatavardhaka Ahara (diet which increases Vata) and follows the lifestyle, viz., excessive traveling, speaking, etc., which aggravates it, vitiating the Vata creates various disorders after getting placed in uterus. The vitiated Vata by its Ruksha (dry), Sheeta (cold), Sukshma (minuteness/penetrating) properties spreads through Rasavaha Srotasa (channels carrying nutrient fluids) and leads to Rasavaha, Raktavaha (channels carrying blood tissues), Artavavaha (fallopian or uterine tubes), and Srotodushti (dysfunctioning of microchannels). Dosha—Dushya Sammurchhana (etiological progression)—takes place in the uterus. Here due to vitiation of Vyana and Apana Vayu, the Akunchana (contraction) and Prasarana (relaxation) Kriya (process) of the uterus do not take place properly, the state exactly that of dysrhythmia of uterine muscles, which will hinder the proper flow of menstrual blood, leading to dysmenorrhea. Vataja Yoni Vyapad and Vataja Artava Dushti (menstrual disorders caused by Vata) are the examples for this type of Samprapti (pathogenesis). Unmargagamana (deviation from the usual pathway) type of pathogenesis can also occur in the same way, if there is any type of alteration in the path of Apana Vayu. This type of pathogenesis can be understood very well in the Udavarta Yonivyapad, where Apana Vayu gets altered for its functions due to Urdhvagamana (upward movement) and causes pain.
Margavarodha/obstruction of passage
Acharya Sushruta in Sharira Sthana quoted that menstrual passage obstructed by vitiated body humor can lead to death.[21] Dalhana commented that vitiated body humors responsible for obstruction are Vata and Kapha individually or in combined form. The concept of Avarana (obstructive covering) also seems to play a role in producing pain, especially when the condition of Kaphavrita (covered by Kapha) Vata is concerned. The vitiated Kapha due to its Snigdha (unctuous), Guru (heavy), Pichchhila (mucilaginous), Abhishyandi (dense), and Gunas (attributes) will impair the Agni (metabolic activity) and will cause Jatharagni (digestive fire) and Dhatvagnimandya (cessation of digestive enzymes activity). It produces the condition similar to Ama (partially digested food). A sort of Upalepa (layer) is produced over the fallopian or uterine tubes, which lead to Artava Pravritti Avarodha (obstruction to menstrual fluid) or painful flow of menstrual fluid.
Samprapti Ghataka (factors involved in pathogenesis)
All factors responsible for generating the condition of dysmenorrhea are depicted in [Table 2].
Moreover, Manasika (psychological) factors such as Bhaya (fear), Shoka (grief), Chinta (excessive thinking), Krodha (anger), and Tanava (stress) also aggravate the Vata, resulting in the same pathology of dysmenorrhea.
Rupa (Symptoms)
Rajakrichrata[32] (difficulty in menstrual blood discharge), Artave Sa Vimukte Tu Tatkshanam Labhate Sukham[33] (immediate relief from pain after discharge), Phenila Artavam[34] (frothy menstrual blood), Anila Vedana[35] (feeling of pains like malaise, body ache), Kapha Samsrishta Artava[36] (discharge of menstrual blood with Kapha) (mucous-like substance), Badham Phenilam Phenayuktam Rajo Raktam[37] (discharge of clots along with menstrual blood), Samanthat Vritam Varthulam Yatra Vayuna Sa Thadha[38] (irregular uterine contractions due to excessive movement of Vayu) are some of the symptoms.
Management
Ayurveda considers Tridosha (Vata, Pitta, Kapha) as the fundamental units of entire physiology and pathology. Thus, body humors are the prime factors to be considered, while trying to establish any drug for any disease. Vata Dosha should be managed first as it is the prime factor for the pathogenesis of dysmenorrhea.[39] In Ayurvedic classics, dysmenorrhea is treated with Phala Ghrita, Jeerakadi Modaka, Maharasnadi Kwath, Shatavaryadi Anuvasna Basti, Baladi Anuvasna Basti, etc. Acharya Sushruta has advocated fresh juice of Rasona (garlic) in the morning for the management of pain in Udavarta (abdominal pain and distension).[40] The following is the line of treatment through which dysmenorrhea can be managed.
Pathya Ahara[41] (recommended foods);
Anna Varga (group of cereals)—Sattu (roasted gram flour), old rice, wheat (Phulka), Shaka Varga (group of vegetables)—green leafy vegetables, Dwidala Dhanya (dicots)—Kulattha, Mansa Varga (group of meats)—Harina, Titar, Jangal Mansa, Dugdha Varga (group of milk)—Dugdha, Takra, Navaneeta, Jala Varga (type of water)—Sansakarit (medicated) Jala (water), Phala Varga (group of fruits)—Dadima, Darksha, Kushmanda, Narikela, Anjira, Amalaki, Nimbu, Kand Mula (rhizomes)—Rasona, Palandu, Madhu Varga—Honey;
Pathya Vihara[42] (recommended lifestyle measures);
Vishrama (body rest), Diva Nidra (daytime sleep), Tambul Bhakshan (consumption of betel leaf), Swedana (biofomentation), Langhana (intermittent fasting), avoid mental stress and anxiety and keep mind positive.
Medications
This includes Snehana (oleation) with Traivrita Sneha (mixture of Ghrita, Taila, Vasa), biofomentation, consumption of Gramya, Anupa, Audaka Mamsa Rasa, and Dashmula Ksheera along with Anuvasana Basti and Uttara Basti with Traivrita Sneha.[43]Vatahara Upakrama like Yoni Pichu (tampons) with Taila (oil) prepared with Kushta, Devadaru, Tagara, Vartakini, and Saindhava Lavana.[44] Placing of a sterile soft cotton cloth soaked in oil prepared with decoction of Rasna, Chinnaruha, Malati, Madhuka, Vyaghri, Bala, Devadaru, Chitrakamula, Yuthika, cow’s milk, and cows urine into vagina in order to relieve the pain.[45] Other Pichu (sterile cotton piece) that can be used in the management of dysmenorrhea is Saindhavadi Taila Pichu, Dhatakyadi Taila Pichu, Mushaka Taila Pichu, and Guduchyadi Taila Pichu Basti, viz., Palasha Niruha Basti, Guduchyadi Rasayanika Basti, Shatavaryadi Anuvasana Basti, Shatavaryadi Rasayana Basti, and Baladi Yamaka Anuvasana Basti can also be administered.[46]
Pharmaceutical Formulations[47]
The formulations are as follows: Saptasaram Kashayam, Sukumaram Kashayam, Dhanwantaram Kashayam, Maharasnadi Kashayam, Rasna Swadamstradi Ksheerapakam, Pachottikoovaladi Kashayam, Hinguvachadi Churnam, Pushyanugam Churnam, Sukumara Ghritam, Phala Sarpi, Kumaryasvam, Rajapravartini Vati, Dhanwantaram Gutika.
Various studies have been also conducted on various formulations for the management of dysmenorrhea. These studies have been depicted in [Table 3] and [Table 4]. | Table 3: Ayurvedic formulations studied for the management of dysmenorrhea
Click here to view |
 | Table 4: Other important Ayurvedic pharmaceutical preparations being used in the treatment Kashtartava
Click here to view |
Yoga Asanas (Postures)
These include Halasana, Sarvangasana, Bhujangasana, Ardhamatsyendrasana, Shavasana, Pranayama like Nadishodhana. These asanas are reported to be effective in dysmenorrhea as they enhance the blood circulation to reproductive organs and regulate the hormones responsible for menstruation.[66]
| Discussion | | |
Various studies have reported that dysmenorrhea is one of the most common menstrual problems which significantly affect women’s quality of life, productive ability at work, and health status.[67],[68] It is a disease of women’s reproductive tract (Yoni Roga), which lies in Shroni Pradesh, i.e., pelvic region. Shroni has been considered as one of the major places of Vata Dosha. The classical anatomical site of dysmenorrhea is well in line with the conventional sciences.[69] Various Ayurvedic classics have described dysmenorrhea as a symptom in different diseases. Almost all the Ayurveda seers have mentioned this word, but the references are scattered in context to different disease entities. In the present study, it has been revealed that dysmenorrhea is one of the commonest gynecological problems which is prevalent all over the world. It has also been observed during analysis of classical literature in several diseases where Kashtartava is not mentioned as a terminology but complete clinical presentation of that disease indicates toward the painful menstruation, i.e., dysmenorrhea. For instance, it is not indicated directly as pain rather referred as Kashta (discomfort with pain) in the disorders like Vataja Yonivyapada, Udavartini Yonivyapad, etc. Based on etiological factors and the clinical features of diseases, it can be classified as primary and secondary.[70] In the conventional system of medicine, cause of dysmenorrhea is not well ascertained but the hyperproduction of uterine prostaglandins, specifically PGF2a and PGF2, is considered as the major responsible factor for the modification of the central nervous system leading to increased uterine tone and contractions of high amplitude in uterus.[71],[72] Similar factor and etiology have been quoted by Acharya Charaka that none of the gynecological disorders can arise without involvement of vitiated or aggravated Vata,[7] which is considered to regulate all neurological functions and in turn regulate the cerebral activities and all endocrinal secretions. In another study, it is found that all types of pain induce heightened sympathetic nervous system activity, which acts as a stressor leading to changes in neuromediators along with changes in neuroendocrine and hormonal secretions.[73] These findings further establish and validate that vitiated Vata is the foremost responsible and major factor in the pathogenesis, though other Doshas are only being present as associated factors to it. In the present study, it has also been found that faulty dietary habits, psychological status, and stress factors are also responsible for the manifestation of dysmenorrhea and same has been reported in a study as causative factors of dysmenorrhea and somatoform syndrome.[74] Owing to these facts, different Yoga postures and model code of conduct along with recommended diet chart have been advocated in various Ayurvedic literatures. Conventional medicine advises non-steroidal anti-inflammatory drugs which manages pain and inflammation as the first line of treatment[75],[76] for dysmenorrhea, and it has been observed that every treatment modality, whether dietary or medical, primarily manages Vata Dosha (responsible for pain) followed by Pitta (responsible for inflammation) and Kapha, by the virtue of their Tridosha-pacifying properties, e.g., medicated enemas, oil, ghee, etc. All these classical principals and facts have been validated by numerous scientific studies.[77],[78] Therefore, while planning the treatment, Vata should be normalized first and other Doshas should be treated successively. It has been found that Ayurvedic literatures have mentioned various formulations in different dosage forms, i.e., powder, tablet, decoction, medicated enemas, medicated ghee, oils, etc. for the management of dysmenorrhea. The present study provides comprehensive information about the prevalence, causative factors, and management of dysmenorrhea described in Ayurveda and validated by numerous clinical studies. In this review, a robust approach has been made to comprise all scientific studies published online as well as offline to present a complete overview of dysmenorrhea but it has been realized that well-designed clinical trials pertaining to dysmenorrhea is lacking. Therefore, well-designed clinical and survey studies with larger sample size should be initiated to generate sufficient data which can further help in developing health policies, programs, and protocols for the same.
| Conclusion | | |
Ayurvedic concept of Ahara-Vihara should be followed to prevent or minimize the incidence of dysmenorrhea. It is the need of the hour that various awareness programs regarding dysmenorrhea should be launched, and Dincharya (daily regimen) and Ritucharya (seasonal regimen) mentioned in Ayurveda should be incorporated in academic syllabus to enable people to adopt healthy lifestyle.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 47. | Ibidem 46. |
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| 50. | Ibidem 49. |
| 51. | Prakash H Lashuna tail vasti in the management of dysmenorrhea (Kashtatrava). Int Ayu Med J 2015;3:2327-30. |
| 52. | Ibidem 48. |
| 53. | Tomar P, Lal SK, Garg S Clinical comparative evaluation of efficacy and safety of Kumaryasava and Rajahpravartani vati in the management of Prathmik Kashtartava W.S.R. to primary dysmenorrhea. Int J Ayurveda Phar Res 2017;5:1-13. |
| 54. | Ibidem 53. |
| 55. | Dhiman S, Dhiman M, Kumar A Comparative study of Kumari Swarasa and Kanyasara in management of Kashtartava. Int J Ayu Pharm 2016; 7: 36-39. |
| 56. | Ibidem 55. |
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| 59. | Ibidem 58. |
| 60. | Meena NK, Sharma RV Management of spasmodic dysmenorrhea (Udavartini Yonivyapada) with Chaturbeeja Churna and Yoga Practices. Ayushdhara 2017;4:1363-72. |
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| 62. | Ibidem 61. |
| 63. | Patil S A Comparative Study of Boladi Vati and Katutrayadi Kashya. MD dissertation. SDM College of Ayurveda Udupi, Rajiv Gandhi University of Science Bangalore, Karnataka. 2009-2010. |
| 64. | Ibidem 63. |
| 65. | Satya Priya T, Deeja CR, Ram Mohan Rao G, Badari Narayana V, Suneela P, Sri Durga CH Clinical evaluation of Shankhpani Rasa in management of Kashtartava (dysmenorrhea). Int J Ayu Med 2013;4:379-86. |
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| 70. | Bereks JS Berek and Novak’s Textbook of Gynaecology. 15th ed. Mumbai: Lippincott Williams & Wilkins; 2012. p. 517-8. |
| 71. | Iacovides S, Avidon I, Baker FC What we know about primary dysmenorrhea today: A critical review. Hum Reprod Update 2015;21:762-78. |
| 72. | Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update 2014;20:737-47. |
| 73. | Morotti M, Vincent K, Brawn J, Zondervan KT, Becker CM Peripheral changes in endometriosis-associated pain. Hum Reprod Update 2014;20:717-36. |
| 74. | Patel V, Tanksale V, Sahasrabhojanee M, Gupte S, Nevrekar P The burden and determinants of dysmenorrhoea: A population-based survey of 2262 women in Goa, India. BJOG 2006;113:453-63. |
| 75. | Zahradnik HP, Hanjalic-Beck A, Groth K Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: A review. Contraception 2010;81:185-96. |
| 76. | Harel Z Dysmenorrhea in adolescents and young adults: An update on pharmacological treatments and management strategies. Expert Opin Pharmacother 2012;13:2157-70. |
| 77. | Ibidem 71. |
| 78. | Ibidem 72. |
[Table 1], [Table 2], [Table 3], [Table 4]
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