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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 308-312
The impact of dysmenorrhea on pulmonary functions
HY Dogru1, G Oktay2, ZC Ozmen3, AZ Ozsoy1, HI Koseoglu4
1 Department of Obstetrics and Gynecology, Medical Faculty, Tokat Gaziosmanpasa University, Tokat, Turkey
2 Department of Family Medicine, Medical Faculty, Tokat Gaziosmanpasa University, Tokat, Turkey
3 Department of Medical Biochemistry, Medical Faculty, Tokat Gaziosmanpasa University, Tokat, Turkey
4 Department of Chest Diseases, Medical Faculty, Tokat Gaziosmanpasa University, Tokat, Turkey
Correspondence Address:
Dr. H Y Dogru
Gaziosmanpasa University, Medical Faculty, Department of Obstetrics and Gynecology, 60100, Tokat
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_40_20
Abstract
Background: Primary dysmenorrhea (PD) is characterized by symptoms including sweating, headache, nausea, vomiting, diarrhea, tremulousness, usually begins adolescence, those can be associated with autonomic dysfunction affecting pulmonary functions. Aim: The aim of the present study is to investigate the impacts of PD on pulmonary function tests. Subjects and Methods: A prospective cross-sectional design was selected. All subjects were invited to admit to the Department of Obstetrics and Gynecology outpatient unit for venous blood test detecting the levels of estrogen and progesterone during the follicular and luteal phase of their menstrual cycle. After drawing blood, women were taken to the pulmonary function tests laboratory to perform the test. The comparisons between Group PD and Group Control were performed by the independent samples t-test or Mann–Whitney U test. Intragroup comparisons were completed by paired samples t-test. Results: The comparisons between Group PD and Group Control among estrogen and progesterone in follicular and luteal phase, pulmonary function test results did not show any significance (P > 0.05). The intragroup comparisons of estrogen and progesterone levels, and pulmonary functions test results revealed no significant difference (P > 0.05). Conclusion: The present study showed that PD does not influence the spirometric measurements and also respiratory functions are not impaired by the different phases of menstrual cycle.
Keywords: Dysmenorrhea, pain, respiratory function tests, spirometry
Introduction 
Primary dysmenorrhea (PD) clinically manifests with recurrent cramping pain in the lower abdomen during menstruation without any pelvic pathology. The disorder, which is characterized by symptoms including sweating, headache, nausea, vomiting, diarrhea, tremulousness, usually begins adolescence and is the most common gynecological condition of women in reproductive years.[1] Dysmenorrhea affects adolescent females ranging from 60% to 93%, of those 13–33% show severe symptoms. {PD is the major cause of workforce loss in women with childbearing age or short-term school absenteeism.[2] Dysmenorrhea is caused by the overproduction of endometrial prostaglandin F2 alpha (or increased ratio of prostaglandin F2 alpha/prostaglandin E2) leading to dysrhythmic uterine contractions, hypercontractility, and increased uterine muscle tone resulted in uterine ischemia. These factors may also stimulate the gastrointestinal tract causing nausea, vomiting, and diarrhea.
The hormonal rhythmic fluctuations during menstrual cycle led to changes in several systems particularly in the reproductive system. Pulmonary functions show differences throughout the menstrual cycle period in which women with asthma exhibit impaired symptoms during premenstrual and menstrual phases of their menstrual cycle.[3],[4] Bronchodilators supported with progesterone hormone administration in female patients showed promising results to treat bronchial asthma and acute exacerbations.[5] The possible explanation could be that the receptors of sex steroid hormones are located in the lung tissue affecting the pulmonary functions as well.[6] Moreover, decreased parasympathetic activity is shown in women with dysmenorrhea during luteal phase of menstrual cycle. Episodic menstrual pain is an evident factor dominantly related to the variations in autonomic activity.[7] Autonomic nervous system is responsible for controlling heart rate, blood pressure, constriction of airway smooth muscle, secretion from submucosal glands, capillary permeability and blood flow of the bronchial circulation, and release of mediators from the mast cells and other inflammatory cells.[8] In this respect, we hypothesized that alterations in sex hormones along with autonomic dysfunction during dysmenorrhea may have a disruptive effect on pulmonary functions which directly reflected by an impairment on the pulmonary function tests.
Pulmonary function tests are simple to perform and provide detailed information associated with the large and small airways. They are also used for the evaluation and monitoring of the patients with respiratory disease.
Considering the given information above, the aim of the present study is to investigate the impacts of PD on pulmonary function tests.
Subjects and Methods After approval of Gaziosmanpasa University Clinical Research Ethics Committee (Grant number: 15-KAEK-144, 25-Aug-2015), women who were admitted to the outpatient units of the Department of Obstetrics and Gynecology, and Family Medicine between July 2015 and July 2016 were enrolled in this study. Women with and without primary dysmenorrhea were randomly included in the study (computer generated random numbers). The exclusion criteria for the study were the following: Women who had obstructive lung disease including chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, endometriosis, pelvic inflammatory disease, ovary cyst, uterine fibroids, secondary dysmenorrhea or did not cooperate in lung function test. Written informed consent was obtained from all participants. Women with PD were enrolled in Group PD (PD), where women without PD in Group C (C). All subjects were invited to admit to the Department of Obstetrics and Gynecology outpatient unit for venous blood test detecting the levels of estrogen and progesterone on the 9–12th day during follicular phase and 19–22nd day during luteal phase as estimated from their menstrual histories for the preceding 3 months. The hormone level measurement was performed by chemiluminescence immunoassay method using the Roche cobas e601 analyzer (Roche Diagnostics GmbH, Germany). After drawing blood, women were taken to the pulmonary function tests laboratory to perform the test. Patients were asked to sit in a chair, and a soft clip was placed over his/her nose. After taking a maximal inspiration, patients forcefully expel air as long and as quickly as possible through a mouthpiece connected to the spirometer (MasterScreen Pneumo, Erich Jaeger, Wurz-burg, Germany). Each patient was asked to complete the test procedure for three times and the best (highest) values including forced expiratory volume 1st second (FEV1), forced vital capacity (FVC), FEV1/FVC, maximal (mid-) expiratory flow (MMEF), and peak expiratory flow (PEF) were expressed in milliliters and percentage of the predicted value, using a dry spirometer (MasterScreen Pneumo, Erich Jaeger, Wurz-burg, Germany) along with demographic data were recorded.[9]
Previous studies showed a mean FVC value of 3.3 ∓ 0.6 liter.[10] Assuming 15% of decrease in FVC in women with primary dysmenorrhea, with a two-sided type I error of 0.05, and a power of 0.80, accompanying with an increase by 10% percent to suppress the effects of missing values, a total of 50 subjects consisted of 25 in each group were required to find a significant difference between follicular and luteal phase of menstrual cycle.[11]
Statistical analysis
The distribution of the data was analyzed using one-sample Kolmogorov–Smirnov test. Quantitative values are presented as means and standard deviation, and qualitative data as frequency and percentage. The comparisons between PD and C were performed by the independent samples t-test or Mann–Whitney U test. Intragroup comparisons were completed by paired samples t-test. Analyses were completed by using the Statistical Package for Social Sciences (SPSS) version 20.0 (Chicago, IL, USA) program. The statistical significance for all analyses was set at P < 0.05.
Results A total of 55 women consisted of 26 in PD and 29 in C were included in the study. Enrollment of the subjects are presented in [Figure 1], where demographic characteristics are in [Table 1]. The mean age of the women was 22.38 (1.90; Confidence Interval: 21.86–22.82), since weight, height, and BMI were 58.96 (10.47; Confidence Interval: 56.13–61.79), 164.45 (5.15; Confidence Interval: 163.06–165.84), and 21.80 (3.78; Confidence Interval: 20.77–22.82), respectively. The comparisons between PD and C among estrogen and progesterone in follicular and luteal phase, pulmonary function test results did not show any significance (P > 0.05; [Table 2]). Luteal phase progesterone and estrogen levels were higher compared to follicular phase in PD and C, and pulmonary functions test results revealed no significant difference (P < 0.001; P < 0.001; P > 0.05; respectively; [Table 2]].
Table 2: The comparisons of the hormones and pulmonary function test results Discussion The present study showed that pulmonary function test values did not change with the presence or the absence of primary dysmenorrhea, and follicular and luteal phase of the menstrual cycle as well.
It is well known that menstrual cycle is divided into two including follicular (Day 1–13) and luteal (Day 14–28) phases in which rhythmic changes are occurred in the levels of ovarian hormones particularly progesterone and estrogen. Estrogen and progesterone are low during menstruation and late luteal phase, where both increased during luteal phase and turn back to lower levels close to menstruation.[12] Menstruation leads to several hormonal fluctuations on women in which some of these alterations may directly affect the lung tissue or the whole body. Researchers obtained distinct results on lung volumes measured during follicular and luteal phase of the menstrual cycle. Arora et al. and Kannan et al. conducted a study on females aged between 18 and 23 years old with regular menstrual cycle and showed that FVC and FEV1 were increased in the luteal phase compared to follicular phase of menstrual cycle.[13],[14] In addition, a recent study by Mishra et al. demonstrated that FVC, FEV1, and PEFR were higher in both proliferative and secretory phases when compared to menstrual phase.[15] Furthermore, Kaur et al.[16] revealed that FVC, FEV1, and MVV in secretory phase were found significantly higher than those in follicular and menstrual phase. Many of the authors have indicated the similar mechanism that the improved pulmonary functions are associated with the increase in progesterone levels during luteal phase of the menstrual cycle.[14],[16],[17],[18] Forced expiratory volume in one second and FVC are measured at the lowest levels following ovulation in the peri-ovulatory phase of the menstrual cycle in which estradiol is increased since progesterone is normal.[12] Progesterone leads to hyperventilation by the stimulation of central medullary and peripheral receptors (increase the chemoreceptor response to hypoxia and hypercapnia) and increases the sensitivity of respiratory receptors during the luteal phase, and also provides upper airway and bronchial smooth muscle relaxation.[16],[19] Moreover, researchers reported that oral contraceptive pills including progesterone may improve PEFR and FEF25-75 by decreasing the resistance of small bronchioles.[20],[21]
In contrast to the findings above, Farha et al. showed that FVC and FEV1 are reached to the peak during the perimenstrual period while estradiol and progesterone levels are at the baseline values.[22] However, another study by Williams et al. revealed that menstrual cycle phase does not lead to any disturbances on the spirometric or ventilatory responses at rest, while submaximal or maximal exercise.[23] In relation, Chong et al. and Silva et al. observed the similar results that no significant differences were detected between the phases of menstrual cycle for any of the spirometric measurements.[24],[25]
There has been no study found on the effects of primary dysmenorrhea on the spirometric measurements. Using the given conflicting information above, the spirometric findings in the present study are expected to be better during the luteal phase of the menstrual cycle compared to follicular phase, those could be explained by the impairment of the autonomic dysfunction related to pain, and elevated progesterone levels during the luteal phase of the menstrual cycle. However, there was no significant difference found between women with and without primary dysmenorrhea among spirometric values. In addition, no difference was existed between follicular and luteal phase spirometric measurements of the women with or without primary dysmenorrhea. Therefore, it can be speculated that the hormone fluctuations may not have an impact on volumetric measurements of the respiratory functions.
This study has some limitations. First, female sex hormones including follicular stimulating hormone and luteinizing hormone could be measured along with estrogen and progesterone. Second, no high-quality trials were identified to compare the results of the present study. Third, ventilatory measurements could be added to find detailed results of respiratory functions. However, we have limited foundation to achieve that goal.
In conclusion, the present study showed that primary dysmenorrhea does not influence the spirometric measurements and also respiratory functions are not impaired by the different phases of menstrual cycle. Further studies with larger sample size should be required to confirm this outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgements
Authors are very grateful to the support given by Dr Serkan Dogru.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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