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Kim H1, Zarif N1, Hode L2. The effect of 904 nm low level laser treatment of menstrual pain – a pilot study.

  1. Royal Institute of Technology, Stockholm, Sweden
  2. Spectro Analytic Irradia AB, Stockholm, Sweden

Introduction
“Every month nearly 100000 women stay at home from work because of painful periods.” This preamble greeted readers in the November 1st 2004 edition of the Swedish evening journal Expressen’s online edition.

The Swedish market research company TEMO reported that menstruation affects work or study for more than one third of Swedish women between 20 and 35 years. In eleven percent pains are so severe that women are forced to stay home from work, which means, in addition to the physical pain, also loss of income. Expressen returned on May 26, 2008 to the topic and conducted a Gallup poll in where they asked the following question: “Do you suffer from severe menstrual pain?” Of the 1529 respondents 70% suffered from such severe pain that they sometimes stayed home from work or school [1]. A problem for women is that their pain is not generally considered to be “true”, because the course is completely natural and a part of the female physiology. Because of this it is often perceived as embarrassing for many women to take time off from work for the pains during menstruation because they are not really sick. This has led to that research on menstrual pain has low priority [1].

Women’s anatomical sex organs consist of two ovaries and fallopian tubes and uterus and vagina. The ovaries contain approximately 400.000 genes to the egg that the woman is born with. The influence of certain hormones during puberty, namely follicle stimulating hormone (FSH), estrogen and luteinizing hormone (LH) causes the ovaries begin to develop eggs and disconnecting one (or more) mature egg each month. The mature egg then migrate through the fallopian tube into the uterus. Progesterone, a hormone that begins to form after ovulation simultaneously with the above-mentioned hormones makes the lining of the womb is ready to receive the egg. If the egg becomes fertilized stuck it into the uterus and develop into a fetus, which is the beginning of pregnancy. If the egg is not fertilized, progesterone drops, the lining of the uterus sloughs off and menstruation begins.
Menstruation is vaginal bleeding that occurs every month about two weeks after ovulation. The estranged lining of the uterus and a little fresh blood from some superficial bleeding in the uterus forms the menstrual blood content. The amount of menstrual blood varies from person to person but is usually not more than about 1 ½ deciliter. The entire menstrual cycle typically lasts approximately 28 days, but may be anything from 25 days to 35 days. The menstrual cycle length can be affected by stress, exercise, eating habits, etc. [2].

Symptoms and collaboration of prostaglandin
Menstruation and bleeding for some women followed by sharp pain and discomfort while other women do not get any trouble at all. A little pain and discomfort during menstruation is quite normal. Menstrual pain due to muscle contractions that occur in the uterus to expel the mucosa formed in the uterus during ovulation. Studies have shown that these contractions are caused by the signal substance prostaglandin that used to be connected to pain, aches and fever in the body, but that is natural for uterine function [3]. Women with severe menstrual period (also called dysmenorrhea) is plagued by so much pain that affected their normal activity. Symptoms may be different. They often suffer from spasmodic contractions in the abdomen, pain in the abdomen, pain in the lower back, nausea and vomiting, diarrhea, sweating, fatigue and lack of energy.

Current treatments and side effects
Mild menstrual pain is currently treated with prescription pain pills but heavy menstrual pains require something stronger prescription anti-inflammatory tablets. According to Dr. Göran Holmberg [x], the first step is NSAIDs such as diclofenac, naproxen and aspirin. This class of drugs has inflammation-absorbing, antipyretic and, in particular analgesic effects. Dr. Holmberg believes, however, that “you have to start taking pills two days before menstruation begins and continue consumption to two days after menstruation began to not experience any pain at all and it is often missed because you lack knowledge of the mechanism. The common mechanism of action is that NSAIDs block the synthesis of prostaglandins, which in turn causes the womb to significantly tighten. Block of prostaglandins may not be sufficient. If pain prevails, the next step is to add paracetamol. This may cause heavier bleeding, which in turn allows these women already having heavy bleeding to lose much iron [11]. All types of pain medication have some sort of side effects. They can especially lead to irritation of the stomach lining and cause various kinds of stomach problems such as gastric ulcer. Damage to the small intestine, colon and kidney can also appear.

Therapeutic lasers
Unlike thermal lasers, the effect of therapeutic laser is not based upon heat but to photochemical reactions in the cells. Therefore, these are called often biostimulating lasers, therapeutic lasers or low-level laser therapy (hereafter LLLT). The processes that occur when the laser light is absorbed in the photochromic molecules in cells and tissue is extremely complicated. They affect several of the cells’ own functions and thus are affected, inter alia, the immune system, blood circulation, lymphatic circulation, cell metabolism and excretion of various substances, such as endorphins and prostaglandins including affect pain [4]. There is evidence in the scientific literature to suggest that LLLT relieves inflammatory pain by reducing the levels of biochemical markers (PGE2, COX-2 mRNA, II-1β, TNF), neutrophil cell influx, oxidative stress and the formation of edema and hemorrhage. Studies have also shown that LLLT can affect inflammatory processes and can significantly reduce acute inflammatory pain in a clinical setting [6, 7]. No evidence so far has shown that laser treatment involves risk or side effects. The instrument is in the present study was an Irradia MID laser, GaAs, wavelength 904 nm, 4 × 60 mW of average power, linear polarized and superpulsed with peak power of 60 watts, pulse width of 100 ns, pulse frequency of 700 Hz. Total treatment time per session was 15 minutes, giving a total energy 200 joules. The penetration depth is as large as 3 to 5 cm depending on the working method and the type of tissue but the light does not go into the tissue as a “spike” but spread so that it forms a ball of light much like half a Ping-Pong ball around the point of impact. A short wavelength provides a round ball while longer wavelengths, as in this study (904 nm), provides a more egg-shaped light distribution. The strength decreases rapidly down the tissue. With direct contact to the skin surface formed almost no reflection of the laser light.

Research and previous studies
Dr. Britt-Marie Landgren, professor of gynecology at Karolinska University Hospital says in an interview with Expressen (2004-11-02) that this type of research has low priority, and it is almost impossible to get funding. She believes therefore that there is a need for creating a body of opinion that these issues get sufficient attention [3]. The first study done on this type of problem was performed by Dr. Sandor Takac in Novi Sad, Serbia. He treated eight women with severe menstrual problems. It turned out that all but one had a significant relief. Treatment was carried out with a therapeutic laser, GaAs 904 nm, 15 mW × 4 [8].

Subjects of the present study
Two advertisements in two newspapers sought women who wanted to participate in the study. The women who wished to participate in the study were informed that participation was voluntary and that at any time during the study could cancel his participation without giving a reason. The subjects were guaranteed that their responses would be kept confidential and not be disclosed in any form. The study was conducted on 20 women who claimed to have very sharp pains during menstruation but healthy in general. A total of 20 women were included. No age limit was set for participation, but the expectation was that women under 30 who suffer from severe menstrual pain would be involved. This turned out not to be entirely correct. Eight of the women were over the age of 30 and four of them over 40 years. The oldest woman was 54 years old.

Survey
At the first visit, all subjects filled in a log sheet. They were unaware how lasers work and were told that the results and effectiveness can vary from person to person. Two follow-ups were made, after four sessions and after eight sessions of LLLT

Treatment
All subjects received its first reading at baseline and at each visit booked the time for the next treatment. All eight treatments were performed. The study started in week 24 (June 9) and lasted for eight to ten weeks. All subjects received a treatment every week and each treatment took about 15 minutes. The subject was resting on a comfortable massage table. They did not undress other than to the lower abdomen. The laser light coming out of a probe was held in light contact with the skin. The probe was placed directly over each ovary during five minutes and then over the uterus. Among all subjects only one had children. All women considered themselves to be fully healthy and not having any serious illnesses. The subjects were asked if there is anyone else in the family with severe menstrual disorders. Figure 2 shows that about 45% had a family member who also suffers or have suffered from the same problems. Approximately 65% of the women had regular and 35% had irregular periods.

Throughout the study no difference was reported in the typical menstrual period. Nearly all had the same typical menstrual period as they had before, except a person after 8 sessions who claimed she had longer menstrual period compared to before. Bleeding was changed for some participants. Some subjects experienced less bleeding and less blood clots after LLLT.

Some women had sleep problems and other disorders such as migraine, itching, burning and swelling during menstrual period. Tables 1 and 2 show the effect of laser treatments of these disorders: Out of a total of ten participants who responded that they had sleep problems had better sleep after laser treatments (70%). Even person number 4 who did not report sleeping problems had improved sleep. Of a total of eight participants who had other symptoms during menstruation, five reported reduced discomfort after laser treatments (62.5%). Satisfaction rate with laser treatments was about 2 degrees higher than the satisfaction rate with pharmaceuticals.

Discussion
An analysis of the study results showed that 14 of 17 (82%) had a significant pain relief. Most participants felt slightly more comfortable during menstrual periods by having improved sleep (about 70% of those who had sleep problems) and less menstruation-related disorders (about 60% of those who had other problems). The period length was unchanged but some volunteers experienced decreased bleeding after the treatments. This is considered as a positive effect when heavy bleeding brings iron deficiency, less energy and fatigue. Satisfaction rate of laser treatments was higher than for drugs.

The results of the study showed that it would be enough with only four treatments for those who react well to laser treatments. One would rather have been able to plan the final four treatments to be a treatment every two weeks so that the effect of the treatment could be maintained during a longer period. Time limitations in this study did not offer this opportunity. Results of the study showed that the result in each case is not guaranteed. This was well with our expectation that everyone would not get the same results when all individuals are different.

Is it possible to continue or develop the study?
This study showed that “tales” about pain relief with therapeutic laser are true and we therefore believe that it is worthwhile for improving the approach and develop a larger study. Improvements can be made in many different directions:
• A better method of pain measurement. Prostaglandin levels in the blood during the menstrual period can measure the real degree of pain. It is not certain that there is proportionality between the experience of pain and prostaglandin levels, however it is an objective parameter.
• A longer period of study allows for more follow-ups and you can really see how long the effect of laser treatments last.
• More subjects allows for a larger study, where you can group the subjects with respect to their age, whether they have children or not have children, the pain level, family history, etc. and thus analyze the performance of each group and compare with other groups.
• A randomized double-blind study is more appropriate to publish in scientific journals. However, this is not possible until you have a bigger group with more volunteers.

Conclusion and the most important results
• The results show that therapeutic laser has a significant effect even in the treatment of menstrual pain.
• The study also showed that laser therapy not only has the same analgesic effect as pharmaceuticals, but that the subjects were more satisfied with laser than with drugs.
• The study showed that laser therapy allows for a more comfortable and less painful life for women with extremely difficult menstrual period without having to consume large doses of pharmaceuticals.

References

References to electronic sources
[1] http://www.rfsu.se/har_du_mens_eller_.asp 2008-08-01 kl.14.14
[2] http://netdoktor.passagen.se/default.ns?lngItemID=3554 2008-08-01 kl.12.03
[3] http://netdoktor.passagen.se/default.ns?lngItemID=3555 2008-07-21 kl.13: 15
[4] http://www.slms.org/pdf/laser-som-laeker.pdf 2008-11-01 kl.22.15

Book and journal references
[5] Wallace JL. Nonsteroidal anti-inflammatory drugs and gastroenteropathy: The Second Hundred Years. Gastroenterology 1997; 112: 1000-16.
[6] Bjordal JM, Lopes-Martins RA Iversen VV. A randomized, placebo-controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 Concentrations. Br J Sports Med. 2006 Jan; 40 (1): 76-80
[7] Bjordal JM, Johnson MI, Iversen V, Aimbire F, Lopes-Martins, RA. Photoradiation in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed Laser Surg. 2006 Apr; 24 (2): 158-68
[8] Presented by Takac S. at the Swedish Laser-Medical Society’s Spring meeting in 2001.
[9] Gür A. et al: Efficacy of 904 nm gallium arsenide Low Level Laser Therapy in the Management of Chronic Myofascial Pain in the Neck: A Double-Blind and Randomized-controlled trial. Lasers in Surgery and Medicine 35: 229-235 (2004).
[10] Kreisler MB et al: Efficacy of low level laser therapy in reducing postoperative pain after endodontic surgery - A randomized double blind clinical study. Int. J. Oral Maxillofac. Surg. 2004; 33: 38-41.
Reference to personal communications
[11] Dr. Göran Holmberg MD, gynecologist. 2008, Irradia Laserklinik, Norra Hamngatan 3-5, 115 42 Stockholm, Sweden

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