• Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Cyclic perimenstrual pain and discomfort: nursing management. Evidence-based clinical practice guideline. Washington (DC): Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN); 2003. 48 p. [129 references]

This is the current release of the guideline.

Quality of Evidence Ratings (I, II-1, II-2, II-3, III) are defined at the end of the "Major Recommendations" field.

Screening for Cyclic Perimenstrual Pain and Discomfort (CPPD)

1. Ideally, all women should be screened for CPPD on a routine basis.

   (Robinson & Swindle, 2000; Jamieson & Steege, 1996; Hewison & van den Akker, 1996: Evidence Rating: III)

2. Incorporate screening questions into a self-assessment that is routinely collected during intake.

   Much of the basic subjective data can be collected via a structured questionnaire. The following screening questions are effective:

   1. Do you ever have pelvic pain or cramps during or around the time of your period?
   2. Are you able to treat this pain so it doesn't bother you?
   3. Do you ever have other physical or mood discomforts during or around the time of your period?
   4. Are you able to treat these discomforts so they don't bother you?

   (Wittchen et al., 2002: Evidence Rating: II-1; Banikarim, Chacko, & Kelder, 2000: Evidence Rating: III)

Nursing Assessment of Cyclic Perimenstrual Pain and Discomfort

1. Conduct a focused nursing assessment for women with CPPD for whom current treatments or selfcare therapies are ineffective.

   (Jamieson & Steege, 1996: Evidence Rating: III) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I)

   An interview by a nurse can confirm self-report data as well as collect additional data. Start with a focused health history whenever possible (see Appendix A in the original guideline document).

   (Runtz, 2002: Evidence Rating: II-2) (Hornsby, Wilcox, & Weinberg, 1998: Evidence Rating: II-2) (Jamieson & Steege, 1996: Evidence Rating: III) (Montero et al., 1996: Evidence Rating: II-2) (Parazzini et al., 1994: Evidence Rating: II-2) (Harlow & Park, 1996: Evidence Rating: II-3) (Jarrett, Heitkemper, & Shaver, 1995: Evidence Rating: III) (Sundell, Milsom, & Andersch, 1990: Evidence Rating: II-1)

2. Identify the individual woman's pattern of CPPD.

   The menstrual cycle may be divided into three phases: premenstrual, early menstrual (days 1-3 or days of heavy flow), and late menstrual (day 4 and onward or days of lighter flow).

   (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I) (Brodie & Niven, 2000: Evidence Rating: II-2)

   The following areas should be assessed:

   1. Pattern of severity of CPP across pre- and early menstrual phases
   2. Rating of overall distress caused by CPP
   3. Pattern of severity of other cyclic discomforts across pre- and early menstrual phases
   4. Rating of overall distress caused by cyclic discomforts
   5. Influences on the cyclic pain symptoms -- e.g., work stress, diet, or exercise

   (Woods, Mitchell & Taylor, 1999; Taylor, 1999: Evidence Rating: I)

3. Identify the individual woman's pattern of symptom management by gathering the following information:
   1. Interventions, including self-care strategies
   2. Pattern of use across pre- and early menstrual phases
   3. Rating of relief obtained from intervention
   4. Rating of satisfaction with pain and symptom control
   5. Rating of adherence (i.e., consistent use of treatment)

   (Taylor, 2000: Evidence Rating: II-2) ("A model for symptom management," 1994: Evidence Rating: III) (Campbell & McGrath, 1997: Evidence Rating: II-2).

4. Conduct a focused history and physical assessment using data from the history as a basis.

   The components of a focused history and physical assessment are provided in Appendix A in the original guideline document. Assessment and diagnosis are a dynamic process. The items in the appendix are presented in a logical order but may be adapted to fit within the routines of the nurse's practice.

   (Taylor, 2000; Evidence Rating: II-2)

5. Refer the woman to or co-manage with an appropriate health care provider as needed.

   (American Nurses Association, 1997: Evidence Rating: III).

6. Throughout the assessment and diagnosis processes, use of standardized nursing language to communicate about CPPD is preferred.

   (Johnson & Maas, 1998: Evidence Rating: III)

Nursing Diagnosis of Cyclic Perimenstrual Pain and Discomfort

1. Organize assessment data into symptom patterns and identify relevant nursing diagnoses as follows:
   1. Cyclic Pelvic Pain (CPP)
      • Abdominal cramps
      • Nausea, vomiting
      • Backache
      • Change in bowel frequency
   2. Perimenstrual Physical Discomforts
      • Fatigue
      • Headaches
      • Fluid retention
      • Joint aches and pain
      • Breast tenderness
      • Leg/thigh discomfort
      • Change in energy and appetite
   3. Perimenstrual Mood Discomforts
      • Depression
      • Irritability
      • Tension
      • Impatience
      • Anxiety
      • Anger
      • Mood swings
      • Hostility
      • Change in sexual desire
      • Guilt
      • Feeling out of control
      • Tearfulness

   (Taylor, 1999: Evidence Rating: I) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I) (Angst et al., 2001: Evidence Rating: II-2)

Planning Expected Outcomes and Care

1. Review assessment data together with the woman and identify the outcomes important to the woman and amenable to nursing intervention. Expected outcomes for CPPD management may include the following:
   1. Improvements in CPP symptom frequency, severity, distress and pattern
   2. Improvements in discomfort symptom frequency, severity, distress, and pattern
   3. Increased comfort level (physical and psychosocial well-being)
   4. Successful use of treatments to manage symptoms
   5. Relief of pain/discomfort
   6. Enhanced role performance (work, family/friends, school, leisure)
   7. Patient understanding of the cost of various forms of treatment

   (Thompson & Gick, 2000: Evidence Rating: II-2) (Zander, 1996: Evidence Rating: III) (Dawood, 1985: Evidence Rating: III) (Harlow & Park, 1996: Evidence Rating: II-3) (Hewison & van den Akker, 1996: Evidence Rating: III)

2. Review symptom patterns and establish expected outcomes through mutual goal-setting with the woman.

   (Banikarim, Chacko, & Kedler, 2000: Evidence Rating: III) (Taylor, 2000: Evidence Rating: II-2)

   Use the assessment as an opportunity to educate women about managing pain and discomfort.

   (Dodd et al., 2001: Evidence Rating: III) ("A model for symptom management," 1994: Evidence Rating: III) (Hegyvary, 1994: Evidence Rating: III) (Robertson, 1991: Evidence Rating: III) (Taylor, 1999: Evidence Rating: I)

3. Develop an individualized treatment plan, incorporating the following concepts:
   1. Multimodal treatment strategies
   2. Participant involvement through personal choice whenever possible

   (Bulechek & McCloskey, 1999: Evidence Rating: III) (Taylor, 1999: Evidence Rating: I)

Nursing Interventions for Cyclic Perimenstrual Pain and Discomfort

1. Implement one or more of the following fundamental symptom management interventions as indicated:
   1. Collaborative pain assessment
      • Focused assessment with participation by the woman

      (Taylor, 2000: Evidence Rating: II-2) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I)

   2. Mutual goal-setting
      • Identify goals of care with the woman
      • Explore with the woman ways to best achieve the goals

      (Taylor, 2000: Evidence Rating: II-2) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I)

   3. Coping enhancement
      • Provide atmosphere of acceptance
      • Provide factual information concerning diagnosis, treatment, and prognosis

      (Taylor, 2000: Evidence Rating: II-2) (Woods, Mitchell & Taylor, 1999: Evidence Rating: I)

2. Consider implementation of one or more of the following self-monitoring interventions:
   1. Coping enhancement
   2. Tracking symptoms (using a calendar or chart; see Appendix B in the original guideline document)
   3. Tracking stressors, function, health status

   (Taylor, 2000: Evidence Rating: II-2) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I) (Taylor, 1999: Evidence Rating: I) (Goodale, Domar, & Benson, 1990: Evidence Rating: I) (Steiner et al., 1995: Evidence Rating: I)

3. Consider implementation of one or more of the following symptom regulation interventions:
   1. Pharmacological symptom management
      • Over-the-counter (OTC) medication
      • Timing and strength of the medication are critical to pain relief. Women should be advised to take an adequate dose of medication at the first sign of pain or before bleeding occurs.
      • Manufacturers' recommendations for Over-the-Counter medications should not be exceeded (see prescriptive levels for others) unless alternative dosing is recommended by a health professional with prescriptive authority.

      (Harlow & Park, 1996: Evidence Rating: II-3) (Dawood, 1985: Evidence Rating: III)

      • Nonsteroidal anti-inflammatory drugs (NSAIDS, e.g., ibuprofen, ketoprofen, naproxen sodium, and aspirin)
      • Women should be advised to read labels of other OTC medications taken concomitantly, particularly cold and sleep remedies.
      • Women should be advised regarding appropriate duration of use because of the potential for gastrointestinal distress or other side effects.

      (Lethaby, Augood, & Duckett, 2002: Evidence Rating: I).

      • Prescription NSAIDs such as:
        • Ibuprofen
        • Naproxen
        • Ketoprofen
        • Celecoxib
        • Rofecoxib
        • Valdecoxib

      (Daniels et al., 2002; de los Santos et al., 2001; Morrison et al., 1999: Evidence Rating: I)

      • Analgesic pain relief
        • Consider acetaminophen for pain relief.

      (Zhang & Li Wan Po, 1998: Evidence Rating: I)

      • Hormones
        • Combination estrogen-progestin oral contraceptives
        • Progesterone intrauterine device

      (Creatsas et al., 1990: Evidence Rating: I) (Iyer, Farquhar, & Jepson, 2000: Evidence Rating: I) (Dawood, 1985: Evidence Rating: III) (Milsom, Sundell, & Andersch, 1990: Evidence Rating: III) (Brown, Ling, & Wan, 2002: Evidence Rating: II-2) (Oinonen & Mazmanian, 2002: Evidence Rating: III) (Freeman et al., 2001: Evidence Rating: II-2) (Wyatt et al., 2001: Evidence Rating: I) (Wildemeersch, Schacht, & Wildemeersch, 2001: Evidence Rating: II-3).

      • Nutraceuticals

        The following nutraceuticals may be considered in addition to a healthy diet and a general multivitamin and mineral supplement if the woman has no contraindications. (See also "General dietary modification" section for CPPD symptom management.)

        (Proctor & Murphy, 2002: Evidence Rating: I) (Stevinson & Ernst, 2001: Evidence Rating: I) (Oakley, 1998: Evidence Rating: III) (Willett, 2001: Evidence Rating: III)

        The doses recommended below are in addition to the amounts generally found in multivitamin and mineral supplements.

        • Calcium

          The usual recommended dose is 1,200 mg/day in divided doses and no more than 2,500 mg/day, including dietary sources.

        (Thys-Jacobs et al., 1989; Thys-Jacobs et al., 1998: Evidence Rating: I)

        • Magnesium

          The usual recommended dose is 250 mg/day; increase or decrease dose in relation to constipation symptoms or laxative effect. Do not exceed 500 mg/day.

        (DeSouza et al., 2000; Proctor & Murphy, 2002; Taylor, 1999: Evidence Rating: I)

        • Essential fatty acids

          The usual recommended dose of fish oil capsules or supplements is 1,000 mg/day of eicosapentaenoic acid (EPA) and 700 mg/day of docosahexaenoic acid (DHA) in one or two divided doses for 2 months. Ideally, this regimen should also include vitamin E supplements.

        (Deutch, 1995: Evidence Rating: III) (Harel et al., 1996: Evidence Rating: I)

        • Vitamin B complex

          The usual recommended dose of vitamin B6 is 50-200 mg/day, not to exceed 200 mg/day.

        (Abraham & Hargrove, 1980: Evidence Rating: I) (Doll et al., 1989: Evidence Rating: I) (Kleijnen, Ter Riet, & Knipschild, 1990: Evidence Rating: III)

        The usual recommended dose of vitamin B1 is 100 mg/day.

        (Gokhale, 1996: Evidence Rating: I)

      • Antidepressant medication
        • Antidepressant medication may be considered for women with severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD).
        • Women should be referred to a mental health professional as indicated for symptoms of depression

        (Dimmock, et al., 2000: Evidence Rating: I) (Steiner et al., 1995 Evidence Rating: I) (Steiner et al., 1997 Evidence Rating: I) (Steiner et al., 2001: Evidence Rating: I) (Taylor, 1999: Evidence Rating: II-2)

      • Medications under investigation
        • Nimesulide
        • Transdermal nitroglyceride
        • Vasopressin antagonists
        • Note: Further research is needed to clarify appropriate clinical use of these drugs to treat CPPD

        (Pirhonen & Pulkkinen, 1995; Mehlisch & Fulmer, 1997; Facchinetti et al., 2002; Marchini et al., 1995; Moya et al., 2000; "Transdermal nitroglycerine," 1997; Brouard et al., 2000; Valentin et al., 2000: Evidence Rating: I)

   2. Topical/cutaneous symptom management

      The following methods may be considered to help manage CPPD symptoms:

      • Heat application
        • Heating pad (as needed)
        • Hot baths (as needed)
        • Disposable heat wrap (see manufacturer's instructions)

      (Akin et al., 2001: Evidence Rating: I)

      • Therapeutic massage
        • Head/neck
        • Full body massage
        • Foot massage

      (Hernandez-Reif et al., 2000: Evidence Rating: I)

      • Acupressure

      (Taylor, Miaskowski, & Kohn, 2002: Evidence Rating: I)

      • Transcutaneous electrical nerve stimulation (TENS)

      (Dawood & Ramos, 1990: Evidence Rating: I) (Kaplan et al., 1994: Evidence Rating: II-3) (Proctor et al., 2002: Evidence Rating: I)

   3. Behavioral/cognitive symptom management

      The following techniques may be recommended to help manage CPPD symptoms:

      • Behavioral relaxation
        • Breathing exercises
        • Stretching exercises
        • Progressive muscle relaxation
        • Autogenic training

      (Goodale, Domar, & Benson, 1990: Evidence Rating: I)

      • Cognitive relaxation
        • Thought-stopping strategies
        • Thought substitution
        • Decreased negative self-talk
        • Meditation
        • Mindfulness meditation
        • Guided imagery
        • Prayer
        • Affirmations
        • Biofeedback
        • Distraction

      (Kirkby 1994: Evidence Rating: II-I) (Taylor, 1996: Evidence Rating: II-2) (Van Zak, 1994: Evidence Rating: I) (Taylor, 1999: Evidence Rating: I)

4. Encourage the following lifestyle modifications as indicated:
   1. General dietary modification
      • Decreasing intake of caffeine, simple sugars, and salt
      • Eating frequent, small meals
      • Increasing water and fluid intake to 6-8 glasses/day

      (Barnard et al., 2000: Evidence Rating: II-1)

      • Reducing alcohol intake
      • Increasing intake of foods that can decrease symptoms, such as those that:
        • decrease fluid retention
        • are rich in essential fatty acids
        • are rich in B complex vitamins
        • are rich in calcium and magnesium
      • Using a daily multivitamin and mineral supplement
      • Using a premenstrual syndrome-formula vitamin and mineral supplement during premenses

      (Sayegh et al., 1995: Evidence Rating: I) (Rossignol & Bonnlander, 1990: Evidence Rating: II-2) (Harlow & Park, 1996: Evidence Rating: II-3) (Hornsby, Wilcox, & Weinberg, 1998: Evidence Rating: II-2) (Parazzini et al., 1994: Evidence Rating: II-2) (Taylor, 1999: Evidence Rating: I)

   2. Smoking cessation
      • Encourage smoking cessation, particularly early in the menstrual cycle (follicular phase)

      (Allen et al., 2000: Evidence Rating: I) (Perkins et al., 2000: Evidence Rating: II-2).

   3. Exercise
      • Encourage one or more of the following types of exercise as indicated and as can be tolerated:
        • Regular aerobic exercise
        • Nonaerobic exercise (e.g., yoga, tai chi, stretching/relaxation)
        • Exercise modification across the menstrual cycle

      (Jarrett, Heitkemper, & Shaver, 1995: Evidence Rating: II-2) (Giacomoni et al., 2000: Evidence Rating: I) (Golumb, Solidum, & Warren, 1998: Evidence Rating: III) (Prior et al., 1987: Evidence Rating: II-1) (Taylor, 1999: Evidence Rating: I)

5. Consider the following environmental modification interventions:
   1. Environmental stress management

      (Taylor, 1996: Evidence Rating: II-2) (Woods, Mitchell, & Taylor, 1999: Evidence Rating: I) (Brown & Zimmer, 1986: Evidence Rating: II-2)

   2. Time management

      (Taylor, 1999: Evidence Rating: I)

   3. Social support

      (Morse, 1997: Evidence Rating: II-2) (Robertson, 1991: Evidence Rating: III) (Taylor & Bledsoe, 1985: Evidence Rating: II-3) (Taylor, 1996: Evidence Rating: II-2) (Alonso & Coe, 2001: Evidence Rating: II-3) (Taylor, 2000: Evidence Rating: II-2)

6. Consider other emerging therapies that may help manage symptoms. In most cases, further research for emerging therapies is required to conclusively determine safety and effectiveness. Nurses should inquire about these therapies when assessing patients, and when providing counseling should take into account the best available scientific evidence, risks and benefits of therapies.
   1. Acupuncture

      (Helms, 1987: Evidence Rating: I) (Proctor et al., 2002: Evidence Rating: I)

   2. Chiropractic therapy

      (Liebl & Butler, 1990: Evidence Rating: II-3) (Proctor et al., 2001: Evidence Rating: I)

   3. Chinese herbal medicine

      (Kotani et al., 1997: Evidence Rating: I)

   4. Homeopathy

      (Yakir et al., 2001: Evidence Rating: I)

   5. Botanical and herbal therapies
      • Chaste tree berry (Vitex agnus castus, also known as chasteberry) may be recommended, but is contraindicated for women who are lactating or taking oral contraceptives.

        (Schellenberg, 2001: Evidence Rating: I) (Bascom & American College of Emergency Physicians, 2002: Evidence Rating: III).

      • If omega-3 fatty acids do not sufficiently address pain and breast tenderness, consider evening primrose oil capsules (gamma linolenic acid, an omega-6 fatty acid), 2,000-3,000 mg/day, in combination with vitamin E supplements. Potential side effects of evening primrose oil, although uncommon, include gastric discomfort, nausea, and headache.

        (Taylor & Colino, 2002; Hardy, 2000: Evidence Rating: III)

   6. Referral for surgical evaluation

      (Chen & Soong, 1997: Evidence Rating: III) (Wilson et al., 2000: Evidence Rating: I)

Evaluation

1. Re-assess the woman's CPPD symptoms.
   • Ideally, the same assessment tools should be used for both the initial assessment and follow-up evaluation. (See Appendices A and B in the original guideline document.)

     (Zander, 1996: Evidence Rating: III)

2. Evaluate outcomes of intervention.
   • Achievement of expected outcomes initially identified by the woman in collaboration with her health care provider should be evaluated.
   • When a woman is referred to another health care provider for additional evaluation or treatment, follow up on the woman's progress whenever possible and indicated.

     (Dodd et al., 2001: Evidence Rating: III)

Definitions:

I: Evidence obtained from at least one properly designed randomized, controlled trial or meta-analyses of randomized, controlled trials

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees

None provided

Each clinical practice recommendation presented in the Guideline is supported by a referenced rationale using American Psychological Association format and includes the quality of evidence ratings for each reference. The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Cyclic perimenstrual pain and discomfort: nursing management. Evidence-based clinical practice guideline. Washington (DC): Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN); 2003. 48 p. [129 references]

Not applicable: The guideline was not adapted from another source.

2003

Association of Women's Health, Obstetric, and Neonatal Nurses - Professional Association

Association of Women's Health, Obstetric, and Neonatal Nurses

Evidence-Based Clinical Practice Guideline Development Team

Team Members: Beth A. Collins Sharp, PhD, RN (Team Leader); Nancy A. Prince, MSN, RN; Claudia Reid Ravin, CNM, MSN; Anne Santa-Donato, RNC, MSN; Diana L. Taylor, RN, NP, PhD, FAAN; Jeanne M. Wilton, RNC, MS, IBCLC, WHNP

Reviewers: Sue Woodson, CNM, MSN; Katherine E. Shelby, MSN, WHNP; Kristin Metcalf-Wilson, MSN, RNC, WHNP; Deborah Marcus, RNC, MSN, WHNP

Editorial Consultant: Dana Trevas

Not stated

This is the current release of the guideline.

This NGC summary was completed by ECRI on January 26, 2006. The information was verified by the guideline developer on March 6, 2006. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.