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dysmenorrhea (menstrual pain)

Etiology: 1) primary dysmenorrhea a) increase in PGF2-alpha in endometrial lining during menstruation b) increased myometrial resting tone & pressure c) increased frequency of myometrial contractions d) uterine hypoxia 2) secondary dysmenorrhea a) endometriosis (most common cause) [7] b) complications of pregnancy - ectopic pregnancy - spontaneous abortion - incomplete abortion c) pelvic inflammatory disease d) intrauterine device (IUD) e) ovarian cyst f) tumor - adenomyosis - uterine leiomyoma (fibroids) - adenocarcinoma g) adhesion - postoperative, dilatation & curettage (D&C) - infection h) cervical obstruction - polyps - submucous fibroids - infection - post-procedural - electrocautery - cryotherapy - conization - radiation i) congenital malformation - Mullerian duct - bicornate uterus - septate uterus - rudimentary uterine horn - cervical stenosis j) pelvic congestion Epidemiogy: - dysmenorrhea in adolescents is generally primary & occurs without pelvic pathology [7] Clinical manifestations: 1) primary dysmenorrhea a) 80% of symptomatic women develop symptoms within 3 years of menarche b) physical examination is generally normal c) pain typically begins 1-2 hours before menstrual flow & lasts several hours to 1-2 days (2-3 days) [2] d) pain often decreases with menstrual flow e) pain is generally diffuse, dull or cramping, centered in the midline just above the pubic symphysis often radiating to the lower back &/or anterior thigh f) associated symptoms of nausea/vomiting, diarrhea, headache, dizziness or fatigue may be present g) pelvic examination may not be indicated in non sexually active adolescents with a typical history 2) secondary dysmenorrhea a) generally noted with 1st menstrual cycles after menarche (congenital) or after age 25 b) pain often begins a few days before menstrual flow & lasts several days c) painful nodules in posterior cul de sac & restricted motion in late luteal phase suggests endometriosis d) bilateral adnexal & cervical motion tenderness suggests infection e) IUD may be malpositioned f) pelvic mass or uterine enlargement g) restricted uterine motion suggests adhesions h) inability to pass a small probe through the cervix suggests cervical obstruction i) worsening dysmenorrhea, abnormal bleeding, mid-cycle pain, no response to empiric treatment, or family history of endometriosis (ACOG) [7] Laboratory: 1) pregnancy test 2) if pelvic pathology not suspected, no further testing required [2] 2) additional testing as indicated a) Papanicolaou smear, HPV DNA testing b) GenProbe for Neisseria gonorrhoeae & Chlamydia Special laboratory: 1) not routinely indicated 2) exploratory laparoscopy - for definitive diagnosis of endometriosis 3) hysterosalpingogram or hysteroscopy - polyps, tumors, adhesions, congenital malformations Radiology: - pelvic ultrasound to assess pregnancy, fibroids & other tumors, ovarian cysts, congenital malformations - not routinely indicated [2] - useful for evaluation of secondary dysmenorrhea [7] Differential diagnosis: 1) endometriosis 2) premenstrual syndrome Management: 1) general - attention for sexually-transmitted disease - consider physical, sexual or emotional abuse 2) primary dysmenorrhea a) pharmacologic agents - non-steroidal anti-inflammatory drugs (NSAIDs) 1st line [2,4] - acetaminophen not as effective as NSAID - need for effective contraception takes priority vs analgesia with NSAID - oral contraceptives (low-dose combinations) [1,2,3] if unresponsive to NSAIDS [2,4] - data for progestin only contraception to treat dysmenorrhea is lacking, but suggested [2] - calcium channel blockers (not approved) - clonidine (not approved) b) other modalities - transcutaneous electrical nerve stimulation (TENS) - acupuncture (not approved) - osteopathic manipulation (not approved) c) SSRI for premenstrual syndrome & premenstrual dysphoric disorder 3) secondary dysmenorrhea a) treat primary cause b) surgery - intractable, severely debilitating pain - presacral neurectomy - laser ablation of uterosacral nerves/ligaments 4) patient education a) pamphlet: Dysmenorrhea, ACOG (1985), 200 Maryland Ave. SW, Suite 300 East, Washington DC 20024-2588 b) Homehealth Handbook: Menstrual Cramps: Dysmenorrhea, Packet 3d, Group 8, Card 45, MCMXLI, IMP BV/IMP, Inc

Related

amenorrhea (oligomenorrhea) menstrual (estrous) cycle vaginal bleeding; abnormal uterine bleeding; anovulatory bleeding

General

sign/symptom menstrual disorder pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 385-88
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Davis AR, Westhoff C, O'Connell K, Gallagher N. Oral contraceptives for dysmenorrhea in adolescent girls: a randomized trial. Obstet Gynecol. 2005 Jul;106(1):97-104. PMID: 15994623
  4. Harel Z. Dysmenorrhea in adolescents and young adults: from pathophysiology to pharmacological treatments and management strategies. Expert Opin Pharmacother. 2008 Oct;9(15):2661-72 PMID: 18803452
  5. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014 Mar 1;89(5):341-6. Review. PMID: 24695505 Free Article
  6. Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006 Aug;108(2):428-41. Review. PMID: 16880317
  7. American College of Obsetrician and Gynecologists (ACOG) ACOG Committee Opinion 2017 Number 760 Committee on Adolescent Health Care. Dysmenorrhea and Endometriosis in the Adolescent https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Dysmenorrhea-and-Endometriosis-in-the-Adolescent
  8. Kho KA, Shields JK. Diagnosis and management of primary dysmenorrhea. JAMA. 2020;323:268-9. PMID: 31855238