April R Vance, Sherrill H Hayes and Neil I Spielholz

Microwave Diathermy Treatment for Primary
Dysmenorrhea
April R Vance, Sherrill H Hayes and Neil I Spielholz
PHYS THER. 1996; 76:1003-1008.
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Microwave Diathermy Treatment for
Primary Dysmenorrhea
This case report documents the use of microwave diathermy in a
31-year-old woman who had had primary dysmenorrhea since menarche began at age 13 years. For 18 years, she had severe monthly pain,
frequently resulting in emergency department admissions and 1 to 3
days lost from work. Conventional treatments, including pain-relieving
drugs, anti-inflammatory drugs, muscle relaxants, superficial heat, and
oral contraceptives, had all been unsuccessful in relieving or abating
the intense and debilitating pain. Microwave diathermy (45 W total
power) was administered for 20 minutes each month on the day
symptoms began (usually the first day of menstruation). Over a
7-month interval, diathermy was followed by almost-immediate and
long-lasting relief of symptoms. During the 7 months of treatment, the
patient lost no workdays due to severe pain. This case demonstrates the
potential use of microwave diathermy as an effective treatment for
women with this condition. [Vance AR, Hayes SH, Spielholz NI.
Microwave diathermy treatment for primary dysmenorrhea. Phys Ther.
1996;76:1003-1008.1
Key Words: Diathermy, Dysmenorrhea, Physical therapy.
April R Vance
Sherrill H Hayes
Neil I Spielholz
Physical Therapy . Volume 76 . Number 9 . September 1996
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Primary
ysmenorrhea (painful m e n ~ t r u a t i o n )affects
~
between 40% and 95% of menstruating women.' Two types of dysmenorrhea have been
identified: primary (associated with normal
ovulatory menstrual periods and normal pelvic examination) and secondary (associated with pathology, as in
pelvic inflammatory disease, endometriosis, or use of an
intrauterine
Primary dysmenorrhea, the subject of this case report, is one of the most frequent
gynecologic disorders, with about 10% of women
affected being incapacitated for several days each
month.2 Primary dysmenorrhea has been estimated to
cause the loss of 140,000,000 work hours a n n ~ a l l yIt. ~is
the single greatest cause of absence from school and
work among women of menstruating age.
D
Symptoms of primary dysmenorrhea are the following:
Pain is spasmodic and is usually felt in the lower abdomen, although sometimes the pain radiates to the back
and thighs; the pain usually begins just before or at the
onset of menstruation; and other symptoms may include
nausea, vomiting, headache, diarrhea, low back pain,
dizziness, and, in severe cases, syncope and collapse. The
symptoms last from several hours to several days, rarely
exceeding 3 days, and tend to decrease or disappear
after the individual has experienced childbirth the first
time and to decrease with age.2
The pain of primary dysmenorrhea is believed to be due
to increased prostaglandin production by the endometrium, leading to increased contractility of the myometrium and resultant i s ~ h e m i a .The
~ . ~ use of prostaglandin inhibitors (eg, ibuprofen, aspirin), which block
prostaglandin synthesis, is the primary pharmacological
treatment to manage the pain of primary dysmenorEndometrial prostaglandin synthesis is also
inhibited by progesterone, which is why oral contraceptives are often prescribed to reduce the severity of
primary d y s m e n ~ r r h e a .Oral
~ , ~ contraceptives also have
been used to suppress ovulation, as primary dysmenorrhea occurs only if preceded by o v u l a t i ~ nPsychological
.~
support has been offered, although primary dysmenor.~
rhea is not a behavioral or psychologic d i ~ o r d e rPhysical therapy has offered transcutaneous electrical nerve
stimulation (TENS), heat, and exercises,' although exercise does not influence the severity or prevalence of
dy~menorrhea.~
is
A MEDLINE search
encompassing the period
1966 to June 1995yielded
no
research reports relatCause of absence
ing to the use of diafrom S C ~ O Oand
~
thermy
for
primary
dysmenorrhea. A search
work among
using the key words "prim a y dysmenorrhea and
women of
TENS" yielded five artic l e ~ . All
~ - of
~ these artimenstruatingage*
cles described studies of
patients with primary
dysmenorrhea
using
TENS and ibuprofen compared with ibuprofen only and
found that subjects required a lesser dosage of ibuprofen
for pain management with the addition of TENS. Smith
and Heltze15 found that although TENS decreased the
pain of dysmenorrhea, uterine contractions continued.
This finding gives credence to the belief that uterine
activity causes pain in primary dysmenorrhea and that
TENS provides analgesia by an alteration of the body's
ability to receive or perceive the pain signal.
the
greatest
Pelvic inflammatory disease (PID), although distinct
from primary dysmenorrhea, causes similar symptoms of
severe debilitating pelvic and abdominal pain, often
accompanied by nausea and vomiting, which is unresponsive to traditional pain-relieving medications, antibiotics, or modalities. Although the exact cause of primary dysmenorrhea is unknown, PID is caused by
bacterial infections, the most common of which are
Neisseria gonomhoeae and Chlamydia trachoma ti^.^ Using the
key words "diathermy and pelvic inflammatory disease,"
a second MEDLINE search yielded only one reference, a
case reportg in Physical TherapV. The patient had constant
and diffuse abdominal pain radiating to the lumbar
region due to PID. Following a series of nine treatments
with shortwave diathermy (SWD) over a short period of
time (less than 3 weeks), the patient was pain-free, and
remained so for 6 months after treatment (at the time
the case report was written).
A review of recent physical therapy textbooks uncovered
three references that describe the treatment of PID with
either SWD or microwave diathermy (MWD), but these
references were not research based.lO-l2 A review of
AR Vance, PT, BSN, is Co-owner, Relax-the-Back Store, 2020 Glen Echo Rd, Nashville, TN 37215 (USA) ([email protected])
Address all correspondence to Ms Vance.
SH Hayes, PhD, PT, is Professor and Director, Division of Physical Therapy, University of Miami School of Medicine,
5915 Ponce de Leon Blvd, Coral Gables, FI, 33146.
N1 Spielholz, PhD, PT, is Associate Professor, Division of Physical Therapy, University of Miami School of Medicine
Thzs article was submztled October 10, 1995, and was acceptecl June 11, 1996.
1004 . Vonce et
01
Physical Therapy. Volume 76 . Number 9 . September 1996
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rehabilitation medicine textbooks written before 1960
also yielded descriptions of SWD and MWD in treating
PID (usually secondary to gonorrhea), with references to
earlier research papers.13 More recent rehabilitation
medicine textbooks, if they d o mention PID, still refer to
articles written in the 1930s and 1940s, o r to the book
chapters mentioned earlier.14.15Antibiotics have apparently lessened the need for "deep heatingn techniques in
treating patients with PID from the medical management perspective. Nothing could be found in the literature documenting the use of either SWD or MWD in
treating patients with primary dysmenorrhea.
Diathermy utilizes high-frequency electromagnetic
waves to heat deep tissues, especially those with high
water content. Presumably, dissolved molecules and ions
oscillate at the frequency of the reversing electromagnetic field, generating heat. Skin, especially when dry,
contains relatively little water, and thus becomes only
mildly heated. Deeper structures, such as muscle, extracellular fluid, and blood, are heated more selectively.
Microwave diathermy utilizes higher-frequency electromagnetic waves than does SWD (2,450 MHz versus 27.12
MHz) . These higher-frequency transmissions, generated
by a magnetron," are focused and "beamed" into the
tissues from varying distances. The selection of SWD or
MWD is correct when the desired treatment outcome is
to raise tissue temperature, increase extensibility of deep
collagen tissue, decrease joint stiffness, relieve deep pain
and muscle spasm, increase blood flow, and assist in the
resolution of inflammation.I2 Potential hazards with
either type of diathermy are from internal and external
metallic objects and electromedical devices at the treatment site, including metal implants and metallic intrauterine devices. People using metallic intrauterine
devices should not receive either diathermy modality to
the lurrtbar, pelvic, or abdominal area." In addition,
SWD and MWD are generally contraindicated in the
presence of hemorrhage.
The frequencies used for SWD and MWD are too fast to
depolarize nerve or muscle membranes. Thus, neither
innervated nor denervated muscles contract." This factor is important because the pain of primary dysmenorrhea is believed to be caused by the contraction of the
muscles of the uterus2 and further contraction of these
muscles would not be desired. The Federal Communications Commission regulates the frequencies that can
be generated by medical devices. In the United States,
the assigned frequencies for SWD are 13.56, 27.12, and
40.68 MHz, whereas 2,450 MHz is reserved for MWD.
The effectiveness of diathermy treatment depends on its
intensity and duration.12 A recent German article
reported close correlations between magnitude of blood
Table 1.
Definitions of Dosage, According to Kloth"
Dose
Level
Definition
I
Lowest
II
Low
111
Medium
IV
Heavy
Just below the point of any sensation of
heat (acute inflammatory process)
Mild heat sensation, barely felt
(subacute, resolving inflammatory
process)
Moderate, but pleasant, heat sensation
(subacute, resolving inflammatory
process)
Vigorous heating that produces a welltolerated sensation (chronic
conditions; the pain threshold may be
reached, but the output is
immediately lowered to just below
maximal tolerance)
flow, length of treatment, and therapeutic intensity. The
20-minute treatment was the most effective treatment.16
Therapists must use the patient's heat-sensation
response as a guide for dosage. Table 1 defines the four
types of dosages that are used." Documentation of
treatments should include the following: (1) type of
electromagnetic energy; (2) commercial model name;
(3) type of applicator used; (4) description of where on
the body the applicator was applied or directed;
(5) duration of treatment; (6) power output level;
(7) pulse frequency and duration, if pulsed diathermy is
used; and (8) the patient's response to the treatment.
Case Description
The patient was a 31-year-old woman who complained of
extremely painful cramping, beginning with her initial
menses at age 1 3 years. She was subsequently diagnosed
with primary dysmenorrhea. The history revealed c r a m p
ing severe enough to warrant regular monthly visits to
the emergency department. The emergency department
visits were necessitated, according to the patient, due to
the increase in severity of pain throughout the day and
the unavailability of her physician in the evening. Her
signs and symptoms included severe pelvic and abdominal pain lasting 3 days, accompanied by the passage of
large clots, the inability to stand erect (due to pain),
nausea, vomiting, headaches, backaches, and hot flashes.
She described the pain as a "killing pain," which kept her
awake at night. During this time, if untreated, she was
reduced to tears and remained in bed until the symptoms subsided sufficiently to resume regular activity.
When seen in the emergency department, treatment
consisted of powerful pain-relieving drugs (Demerol,
administered intramuscularly) and return home with
prescribed Tylenol #3. Home treatments of heating pads
applied to her pelvis and back were minimally effective.
These periods of pain made it impossible for her to
attend school o r work or to care for her husband and
two small children. She missed 1 to 3 days of work per
Physical Therapy. Volume 76 . Number 9 . September 1996
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Vance et al
. 1005
All treatments were given with a TAG MED model TDS
2450-2 MWD system.* A circular applicator with a
16.25-cm diameter was used to deliver all treatments
(Figure). During each treatment, the patient was positioned side lying with the applicator placed anteriorly
15.24 cm (6 in) from her area of pain, the pelvic region.
Power options on the TDS 2450-2 hWD system were
"low" (0-15 W) and "high" (0-150 W) . The dosage was
selected by the patient's reports of a moderate, yet
comfortable, feeling of warmth. This dosage corresponded to a level I11 dosage, as defined in Table 1.
During each treatment, the patient received 45 W of
total power for 20 minutes. As the patient had no loss of
sensation and no damp clothing or clothing with metal
objects, all treatments were delivered through her clothing. She received one treatment per month as needed,
except during the first month (September), when she
received one treatment on two consecutive days due to
the severity of her pain.
Figure.
Position of patient during treatment with the TAG MED model TDS
2450-2 microwave diathermy system.
month because of pain due to primary dysmenorrhea.
Her physician had stated the possibility of a decrease in
her symptoms after the birth of her children and subsequent use of oral contraceptives, but her symptoms
remained undiminished and continued to disrupt her
life.
The decision to try a deep heating technique with this
patient was based on the following reasoning. A superficial heating technique (hot packs) had afforded slight
and temporary relief, and a deeper heating technique
may more effectively heat the uterus and have a better
pain-relieving effect by improving blood flow through
the myometrium, thereby facilitating "washout" of the
presumed pain-producing substance, prostaglandins.
Although hemorrhage, or uncontrolled bleeding, is considered a contraindication for deep heating, the
patient's physician did not classify her menses as "uncontrolled bleeding." It was therefore decided to move
ahead cautiously with a deep heating technique.
After written permission was obtained from the patient's
physician and it was determined that she had no metal
implants or intrauterine devices, monthly treatments of
MWD were instituted. Each treatment was initiated on
an as-needed basis the day her symptoms began, which
usually coincided with her first day of menstruation. This
schedule was facilitated because she worked at the
medical center where she received physical therapy.
The patient used a pain scale (0-10) similar to that used
by Balogun and Okonofuag to measure her levels of pain
at four different time intervals: (1) before treatment,
(2) immediately after treatment, (3) 6 hours after treatment, and (4) 24 hours after treatment. The definitions
given to this scale (for the patient's reference) included
O=pain-free, 5=enough pain to stop activity, and
lO=the need to go to the emergency department.
Table 2 summarizes the patient's pain ratings according
to the months her pain was monitored (September
1993-March 1994) and the time intervals for the rating
of her pain before and after each treatment.
Outcomes
Initially, the patient required two treatments 24 hours
apart. On the first day, her pain was rated 9/10, with the
accompanying symptoms of intense nausea, vomiting,
backache, headache, hot flashes, and the inability to
stand erect. Immediately after treatment, she rated her
pain as 1/10. On the second day, she rated her pain as
4/10 and was experiencing the accompanying symptoms, although they were less intense than during the
previous day. All pain and symptoms experienced on the
second day resolved after the second diathermy treatment. This was the only time she required two consecutive days of treatment.
In October, the patient rated her pain 0/10 (no pain) at
the onset of her menses. This was the first month without
pain or the accompanying symptoms since her initial
menses at age 13 years. No treatment was given during
the month of October. The pain in November was rated
6/10 before treatment and 2/10 immediately after treatment. During the 6 and 24hour time periods following
'TAG MED Inc, Boulder, CO 80302.
1006 . Vance et al
Physical Therapy. Volume 76 . Number 9 . September 1996
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Table 2.
Pain Rating on a
0 to 10 Scale Before and After Microwave Diathermy (MWD) Treatment for Primary Dysmenorrhea
September
1993
Time of Pain Measurement
Day 1
Day 2
October
1993
November
1993
December
1993
January
1994
February
1994
March
1994
Before M'ND
Imrnediatt$lyafter M W D
6 hr after M W D
24 hr after M W D
9
1
1
4
4
0
0
0
0
0
0
0
6
2
0
0
4"
0
0
0
0
0
0
0
8
3
3
0
0
0
0
0
"Therapist was no1 available for treatmen1 on this day; pain was managed with analgesics.
treatment, she reported no pain. On the day of the
patient's onset of menses in December, her therapist was
ill and not available to deliver the treatment. Her pain,
however, was rated 4/10 and was manageable with
ibuprofen taken every 3 hours. She was also able to
perform her work duties without interruption. No treatment was given in January, when she again reported
having n o pain. In February, the patient rated her pain
8/10 before treatment, which was reduced to 3/10
immediately and 6 hours after treatment. She was painfree 24 hours after treatment. During March, the last
month monitored, she was also without pain and no
treatment was delivered.
The patient reported that she had never experienced a
pain-free menses before treatment began. She also
reported that after the treatments began, her menstrual
flow reduced slightly and there were fewer blood clots.
This remained consistent throughout the monitored
months. She reported her accompanying symptoms
(nausea, hot flashes, vomiting, backache, headache) also
were reduced or resolved in correlation to her pain.
During the 7 months from September 1993 to March
1994, she lost no workdays due to her primary dysmenorrhea. A follow-up contact was made in August 1995,
and the patient reported she no longer had diathermy
treatmerits and that although some months were worse
than others, she had not lost workdays due to her
primary dysmenorrhea. She managed any pain with
ibuprofen only.
Discussion
It is interesting to speculate about possible mechanisms
to expla.in the outcomes for this patient. If uterine
contractions cause the pain4-Qnd deep heat relieves
perhaps uterine
deep pain and muscle spasm,10-12~15,17
relaxation occurred with a concomitant decrease in
pain. Furthermore, increased blood flow caused by
heating the uterus may have facilitated "washout" of the
prostaglandins, which also have been implicated in
causing the myometrial contraction^.^.^
This case report documents potentially beneficial effects
of MWD in a patient with primary dysmenorrhea. It is
Physical Therapy . Volume
likely that the technique has not been used much in the
past due to hesitancy to use a deep-heating modality in
an area that is bleeding (as in menstruation). This case
suggests, however, that careful application in a cooperative patient with intact sensation, who is bleeding but
not hemorrhaging, may be done safely. Obviously, treatment must cease immediately should bleeding become
pronounced. Furthermore, in this case, treatment was
rendered in a medical facility with easy access to emergency personnel and equipment, should that need have
occurred.
The potential success of this treatment for women with
severe primary dysmenorrhea suggests that the approach
warrants further study. The treatment also may be costeffective if it eliminates overuse of an emergency department for relief of pain, eliminates lost workdays due to
illness, and improves the patient's ability to care for her
family without lost days due to pain and inability to
function. Suggestions for research on the use of diathermy in patients with primary dysmenorrhea are to
apply this treatment to a larger group of similarly
affected patients, to contrast the effectiveness of diathermy compared with TENS for patients with primary
dysmenorrhea, and to compare the effectiveness of SWD
with that of MWD in alleviating pain in patients with
primary dysmenorrhea.
References
1 O'Connor- LJ, Gourley RJ. Obstetric and Gynecologar Care. Thorofare,
NJ: Slack Inc; 1990:91-95.
2 Thomas CL, ed. Taber's Cyclopedzc n;ledzcalDzctzonn~y.Ph~ladelph~a.
Pa:
FA Davis Co; 3993:591-592, 1452-1453.
3 Scott JR, DiSaia PJ, Harnmond CB, Spellacy WN. DanforthS Obsl~trics
and Gynecology. Philadelphia, Pa: JB Lippincott Co; 1994:678-679.
4 Kaplan B, Peled Y, Pardo J, et al. Transcutaneous electrical nerve
stimulation (TENS) as a relief for dysmenorrhea. Clin Exp Obstrt
Gynecol. 1994;21:87-90.
5 Smith RP, Heltzel JA. interrelation of analgesia and uterine activity in
women with primary dysmenorrhea: a preliminary report. JReprod Med.
1991;36:260-264.
6 Dawood MY, Ramos J. Transcutaneous electrical nerve sti~nulation
(TENS) for the treatment of primary dysmenorrhea: a randomized
76 . Number 9 . September 1996
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Vance et al
. 1007
crossover comparison with placebo TENS and ibuprofen. Ohstet
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12 Kahn J . Principks and Practice ofElertrotheropj~.2nd ed. Nrw York, N Y
Churchill Livingstone Inc; 1991:18.
7 Lewers D, Clelland JA, Jackson JK, et al. Transcutaneous electrical
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1989;69:3-9.
13 k u s e n F. Physical Medicine. Philadelphia, Pa: WB Saundel-s Co;
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8 Lundeberg T, Bondesson L, L.uiidstrom V. Relicfof prin~arydyamen01-rhea by Lranscutaneous electl-ical ~ ~ c n .stin~ulalion.
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Acfa Obstvt
Qnec.01 Scc~nd.1985:64:4Y1-4147.
14 Kottke FJ. Heat in pelvic diseases. In: Licht S, ed. Therapeutic Heat
ond Cold. New Haven, Conn: Elizabeth Licht, Publisher; 1958:405-406.
9 Balogun JA, Okonoliia FE. Managcn~cr~t
ot'chroriic pelvic inflammat o ~ ydisease with sl~ortwavediathermy. Phys 7ket. 1988;68:1.541-1545.
15 1.ehrr1annJF, De Lateur BJ. Diatheriny and slipel-ficinl heat, laser,
and cold therapy. In: Kottke FJ. 1,ehmann JF, eds. Krusen's Handbook of
Physic01 Medirirre and Rehabilitation. 4th ed. Philadelphia. Pa: WB
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10 h h n J . Electrical modalities ill obstetrics ant1 gynecology. 111:
Wilder E, ed. Obstetrir o n d C+nrrologic I'~,\iccil ?'/~o.c~py.New York, NY:
Churchill Livingstone lric; 1988:I I :4-129.
16 Pages 1H. Circulatory changes in local and segmental use of
shortwave diathermy [in German]. Win,KIin M'ochenshr. 1993;105:216219. English abstract.
11 Kahn J. Physical agents: electrical, soriic. and radiant modalities. in:
Scully RM, Barnes MR, eds. Physical Th~rapy.Philadelphia, Pa: JB
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17 Kloth L. Shortwave and microwave diathermy. In: Michlovitz SL, ed.
Thrrrnol Agents in Rehabilzfafion.Philadelphia, Pa: FA Llavis Co: 1986.
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1008 . Vance et al
Physical Therapy. Volume 76 . Number 9
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. September 1996
Microwave Diathermy Treatment for Primary
Dysmenorrhea
April R Vance, Sherrill H Hayes and Neil I Spielholz
PHYS THER. 1996; 76:1003-1008.
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