DYSMENORRHEA

 

Dysmenorrhea is defined as pain and cramping during menstruation that interferes with normal activities.  It is a very common disorder that affects approximately 50% of women.   It is one of the most common causes of school and work absenteeism. 

 

Primary Dysmenorrhea

  1. Typically occurs before the age of 20
  2. No underlying pathology is discovered in the pelvis
  3. Most common etiology of pain with menstruation
  4. Pathophysiology- increased production of prostaglandins and leukotrienes leading to vasoconstriction, myometrial stimulation and inflammation.  There may also be a psychological component based on attitudes towards menstruation.
  5. Clinical Symptoms
    1. Cramping pain in the midline in the suprapubic area
    2. Usually begins right before or with the start of menstruation and lasts 1-2 days
    3. May not develop symptoms until months or years after menarche because will not have symptoms with anovulatory cycles
    4. May have associated backache, leg pains, nausea, vomiting, light-headedness and headache
    5. Physical examination is usually benign except for mild suprapubic tenderness.  A thorough abdominal exam and inspection of the external genitalia is important to rule out other etiologies of the pain
    6. Pelvic examination ultrasonography, and laboratory evaluation only necessary if there is suspicion of other pathology and/or poor response to medical treatment.
    7. Clinical suspicion of another etiology if there is a history of pelvic inflammatory disease (PID), menorrhagia, and inter-menstrual bleeding.
  6. Diagnosis
    1. Diagnosis based on history and lack of organic causes
    2. Complete history should include: age at menarche, duration menstrual cycles, onset and duration of cramps, presence of other symptoms and their severity, medication use, sexual history
    3. Most often confused with endometriosis, but endometriosis pain typically begins 1-2 weeks prior to menstruation, worsens just before onset of menstruation, and is relieved by menstrual flow (as opposed to primary dysmenorrhea, which occurs within 1st or 2nd day of menstruation)
  7. Treatment
    1. NSAIDS (1st line tx- commonly aspirin, ibuprofen, naproxen)Ð they decrease the production of prostaglandins within the endometrium.  Must be used in the proper dosage and intervals.  Often patients do not take adequate amounts and may need prescription strength doses to obtain satisfactory symptom relief.
      1. NSAIDS should be taken 24 hours prior to expected onset of symptoms and continued throughout menses
    2. Oral Contraceptives (2nd line treatment)- inhibits the production of prostaglandins secondary to inhibiting ovulation and/or decrease in endometrial proliferation.  90% success rate.
    3. Nonmedical therapy- heating pads, exercise, massage, transcutaneous electrical nerve stimulation, etc
    4. Failure of therapy warrants a diagnostic work-up

 

Secondary Dysmenorrhea- symptoms of dysmenorrhea caused by an identifiable cause

  1. Endometriosis- consider if no response to therapy.  May require laparoscopy
  2. Adenomyosis- consider US or MRI if clinical suspicion
  3. Uterine fibroids
  4. Vaginal or uterine congenital anomalies causing obstruction to flow (e.g. Cervical stenosis, pelvic adhesions)
  5. Foreign bodies

 

References

1.     Hillard P. Dysmenorrhea. Pediatrics in Review. February 2006

2.     Smith, RP. Primary dysmenorrhea and the adolescent patient. Adolesc Ped Gynecol 1988; 1:23.

3.     Callahan, Tamara L.  Blueprints Obstetrics & Gynecology. 4th edition.