Prevalence and effective treatment for Dysmenorrhea and menstrual cramp pain

 What are prevalence and effective treatment for Dysmenorrhea and menstrual cramp pain? 

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Runninghead:

Dysmenorrhea and Menstrual Cramp Pain

Dysmenorrhea and Menstrual Cramp Pain

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Prevalence and effective treatment for Dysmenorrhea and menstrual cramp pain

Miya Chambley

Alabama A&M University

Literature Review

Dysmenorrhea or menstrual pain is the medical name given to pain during the menstrual cycle. To review the prevalence and treatments related to dysmenorrhea, the cause, and the type of medical condition need to be understood. In this study, the type, cause, and effective treatment for menstrual pain will be studied.

Dysmenorrhea:

Dysmenorrhea is the medical word used for pain attached to menstruation. Such pain is often caused by the contraction of the uterine and starts with the onset of menstruation and lasts for more or less three days (MY, 1990). Apart from the pain around the pelvic or abdomen region, there are other symptoms associated with it are diarrhea, nausea, and back pain.

Based on their origin, dysmenorrhea has been classified into two types, primary and secondary. Primary dysmenorrhea specifies the common menstrual pain, whereas secondary dysmenorrhea is caused by the disorder in the reproductive organs.

Primary Dysmenorrhea:

Primary dysmenorrhea refers to the pain that occurs in the lower abdomen just before or after the onset of menstruation. This type of dysmenorrhea is 90% common and typically occurs during adolescence. Women who experience such pain are reported to have an increased level of endometrial prostaglandin, which causes enhanced uterine tone, and stronger, frequent uterine contractions.

Prevalence of Primary dysmenorrhea:

Primary dysmenorrhea is the most commonly reported problem associated with menstruating women. This occurrence of such pain is so common that often it is not reported during the medical examination or interviews. (Yu, 2014) However, the informed prevalence of such pains is as high as 90%. According to a prospective study conducted on college students in one year, 72% of the observed periods were painful, mostly at the start of the menstruation cycle. The study also reported that 60% of the observed women experienced a period of severe pain.

Furthermore, primary dysmenorrhea was reported to be the primary factor behind absenteeism from school and work. A study conducted on women studying in college reported that almost 42% of subjects showed absenteeism or minimal activity once a month; however, the absentees reported ranged from 34 to 50%. (Harel, 2012) Furthermore, another study showed that primary dysmenorrhea was responsible for a loss of 600 million work hours and a 2$ billion dollar lost in productivity each year.

Factors Associated with Primary Dysmenorrhea:

The study showed that there are certain serious factors that have been linked with severe periods of dysmenorrhea, such as early age for menstruation, prolonged menstruation period, overweight, high alcohol consumption, and smoking. However, some studies have not found any substantial linkage between severe dysmenorrhea and obesity and alcohol consumption. Another report, which was conducted through a cross-sectional sample of 1,147 metropolitan adolescents, presented that trying to lose weight was connected with enhanced menstrual pains. Furthermore, no physical activity was found to be associated with increased pain.

There was inconsistent data to validate the view that dysmenorrhea diminished after child-birth. In one study (Sundell G, 1990) presented evidence of reduced prevalence and intensity of dysmenorrhea after parity, but other studies did not support the view. (MY, 1990) Provided that potential for decreasing dysmenorrhea might offer inspiration for women to implement healthy lifestyle changes, such as reduction or ceasing alcohol and smoking consumption.

Causes of Primary dysmenorrhea:

Though the causes of primary dysmenorrhea are not surely reported, the most common symptoms can be described by the action of uterine prostaglandins, also known as PGF. Throughout endometrial removal of dead cells, the degenerated endometrial cells discharge PGF, when menstruation begins. PGF after release stimulates the myometrial retrenchments, sensitization of nerve endings, and ischemia. Production of arachidonic acids and the path cyclooxygenase gets triggered by a drop in progesterone concentration near the end of the secretory phase (Iacovides, 2015). In the late secretory phase, the levels of PG are three times higher than in the proliferative phase. Moreover, during the menstrual phase, the level of PG is again observed to be higher than usual; this higher concentration of PGE2 and PGF2 are observed in women suffering from primary dysmenorrhea.

This theory has been strongly supported by the clinical data, achieved from women who experience severe dysmenorrhea. According to the report, women with severe dysmenorrhea have a higher level of PGF, specifically during the first two days of the menstrual cycle. There are some studies (Ortiz, 2010)which have associated increased levels of leukotrienes and vasopressin, but the connection is still not established.

Clinical Presentation and Diagnostic:

Primary dysmenorrhea usually occurs during the adolescences during the timespan of three years after the first menstruation. (Osayande, 2014) The dysmenorrhea symptoms usually do not start after the first three or six months of menarche. Women experiencing dysmenorrhea feel sharp, recurrent contractions of pain generally centered in the suprapubic area. The pain might be in the lower back or in legs. The fairly common symptoms associated with it are nausea, vomiting, lightheadedness, fever, and headache. The pain usually advances after a few hours of the start of the menstruation cycle and its intensity increases with the flow during the first or day two of the cycle.

Physical examination and thorough patient history are adequate to diagnose primary dysmenorrhea. The history shows the typical cramping pain associated with the menstrual cycle, and the physical examination is normal. The chances of secondary dysmenorrhea can be ruled out by inquiring about the age at which the menstrual cycle begins, the length of the cycle, the consistency and timing of the pain. Moreover, dysmenorrhea can be differentiated from Premenstrual Syndrome (PMS) by considering the patient’s history. Since the pain associated with PMS is connected with breast tenderness and abdominal swelling, rather than lower abdominal pain.

The PMS symptoms can be observed before the starting of the menstrual cycle and settle shortly after the flow of menstrual begins. Moreover, the pain related to Endometriosis may seem as progressive dysmenorrhea, but it is often supplemented by pain felt during intercourse and might impact the fertility rate. Apart from the timing of the pain, a patient’s family history might also help in differentiating the endometriosis from primary dysmenorrhea.

Possible treatments for Primary dysmenorrhea:

The most commonly administered treatment that shows individual improvement in women suffering from primary dysmenorrhea is the NSAID treatment (Kaplan, 2013). Many studies point to a successful pain release in 64 to 100% of the patients. (Harel, 2012) These known drugs have a record of efficiency confirmed by numerous studies over the past 20 years. Another actual and well-studied choice for treatment, especially among women who want to control the birth process, is oral contraceptives. Studies have shown that oral contraceptive has proven to be an effective treatment for 90% of women suffering from primary dysmenorrhea (Dmitrovic R. K., 2012). There is another alternative, for 10% of the women who do not respond to such treatments, stretching from laparoscopic procedure to acupuncture, but the evidence to support both these treatments is insufficient.

Non-Steroidal Anti-Inflammatory Drugs:

The most commonly adopted and first choice for the treatment of primary dysmenorrhea is an NSAID. The medicines under this category work by inhibiting the production and discharge of prostaglandins. As stated earlier, prostaglandins are the source of painful uterine contractions and are known as a consistent symptom for primary dysmenorrhea, along with diarrhea and nausea. The choices under the category of NSAID are many, and no specific NSAID has been confirmed to be more effective than others in treating this particular condition. The response time for treatment with NSAID is noted to be 35 to 60 minutes. However, the response is subjective, and it is advised to use a different agent belonging to a different class if the ache is not relieved after the usage of the first agent.

NSAIDs have proven to be quite effective and are widely available without the use of prescription, but there are many women who are not developing an effective routine for the treatment. (Yu, 2014) The study pointed out that almost 25% of women experiencing primary dysmenorrhea administered less than the suggested dosage of medication, and 43% were not able to grasp the maximum daily frequency. It is advised that patients should be questioned about over the counter drugs, including the amount of the dosage, specifically from younger patients.

Oral Contraceptives:

Oral contraceptive is the second option for women suffering from primary dysmenorrhea, specifically for women who also wish to have birth control. The mechanism of oral contraceptives is totally different from that of NSAIDs. The system of oral contraceptives has been divided into two steps; in the first step, the menstrual fluid volume is reduced, and in the second step, the ovulation process is being suppressed. (Dmitrovic R. K., 2012) Studies have shown that such treatment for primary dysmenorrhea is 90% effective. (Pearlstein, 2012) Studies trying to prove the efficiency of triphasic preparations over the monophasic or on progesterone component have been found inadequate, and all oral contraceptive has been found effective parallel to the placebo.

The patients administered with oral contraceptives should be informed about the three-cycle it takes to diminish the pain. Furthermore, along with oral contraceptives, it is better to prescribe the NSAID for pain relief during the interim period. (Osayande, 2014) A study conducted on 308 pubescent females, with severe symptoms of primary dysmenorrhea, administered with oral contraceptives, were 8 times more likely to be a consistent user of such medications. It is believed that advising young women about the potential benefits of oral contraceptives might improve their motivation to fulfill daily medication. Moreover, the patients should be inquired about their medical history, specifically cardiovascular disease, hepatic, thrombosis, and current pregnancy status.

The combination of NSAID and oral contraceptive are considered an effective treatment, specifically for rebellious cases. Furthermore, electric nerve stimulation Units (TENS), laparoscopic presacral neurectomy, omega-3, transdermal nitroglycerine, and thiamine offer relief to primary dysmenorrhea, but the number of studies on these options was small and less followed up.

Alternative Medicine:

Though there is not sufficient data that support the usage of herbal or supplementary material to cure dysmenorrhea, these alternative methods are the first choice of many women experiencing the pain (Mirabi, 2014). The common ingredients or herbs used for treating the pain associated with dysmenorrhea are vitamin e, fennel, chamomile tea, cinnamon tea, rhubarb, and melatonin. The dietary supplements that are commonly administered to control the pain are zinc-sulfate, omega-3 capsules, and vitamin-B1. The research evidence for the safety of these supplements is insufficient, and further research is recommended. (Rahbar, 2012) The study suggests that thiamin, omega-3, and vitamin E are likely to be effective in curing the pain. Furthermore, Chinese Traditional Medicine (TMC) is another alternative method widely used in Asian countries. However, the evidence to support the administration of TMC was partial by poor methodological quality. (Liu, 2011)Cochrane review on acupuncture for treating primary dysmenorrhea concluded that the effectiveness of acupressure or acupuncture is unknown.

Secondary Dysmenorrhea:

Secondary dysmenorrhea discusses the painful menses that is caused by the pelvic pathology or documented medical condition. Endometriosis is one of the major causes of secondary dysmenorrhea in adolescent women and is mostly associated with patients who have a long history of persistent dysmenorrhea, despite being treated with NSAID or different hormonal agents.

Endometriosis as the main cause of Dysmenorrhea:

Endometriosis is defined as an estrogen-dependent inciting disease described by abnormal growth endometrial stromal tissues and glands. (Bulletti, 2010)The disease is reported to affect 5 to 15% of women during the reproductive age. Some women suffering from endometriosis do not tend to have any symptoms, whereas other women present symptoms such as dysmenorrhea, reduced fertility, and dyspareunia.

Endometriosis is considered a benevolent disease. However, there are many studies that suggest endometriosis as an autonomous risk factor for endometrioid ovarian carcinoma and clear-cell carcinoma (Gadducci, 2014).

Causes of secondary dysmenorrhea or endometriosis:

It has been observed that the concentration of PGs is greater in menstrual blood of the women suffering from endometriosis. (Bulletti, 2010) Bulletti, establish that in women suffering from endometriosis pain, the occurrence, basal pressure, and the amplitude of uterine retrenchments are higher. Thus the women with endometriosis experience high-intensity pain during their menstrual cycle. Moreover, the endometriotic abrasions and bonds might also be the cause of endometriotic pains.

The most accepted theory for the cause of endometriosis is that the ebb tide of menstrual tissue comes into the pelvic peritoneal cavity and implants into intra-abdominal areas. (Bendon, 2012) The theory is reinforced by the fact that the most affected site is nearest to the fallopian tubes. Moreover, endometriosis is common among women without discharge obstruction such as a slanting vaginal septum, imperforate hymen, and cervical stenosis.

Women suffering from secondary dysmenorrhea or endometriosis have a high capacity flow of menstrual blood and endometrial tissues. (Pittatore, 2014) Most women also have some components of reversing menstruation. Studies suggest that women carrying plasminogen activator inhibitor genes are more prone to endometriosis implantation, specifically after retrograde menstruation (Zanatta, 2010).

Based on the coelomic metaplasia theory, endometriotic cells are developed when the coelomic epithelium of the peritoneal cavity starts retaining multi-potential cells. This theory is considered the best way to describe the rare condition of endometriosis among the pre-puberty girls, and women with Mullerian agenesis. (Kobayashi, 2014) Another theory suggests that endometrial tissue could be transported through lymphatic and vascular channels, which can be used to illuminate the rare case of extra-abdominal endometriosis.

Moreover, more recent studies and researches suggest an immunologic element for the developmental process of endometriosis. It has been observed that the concentration of tumor necrosis factor-a, macrophages, interleukin-6, and leptin are higher in the intestinal fluid of the women suffering from endometriosis.

Prevalence and risk factor of endometriosis:

Since endometriosis is a disease that has its decency on estrogen, that affects mostly the women with reproductive age, with a high rate of prevalence among women aged between 25 to 29. (Janssen, 2013) Since the women suffering from endometriosis are often characterized with no symptoms the prevalence of the disease among the general population is hard to access. (Ballweg, 2015)Studies suggest that almost 25 to 38% of the women experiencing chronic pelvic pain are diagnosed with endometriosis and the refractory endometriosis has been identified among 50% to 70% of these patients. According to some studies, the percentage of reproductive women being affected by such disease is 10%. (Bulletti, 2010) About 20 to 25% of women with infertility were diagnosed with endometriosis and 70 to 90% of women with severe pelvic pain.

According to an estimate, the disease leads to $2,801 in health care costs. Based on a survey conducted nation wise 50% of the women diagnosed with endometriosis spend their entire day on the bed during the span of 12 months because of their health.

Reports suggest that women who have first –degree relatives with a severe condition of endometriosis have six times more chances of getting endometriosis. (Mcleod, 2010) A recent more controlled study has reported that a familial impact on the occurrence of endometriosis is not substantial. Early age menstruation and late menopause are some of the key factors for endometriosis as they lead to increased exposure of menstruation. Furthermore, low body mass index, high alcohol, and caffeine consumption are also some of the factors being associated with an increased risk of endometriosis.

Diagnosis:

The diagnosis of endometriosis is primarily based on the pain, menstruation history, and physical examination of the patient. Histologic confirmation is usually attained with the discovery of extra uterine and endometrial cells in the laparoscopy. Furthermore, transvaginal ultrasonography can identify the cystic endometriomas, which is measured as a modality of choice, though the test fails to uncover the minute endometrial implants.

Differential diagnosis is another way to diagnose endometriosis in adolescents, as there can be co-existing diseases such as urinary tract infections, pelvic inflammatory diseases, and gastrointestinal system, pregnancy, and obstructive anomalies. The visible symptoms can vary from restricted abdominal pain, dyspareunia, and dysmenorrhea. The thorough examination will allow ruling out the anomalies of the genital tract. Moreover, the trans-abdominal ultrasound examination on the patient, while full-bladder, will rule out the chances of abnormalities in uterus and ovaries.

Treatment:

The treatment process of endometriosis might be surgical or medical. The surgical methods such as laparoscopy are considered to be the most effective treatment for curing the pain associated with endometriosis. The medical procedures include the administration of drugs or hormones to reduce the intensity of the pain. Like the primary dysmenorrhea, the first line of treatment for endometriosis or secondary dysmenorrhea is NSAID (Prizment, 2010), which is then trailed by hormone therapy. As endometriosis is often confused with primary dysmenorrhea, a confirmed diagnostic through laparoscopy can define the line of treatment for the patient. Suppressive medication in addition to the empiric therapy is an option that can be chosen.

Non-steroidal Anti Inflammatory Drugs:

The comparison of naproxen with placebo was established in a randomized controlled trial during the Cochrane review for evaluating NSAID for treating endometriosis (Brown, 2017). It was established that there was no apparent difference in ache relief among naproxen and placebo. Moreover, there was no supportive evidence about the supremacy of any one NSAID in the treatment.

NSAID is the first choice of treatment because they are efficient for women suffering from primary dysmenorrhea, also because they are readily available and safe for consumption. Though endometriosis is categorized as a condition of secondary dysmenorrhea, research shows that choosing NSAID as the first line of treatment seems a logical option.

Estrogen/ Progestin combination contraceptives:

Research and studies have shown that oral contraceptives are much more effective than regular placebos in reducing pain experienced by women with endometriosis. (Chapron C. S.-P., 2011) A randomized, double-blind meticulous trail on 100 women suffering from endometriosis validated that low dosage of amalgamation oral contraceptives tends to improve the pain associated with endometriosis as compared to placebo. (Vercellini, 2011)Study indicates that the amalgamation of oral contraceptive was seemed to be less efficient during six months when compared to gonadotropin-releasing hormone (GnRH) referents, though both tend to advance the symptoms after the period of 12 months. GnRH therapy is widely administered for adult women but is not recommended for young girls because it tends to reduce bone mineral density. (Casper, 2017) It has been established that using an amalgamation of oral contraceptives have fewer adverse effects as compared to GnRH analog.

Another study compared Ethinyl estradiol/Etonogestrel vaginal ring with the norelgestromin/Ethinyl estradiol transdermal patch on women suffering from endometriosis. (Schrager, 2013) The study pointed out that both treatments tend to reduce pain. However, the ring was considered more efficient for dysmenorrhea. Furthermore, the satisfaction level of patients administering the ring was much higher and continuous usage of such treatment caused advance bleeding than its usage in intervals.

Contraceptives with Progesterone:

As compared to placebo oral Provera (medroxyprogesterone) or Depo-Provera were found to improve the symptoms associated with endometriosis. (Nooh, 2016) Improvement in pain was administered in trial comparing lower dose-depot medroxyprogesterone with GnRH analog leuprolide. The trails showed that administering medroxyprogesterone caused less bone loss and hypoestrogenic adversarial effects than leuprolide. Furthermore, two more studies compared dienogest with the GnRH analog, which also showed signs of improvement in pain associated with endometriosis. Etonogestrel subdermal implant was also found to be an effective treatment for endometriosis pain. Furthermore, small studies have also pointed to levonorgestrel-releasing intrauterine systems also tends to improve the pain.

Gonadotropin Releasing Hormone analogues:

After NSAID or combinations of oral contraceptives are found to be ineffective, the next step in the treatment of endometriosis is the GnRH analogue, such as leuprolide or goserelin. (DiVasta, 2013) The GnRH analogue therapy rejects the regulation of pituitary, which causes medical menopause, and is considered to relieve the pain associated with endometriosis. But, this therapy has been associated with some adverse effects such as bone loss, night sweats, and hot flashes experienced by many women. Furthermore, to counter the medical menopause condition, physicians administer low dose estrogen and progestin commonly.

Danazol:

Another treatment that has been administered to reduce the pain associated with endometriosis is the use of danazol, an androgen (Godin, 2015). However, the side-effects of using this treatment such as acne, male pattern baldness, and hirsutism, often avert the patients from administering it. The packaging of this drug includes the warning of possible thrombosis and teratogenicity.

Surgical Options:

Researches have pointed out that there are some surgical methods, which can prove significant in controlling the pain associated with endometriosis (Falcone, 2018). The physicians can locate the area of endometriosis and examine their size and growth during surgery; it is also possible that they might remove the endometriosis patches for that time.

Surgical options should be carefully planned because often they are irreversible and might affect women’s fertility. Some of the surgical options that might be provided to the patient are given as

Laparoscopy:

Laparoscope is a small instrument with an attached light, which is inserted in the abdomen after it has been inflated slightly with a harmless gas, to administer the growth of endometriosis (Duffy, 2014). In order to remove the endometriosis patches, the surgeons then make two more small incisions in the abdomen area and introduce lasers either to remove the lesions through a process known as excising or to eradicate the lesions through intense heat, a process known as cauterizing. During the surgery, the physician sometimes confiscates the scar tissue as it might contribute to the pain associated with endometriosis.

The main aim of such surgical treatment is to confiscate endometriotic tissues without damaging the healthy tissue around it. (Giudice, 2010)Studies have shown that with laparoscopy most women get relief from pain but that is for short term only, as pain often returns. Surgery can be helpful in relieving the pain only if lesions responsible for pain are removed completely. Some studies show that surgical treatment for endometriosis is best suited for women who have moderate endometriosis rather than in women experiencing minor endometriosis. Women experiencing minimal endometriosis often have changed pain perception once the lesions are removed (Cheong, 2008).

Laparotomy:

It is a major surgical procedure that involves the removal of endometriosis patches. However, sometimes the lesions are too minute to be detected during laparotomy (Galaal, 2018). During the procedure, the surgeon removes the uterus in a process known as hysterectomy. Depending upon the extent of damaged endometriosis tissue, the surgeon might also remove the ovaries and fallopian tubes beside the uterus, and this process of removal of ovaries and fallopian tubes is called a bilateral salpingo-oophorectomy.

During the procedure, the ovaries are tried to keep in place because of the vital role they play in the overall health and quality of life of women. Such treatment is the last option for endometriosis patients as undergoing total hysterectomy will not guarantee about the pain relief and lesions regrowth.

Surgery to cut pelvic nerve:

This is opted when the pain associated with endometriosis is substantial and originated from the center of the abdomen. In this procedure, the nerves present in the pelvic region are cut to decrease the intensity of the pain. This procedure can be also performed while conducting a laparotomy or laparoscopy. There are several reported clinical trials that have pointed out that such treatment is often ineffective in relieving the pain associated with endometriosis (Chapron C. S., 2012). Therefore, this procedure is not recommended or even included in the management of endometriosis.

The two procedures employed to cut the pelvic nerves are presacral neurectomy and laparoscopic uterine nerve ablation. In some patients, the physicians imply the hormone therapy, before or after the surgical procedure, in order to minimize the pain and continue the treatment.

Managing infertility related to Endometriosis:

In the case of mild endometriosis, most physicians recommend a laparoscopy to remove the growth of endometriotic tissue and to improve the fertility rate among women (Bulletti, 2010). The studies indicate improvement in the pregnancy rate among the women undergoing such a procedure, but the success rate has not yet been confirmed.

If treatment through laparoscopy does not result in pregnancy, then a physician might opt for vitro fertilization (IVF) to improve the rate of fertility. Any additional hormonal therapy administered for reducing endometriosis pain will disrupt ovulation and suspend the pregnancy. It is not advisable to perform a second laparoscopy for improving the fertility rate unless the pain symptoms avert undertaking IVF. Studies have shown that numerous surgeries to remove the growth from the ovaries, might decrease ovarian function and obstruct the attainment of IVF.

IVF is a process of combining egg and sperm in a laboratory environment to create an embryo. The fertilized embryo is then placed in a woman’s uterus. The process of IVF is an aided reproductive technology that might be the finest option for women affected by infertility caused to endometriosis (Senapati, 2011). The first step in the process of IVF is the superovulation of women by undertaking hormonal therapies, which activate the body to produce numerous eggs at a time.

Once the eggs get matured, a physician collects them through a probe that is steered by an ultrasound. The collected eggs are then fertilized with man’s sperm in a dish and placed in an incubator. After allowing 3 to 4 days to the embryo in an incubator it is then transferred into the women’s uterus for further development.

Apart from IVF other forms of hormonal therapies such as ACOG are not as successful, as they don’t require the administration of an oral contraceptive or GnRH analog to cure infertility associated with endometriosis (Somigliana, 2017). Opting for such hormonal therapies will further delay the process of ovulation and interrupt the pregnancy.

The hormones administered during the IVF process are not helpful in curing the endometriosis lesion, which implies that the pain associated with endometriosis might recur after delivering. Furthermore, the studies suggest that IVF therapies do not guarantee pregnancy and the studies are still in the process to cure infertility related to endometriosis.

References

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Bendon, C. L. (2012). Potential mechanisms of postmenopausal endometriosis. Maturitas, 72(3), 214-219.

Brown, J. C. (2017). Nonsteroidal anti‐inflammatory drugs for pain in women with endometriosis. Cochrane Database of Systematic Reviews, 1.

Bulletti, C. C. (2010). Endometriosis and infertility. Journal of assisted reproduction and genetics, 27(8), 441-447.

Casper, R. F. (2017). Progestin-only pills may be a better first-line treatment for endometriosis than combined estrogen-progestin contraceptive pills. Fertility and sterility, 107(3), 533-536.

Chapron, C. S. (2012). Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis. Human reproduction, 27(3), 702-711.

Chapron, C. S.-P. (2011). Oral contraceptives and endometriosis: the past use of oral contraceptives for treating severe primary dysmenorrhea is associated with endometriosis, especially deep infiltrating endometriosis. Human Reproduction, 26(8), 2028-2035.

Cheong, Y. T. (2008). Laparoscopic surgery for endometriosis: how often do we need to re-operate? Journal of Obstetrics and Gynaecology, 28(1), 82-85.

DiVasta, A. D. (2013). . The use of gonadotropin releasing hormone analogues in adolescent and young patients with endometriosis. Current Opinion in Obstetrics and Gynecology, 25(4), 287-292.

Dmitrovic, R. K. (2012). Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstetrics and gynecology, 119(6), 1143.

Dmitrovic, R. K. (2012). Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstetrics and gynecology, 119(6), 1143.

Duffy, J. M. (2014). Laparoscopic surgery for endometriosis. Cochrane Database of Systematic Reviews, 4.

Falcone, T. &. (2018). Clinical management of endometriosis. Obstetrics & Gynecology, 131(3), 557-571.

Gadducci, A. L. (2014). Novel insights on the malignant transformation of endometriosis into ovarian carcinoma. Gynecological endocrinology,, 30(9), 612-617.

Galaal, K. D. (2018). Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database of Systematic Reviews, 10.

Giudice, L. C. (2010). Endometriosis. New England Journal of Medicine, 362(25), 2389-2398.

Godin, R. &. (2015). Vaginally administered danazol: an overlooked option in the treatment of rectovaginal endometriosis? Journal of Obstetrics and Gynaecology Canada, 37(12), 1098-1103.

Harel, Z. (2012). Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies. Expert opinion on pharmacotherapy, 13(15), 2157-2170.

Iacovides, S. A. (2015). What we know about primary dysmenorrhea today: a critical review. Human reproduction update, 21(6), 762-778.

Janssen, E. B. (2013). Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain:. Human reproduction update, 19(5), 570-582.

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Alabama A&M University

Master’s Research Report

Guidelines

School of Graduate Studies

Alabama A&M University

Revised 2018

3

The fundamental purpose of a Master’s Research Report involves cultivating an understanding

a process for writing scholarly research that reflects and is a direct result of research conducted

by the graduate student during his or her matriculation at Alabama A&M University. The

Master’s Research Report will contribute further knowledge and content that is useful to

various fields of study, research development, and general audiences.

Graduate writing guidelines specifically outlined in this guide create a model for the overall

format and design standards for all Master’s Research Reports completed at Alabama A&M

University. These standards must be met prior to receipt of final approval of all graduate

requirements having been met and fulfilled.

As a graduate student at Alabama A&M University, you are writing a Master’s Research Report

in partial fulfillment of the requirements for an advanced degree. If there are conflicts between

the styles or requirements set forth in this manual and those in your discipline’s department

guidelines, the current Master’s Research Report guidelines manual takes precedence. If you

have any questions concerning format requirements, do not hesitate to contact the Graduate

Office.

Overview

4

Table of Contents

Overview

Introduction

Purpose of the Guidelines Manual

Ethical Responsibilities of the Graduate Student

Preparing the Research Report

Responsibilities

Writing Style

Format for the Master’s Research Report

Organizing the Research Report

Title

Abstract

Introduction

Body

Results

Conclusion/Summary/Discussion

References

Appendices

A. Sample Title Page
B. Sample

Abstract and Key Words

C. Sample Table Integrated into Text
D. Sample Figure Integrated into Text
E. Sample References

5

Purpose of the Guidelines Manual

Part of the requirements for an advanced degree includes completion of a research report. The

purpose of this manual is to serve as a guide for the preparation of research reports as required

by

the Graduate Office. The conventions and rules described within these guidelines ensure that

research reports produced and completed will be uniform in regards to general appearance and

section sequences within the document. Specific effort has been made to simplify this manual in

order to maximize its applicability across disciplines and to improve its usefulness to the student.

Additional resources that provide assistance in the use of format style are listed in the

Appendices.

Ethical Responsibilities of the Graduate Student Involving Plagiarism

Completing a research report is a scholarly achievement that reflects not only the student’s depth

of knowledge, but also his or her professional integrity. Particular care must be exercised to

properly acknowledge all cited works and copyrighted materials.

Plagiarism and Self-Plagiarism is an unacceptable ethical violation and can be grounds for

dismissal from academic study at Alabama A&M University.

When a writer uses the ideas or words of others, the source of those ideas must be cited.

Plagiarism is the act of copying the language, structure, idea, and/or thoughts of another and

passing it off as one’s own work. Self-plagiarism is the act of producing one’s work as if new

for the first time. Use of one’s own words should be restricted to one paragraph with an

accompanying citation.

When the candidate submits a proposal for format approval, he or she is asserting that his or her

work is original and has not been plagiarized in any form. In addition, by signing the student’s

cover page, members of the advisory committee are also stating that they believe the student’s

work is original and that the integrity of the university has been maintained. Penalties for

plagiarism, a serious academic offense, are specified in the graduate school catalog.

If a student extensively uses copyrighted material, permission must be obtained from the owner

of the material. If the copyrighted material used is only a very small part of the total work, for

example, a few lines out of an entire novel, generally, permission need not be obtained. Material

intended to be consumable such as survey forms, tests, activities, or handouts used for teaching,

etc. may not be used without permission. Once permission has been obtained, source(s) of

material should be properly cited.

Introduction

6

Responsibilities

Role of the Student

It is the objective of the student to identify and analyze the components of a research project and

to produce a profound Master’s Research Report. The student must be in frequent

communication with his/her Advisor providing drafts of the document for review and analysis.

The exchange with the Advisor should result in the approval of each step of the writing process.

The student must not should wait until the last month prior to graduation to begin or complete

this process. The student should start the process early in the semester in order to meet the

published deadline in the Calendar-At-A-Glance for the graduation term. The student should

consult with the AAMU Reviewer staff on a regular basis for assistance with grammatical and

formatting standards. Each semester workshops will be facilitated to provide guidance in the

writing, formatting, and ethical ramifications each semester. The student is required to attend at

least two of the workshops.

Role of the Major Advisor

It is the responsibility of the Advisor to meet with the student to advise, assist and edit his/her

research to completion. This would entail ensuring that the document has met the professional

competences through organization, quality of analysis, and has successfully communicated its

findings. All revisions must be made before the document is submitted to the research Advisor

for critical assessment of the content, style of writing, technical quality and appropriate

formatting in accordance with the AAMU Master’s Research Report Guidelines prior to

submitting to the AAMU Reviewer. The review and approval of the students’ Master’s Research

Report is an electronic process. The advisor/chairperson must submit your document to

aamu.reviewer@aamu.edu for consideration of approval.

Selecting a Research Topic

In conjunction with the Project Major Advisor or instructor, the student will select a research

topic studied in one of his or her courses. This topic must be relevant to the student’s area of

study.

Writing Style

The writer of the research report should convey his or her content and ideas in a clear, unified,

and precise manner. Writing should be free of bias, linguistic features that detract from the

content, and must include accurate usage of grammar conventions.

Preparing the Research Report

mailto:aamu.reviewer@aamu.edu

7

All research reports must conform to an accepted style manual, APA, approved by the Graduate

School, which sets guidelines for references, tables, figures, margins, page numbering,

quotations, etc. Research reports not using the approved style or using more than one style will

not be accepted and will be returned to the student.

The following style manual is available at most local bookstores: Publication Manual of the

American Psychological Association, (6th ed.) published by the American Psychological

Association, Washington, D.C., 2010. APA is the style most frequently used in the sciences,

engineering, and social sciences.

Format for the Master’s Research Report

What Font Type is Appropriate to Use?

The choice of font type has a significant effect on the overall appearance of the finished research

report. Per APA, a 12-point, general font like Times New Roman, should be used consistently

throughout the document. All pages including the text, tables, figure captions, page numbers,

and appendices must all be in the same font for consistency.

Parts of a figure may be in a different font. A smaller font size such as 10-point, no smaller than

8-point and no larger than 14-point, may be used in the tables if its use enables the positioning of

a table onto one page. A 14-point font may be used for the chapter numbers and title. A larger

font size such as 14-point may also be used to emphasize the title on the title page.

What is a Widow?

Care should be taken to observe the customary rules about widow, orphan, and headers. A

“widow” is part of a line from the end of a paragraph that is carried to the next page. Adjust the

text to eliminate these. A header should not be put at the bottom of a page unless there is room

for the header and at least two lines of text. If there is insufficient room, place the header on the

next page.

Margins

The margins for each page of the research report (preliminary pages, text, references) – must

meet the following specifications, measured from the edge of the paper to the text:

Left 1 ½ inch

Right 1 inch

Top 1 inch

Bottom 1 inch

8

This margin in inviolable. The final lines of a paragraph or a table or the page number must be

accommodated without violating the minimum margin of one inch of white space at the bottom.

Holes or perforations are not permitted in any of the margins. Some reproduction or

photocopying processes magnify or spread the material, which may necessitate more careful

attention to the margin spacing. The text may be either “justified” or “left justified” as long as it

is used consistently throughout the entire thesis. However, when using justify students are

responsible for ensuring that the spacing between words and letters conform to the style guide

selected by their department of study. Tabs should be used for a consistent offset at the

beginning of each paragraph and must be of a uniform spacing (five spaces).

Pagination

Starting with the body and continuing through the manuscript, each page must be accounted for

and numbered using Arabic numbers. Although the title page is counted, a number is not placed

on the title page itself. Numbers on all pages including the first page of every major division of

the research report are placed one inch above the bottom edge of the sheet and

centered.

Numbering Tables, Figures, and Appendices

Each table and figure used within the report must be given a unique number and a title. Arabic

numbers are used for both tables and figures. Tables and figures are numbered independently of

each other. See Appendix C and D.

9

Most research reports include the definition of a problem, a hypothesis, experiments conducted,

and conclusions drawn. While variations in the order of the content may depend on the

discipline, the following features should be included in the overall format of the manuscript.

Title, Abstract, Introduction, Body, Results, Conclusions/Summary/Discussion, and

References.

Title

The title serves as a guide for others who wish to gain more information about what has been

done in your research. Therefore, it is doubly important to select a title that is a meaningful and

concise description of the contents of the research report.

The title should be uppercase and double-spaced. The name of the student should be uppercase

and must appear in the same form as he or she is registered at the University. A statement that

the document is submitted in partial fulfillment of the requirements for the degree of (name of

degree program) in the (name of Department) in the School of Graduate Studies, should appear

in lowercase. Followed by Alabama A&M University, Normal, AL 35762. The date on the title

page must indicate the month and year that the student will actually receive the degree. See

Appendix A.

Abstract and Key Words

The ABSTRACT should contain a rationale or justification for the study. Generally, a brief

account of the purpose, need, and significance of the investigation is given. The objectives must

be clear and concise. A brief account of the methodology is provided, particularly those parts that

are unique. The results and principal conclusions are also provided. The abstract should not

merely repeat the title, nor contain illustrations or tables, use abbreviations, or cite references. It

should be an accurate reflection of the original findings reported in the body of the master’s report

and should be between 150 and 250 words.

The abstract with attendant key words should be placed on its own page in the master’s report.

The title of the document is repeated about the abstract. Two lines, down, the author of the

document is indicated, followed by the degree sought (abbreviated), institution, year, number of

pages in the master’s research report manuscript and the major advisor. The abstract must be

doubled-spaced beginning two lines beneath the author line.

Two lines beneath the abstract, identify the key words that have been selected to augment those

used in the title. A key word is a word that others would search for if they were trying to locate

your work using a search strategy. Usually three to five key words are selected. Do not use the

same words again that have been used in the title since those words are indexed already as a

function of being in the title. See Appendix B for the format of the Abstract and Key Words.

Organizing the Research Report

10

Introduction

The introduction is the first chapter of the master’s research report. The word

INTRODUCTION is the title of the first chapter (or major division) and its placement is

consistent with that of the other chapter titles. Items such as background information, the

definition of the problem, imitations and delimitations of the study, hypothesis or research

questions, significance of the study, and a brief forecast of what the remaining parts of the report

will include are typically included in this section.

Body

This section of the document includes a discussion of the research conducted. It should include

the work done, topic explored, experiment completed, and procedures explored as related to the

research report. Each report must be divided in some manner of logical organization. Each

chapter must be numbered consecutively using Arabic numerals, beginning with number 1 on a

new page. The chapter number and title (or section number and title) must be in all capital

letters. A chapter or section title, which required more than one line, is to be double-spaced and

centered.

Any logical means of subdivision within the chapter or section is permissible, but the scheme

used must be consistent throughout a chapter (or a section). Some chapters may not require

subdivisions, while others may require one or more levels for clear organization. The preferred

form for first order subdivision is left justified, bold, and underlined; for second order

subdivisions, a centered heading; and for a third order subdivision, an italicized paragraph

heading.

Preparation of Tables

A table is an array of information presented in columns and consists of numbers and/or words.

In the text, a table should appear as closely as possible to the point where is first discussed,

usually no farther than the page following. Table captions should be placed above the table,

should be numbered using Arabic numbers, and end with a period.

Tables can be arranged either vertically or horizontally on a page. With a table whose size or

format requires horizontal placement, the bottom of the table faces the outside (or unbound) edge

of the page. The table, table number, and caption should be oriented so that they can be read

when the page is rotated 90 clockwise. Proper margins must still be maintained with particular

attention paid to the 1 and ½ inch margin of the binding edge. The page number should appear

in the usual position at the bottom of the page. If more than one-half page in length, an

individual table should be put on a separate page. More than one table can be put on an

individual page if captions can be placed in their proper positions and if adequate space (at least

½ inch) is provided between tables. See Appendix C.

11

A table can be incorporated directly in the text if it is small (less than one half of the page in

length), it can be confined to one page, and it occurs in numerical order after its first mention in

the text. The table must be offset by a double space preceding and following it.

If a table is very long and must be typed on more than one page, show the table number on the

additional page(s) with a notation of continuation. Show all column headings as necessary on

the additional page and footnote on each page where the information applies.

Preparation of Figures

Some general guidelines for the production of figures are listed below:

 Use line graphs for continuous data and bar graphs for discontinuous data

 Use consistent symbols throughout

 Designate the curves with individual labels or use an inserted legend to differentiate
between treatments.

 Avoid wasted space.

In the text, a figure should appear as closely as possible to the point where it is first discussed,

usually no farther than the page following. Figure captions should be placed outside and at the

bottom of the figure two-line spaces below it and followed by a period. See Appendix D.

If placed horizontally on the page, the bottom of the figure should be at the right side of the page,

with allowances for the proper margins. The caption must be oriented to be read with the figure.

The page number should appear in the usual position at the bottom of the page.

Figures less than one-half in length (including caption) may be placed within the text. The

figure should be set off with two lines preceding the following its placement in the text. If more

than one-half page in length, an individual figure should be put on a separate page. More than

one figure can be put on an individual page if captions can be placed in their proper positions

and if adequate spaced is provided between the figures (at least ½ inch apart). Figures with

component parts may be titled as one figure, with the alphabetical designation placed below and

to the right of the individual part and caption placed below the entire group.

Results and Discussion

Relevant data, observations, and findings should be included in this section as results of the

research. The student may make use of tables, figures, charts, etc., to display research findings

appropriately and effectively. Results and a discussion of the results are intertwined and can be

addressed in this same section. Provide information about the meaning of the results and how

they relate to the significance of the research report. For example, has a solution to the study

problem surfaced and to what extent?

12

Conclusions and Summary

This section should include all primary conclusions of the research project and directions for

future research in reference to the research topic based on conclusions drawn. This includes a

summary of the research report objectives and findings.

References

Any research report, which makes use of other works, either in direct quotation or by reference,

must contain a references page. The heading, REFERENCES, is centered, without punctuation,

two inches from the top of the page. The first entry begins four line spaces below it. References

are double-spaced between entries and single-spaced within each entry. Reference entries

should conform to APA and should be in alphabetical order throughout.

13

Source: Kristen J. Byrd, “Pathogen Crossing Placental Barrier from Mother to Fetus: Zika
Virus Causing Microbiology” Master of Science/Biology, Department of Biological and
Environmental Sciences, Alabama A&M University, Normal, AL, December 2017.

APPENDIX A

SAMPLE TITLE PAGE

A

PATHOGEN CROSSING PLACENTAL BARRIER FROM MOTHER TO

FETUS:

ZIKA VIRUS CAUSING MICROBIOLOGY

by

KRISTEN J. BYRD

A MASTER’S RESEARCH REPORT

Submitted in partial fulfillment of the requirements for the degree of

Master of Science in Biology

in the Department of Biological and Environmental Sciences

in the School of Graduate Studies

Alabama A&M University

Normal, Alabama 35762

December 2017

This page (shown at 60% of normal size) illustrates the format
to be used for the Master’s Research Report title page.

14

Source: Kristen J. Byrd, “Pathogen Crossing Placental Barrier from Mother to Fetus: Zika Virus
Causing Microbiology” Master of Science/Biology, Department of Biological and Environmental
Sciences, Alabama A&M University, Normal, AL, December 2017.

APPENDIX B

SAMPLE ABSTRACT AND KEY WORDS

B

PATHOGEN CROSSING PLACENTAL BARRIER FROM MOTHER TO FETUS:

ZIKA VIRUS CAUSING MICROBIOLOGY

Kristen J. Byrd, M.S., Alabama A&M University, 2017. 30 pp.

Major Advisor: Dr. Florence Okafor

This paper follows the studies of a few published articles that all reach to study

further into questions about a flavivirus crossing the placental barrier and the birth

defects caused by the pathogen. There lies a strong possibility of an infectious

pathogen, Zika Virus (ZIKV), crossing the placental barrier causing a congenital

defect, microcephaly The analysis displays the infection ZIKV in primary human

placental macrophages, referred as Hofbaucer cells (HBC), and in placental villous

fibroblasts. The researchers also observe the Hofbauer cells infection of Zika virus,

or placental villous explant. The movement activity of the HBC may help

dissemination and spread the ZIKA, possibly across the placental barrier causing a

defect to the fetal brain, such as microcephaly. The understanding of the relationship

between the two can clarify the position and how they affect one another. Further

work and tests will assist the association of the ZIKA virus disease and a brain defect

and can even discover preventions, treatments, and possibly cures as well.

KEY WORDS: Zika virus, macrophages, microcephaly

This page (shown at 60% of normal size) illustrates the
format to be used for the page containing the abstract
and keywords. Notice that key words are identified and
do not duplicate words already used in the title.

15

twice as high as that in leaves of seedlings grown in the growth chamber.

Since stomata basically are confined to the abaxial surface, we only used the

abaxial surface in density counts. Stomatal densities were significantly higher in

the IBA control than in the PAC-treated leaves (Table 5-3). The stomatal density of

UNI-treated leaves was lower than the control but not significantly (Table 5-4).

Table 5-4. Stomatal density and conductance means*. Source

Stomatal Density Stomatal Conductance

No./ square cm cm/sec

Paclobutrazol 526.67 b 0.57 a

* Each mean represents 6 replications.

The stomatal density o f Line #4 leaves also was significantly lower than

Line #2. Perhaps PAC affects water loss during the stressful acclimatization phase

in part by decreasing the density and conductance of stomata normally altered by

the in vitro environment. UNI is less mobile than PAC through xylem transloca-

tion (Sterrett, 1987) and therefore a slightly higher concentration of UNI applied in

vitro could possibly significantly affect stomatal density favorably without overly

retarding in vitro growth.

Stomata (guard cells and aperture) on leaves of the IBA control were slightly

more circular in shape than either the triazole-treated or the greenhouse seedling

stomata. In control plants sampled immediately after removal from culture, 90-

95% of the stomata were open as determined by SEM. This contrasts with both the

triazole-treated and the greenhouse-grown plants at 50-55% (Figure 5-9 and 5-10).

99

IBA 656.7 a 0.66 a

Uniconazole 603.34 a 0.64 a

Source: Marybeth Knust Eliasson, “Intro to Acclimatization of Genotypes of Prunus serotina using
Triazole Growth Retardant Pretreatments.” Master of ScienceThesis, Department of Plant
and Soil Science, Alabama A&M University, Normal, AL, July 1992.

C
Appendix C

Sample Page with Table Integrated into text

This page (shown at 60% of normal size) illustrates the
format to be used for integrating tables into the text. This
method is used only for small tables, which constitute less
than one half of the page in length.

16

Source: William Sheng-Te Tang, “The Investigation of a Cost-Conscious Holographic Solar

Concentrator.” Master of Science Thesis, Department of Physics, Alabama A&M University,

Normal, AL, May 1995.

APPENDIX D

SAMPLE PAGE WITH FIGURE INTGRATED

INTO TEXT

D

Direct

Diffuse
Diffuse

Figure 1.9. Distinction between direct and diffuse

radiation.

The difference between direct and diffuse sunlight is important in one sense.

Many of the existing concentration PV systems simply cannot use diffuse light.

Most conventional optical equipment such as lenses can carry out their

concentration function only when the light comes in at normal incidence to the

surface of the lenses. If light is not normally incident (or is diffuse), then these

lenses simply cannot focus the light in the direction and distance desired. See

Figure 1.9.

Furthermore, d i f f u s e light occupies a sizable portion of the total (or global)

sunlight, reaching anywhere between 20% to 60% at different regions of the

earth. Hence a PV design made with circumspection should never overlook the

need to successfully tap into diffuse radiation. Holograms are devices that

possess some angular tolerance; i.e. they can use diffuse radiation to a certain

19

This page (shown at 60% of normal size) illustrates the format
to be used for integrating figures into text. This method is
only used with small figures that constitute less than one half
of the page in length.

17

Note that
the

references
are single-

spaced
within each
entry but
double-

spaced in
between
entries.

E
Appendix E

Sample References Page

R E F E R E NC E S

AACC. 1983. Approved Methods of AACC. American Association of

Cereal Chemists. St. Paul, MN.

Baker, B. A., Davis, E. A. and Gordon, J. 1990a. Glass and metal pans

for use with microwave and conventionally heated cakes. Cereal

Chem. 67(5):448-451.

Baker, B. A., Davis, E. A. and Gordon, J. 1990b. The influence of sugar

and emulsifier type during microwave and conventional heating

of a lean formula cake batter. Cereal Chem. 67(5):451-455.

Bale, R. and Muller, H. G. 1970. Application of the statistical theory of

rubber elasticityto the effect of heat on wheat gluten. J. Food

Technol. 5:295-300.

Bell, D. A. and Steinke, L. W. 1991. Evaluating structure and texture

effects of methylcellulose gums in microwave-baked cakes. Cereal

Food World 36(11):941-944.

Bernardin, J. E. 1978. Gluten protein interaction with small molecules

and ions – the control of flour properties. Bakers’ Digest 52(4):20-

23.

Biliaderis, C. G. 1992. Structures and phase transitions of starch in

food systems. Food Technol. 46(6):98-109.

Biliaderis, C. G. and Tonogai, J. R. 1991. Influence of lipids on the

thermal and mechanical properties of concentrated starch gels. J.

Agric. Food Chem. 39:833-840.

Bloksma, A. H. 1990a. Rheology of the bread making process. Cereal

Foods World 35(2):228-236.

Bloksma, A. H. 1990b. Dough structure, dough rheology and baking

quality. Cereal Foods World 35(2):237-244.

87

Source: Bin Pan, “Effect of Peanut Flour Supplementation of Textural and Rheological Changes
of Wheat Dough during Microwave Baking.” Master of Science Thesis, Department of Food
Science and Animal Industries, Alabama A&M University, Normal, AL, July, 1994.

This page (shown at 60% of normal size) illustrates the format
for preparing the references section at the end of the
Master’s Research Report.

18

All Rights Reserved. This document may not be
copied without written consent from the School of

Graduate Studies at Alabama A&M University.
August 2018