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Dysmenorrhea

Basics

Description

  • Pelvic pain related to menses

  • Primary dysmenorrhea: pain without pelvic pathology; diagnosis of exclusion

  • Secondary dysmenorrhea: due to underlying pelvic pathology, often more severe and treatment-resistant

  • Severity:

    • Mild: rarely limits function, seldom needs analgesics

    • Moderate: affects daily activity, rare absenteeism

    • Severe: daily impairment, absenteeism, poor response to treatment

Epidemiology

  • Primary: starts 6–12 months post-menarche, common in teens to 20s

  • Secondary: more often in 20s–30s

  • Up to 90% of menstruating women have primary dysmenorrhea

  • Up to 42% miss school/work due to symptoms

Etiology & Pathophysiology

Primary:

  • Increased PGF2Ξ± from progesterone drop β†’ hypercontractility, vasoconstriction, uterine ischemia

  • C nerve fiber sensitization causes pain

Secondary:

  • Endometriosis (most common)

  • Adenomyosis

  • Congenital uterine anomalies

  • PID, fibroids, polyps, ovarian cysts

Risk Factors

Primary:

  • Smoking, alcohol

  • Early menarche (<12 years)

  • Family history

  • Heavy/irregular flow

  • Nulliparity, non-use of OCPs

  • Psychological factors

  • History of sexual abuse

Secondary:

  • Pelvic infection

  • Recent IUD use

  • Family history of endometriosis

Prevention

  • Primary: exercise, hormonal contraception, childbirth

  • Secondary: STI prevention

Associated Conditions

  • Heavy/irregular bleeding

  • Anxiety, depression

  • Lowered QoL

Diagnosis

History

  • Primary: cyclic cramping starting at or before menses

    • Associated: nausea, diarrhea, headache, fatigue, back/thigh pain

    • Relief with NSAIDs, heat, orgasm

  • Secondary:

    • Pain between cycles, dyspareunia, chronic pelvic pain

    • Onset >25 years, progressive severity, poor NSAID response

Physical Exam

  • Primary: normal

  • Secondary: findings of infection, uterine abnormalities

Differential Diagnosis

  • Primary: clinical history

  • Secondary: endometriosis, PID, ectopic pregnancy, fibroids, IBD, IBS, etc.

Diagnostic Testing

Primary:

  • Diagnosis clinical

  • Tests only if refractory:

    • Pregnancy test

    • Urine testing, STI screen

    • Pelvic US

Secondary:

  • US, MRI, laparoscopy if needed

Treatment

General Measures

  • Exercise, topical heat [A,C]

  • High-frequency TENS

  • Treat underlying cause (for secondary)

First-Line Medications

  • NSAIDs (equal efficacy; begin 1–2 days before menses):

    • Ibuprofen 400 mg q8h

    • Naproxen sodium 500 mg q12h

    • Celecoxib 400 mg x1, then 200 mg q12h

    • Mefenamic acid 500 mg x1, then 250 mg q6h

  • Hormonal contraceptives:

    • COCs, levonorgestrel IUD, progestins

    • Continuous dosing preferred

    • Estrogen-containing COCs or progestin-only for secondary

Contraindications

  • NSAIDs/COCs:

    • Platelet disorders

    • Gastritis/ulcers

    • Smoking + migraine w/ aura

    • Vascular disease, liver/kidney dysfunction

Second-Line

  • Acetaminophen Β± caffeine

  • Relaxation therapy, yoga

  • Nifedipine

Procedures

  • Laparoscopic nerve ablation, presacral neurectomy (resistant cases)

  • Hysterectomy: last resort, after completed childbearing

CAM

  • Acupuncture, acupressure

  • Aromatherapy massage

  • Promising but less evidence: ginger, fennel, fenugreek, valerian, vitamin K1, vaginal sildenafil, etc.

Inpatient/Admission

  • Outpatient management for both primary and secondary

Ongoing Care

Follow-Up

  • Monitor symptom relief with treatment

Diet

  • No strong evidence for dietary changes

Patient Education

  • Primary dysmenorrhea is treatable and may improve with age or childbirth

  • NSAIDs, hormonal options, exercise, heat are effective

Prognosis

  • Primary: improves with age/parity

  • Secondary: depends on etiology

Complications

  • Primary: anxiety, depression

  • Secondary: infertility

Clinical Pearls

  • Dysmenorrhea is a leading cause of absenteeism in women <30

  • All NSAIDs are equally effective when taken 1–2 days before menses

  • Hormonal contraceptives preferred in women needing both symptom relief and contraception