Basics
Description
Bothersome menses, usually presenting as cramping pain in lower abdomen or back
- Primary dysmenorrhea-in absence of any pelvic abnormalities
- Secondary dysmenorrhea-due to pelvic abnormalities, most commonly endometriosis or reproductive tract anomalies
Epidemiology
- Primary dysmenorrhea
- Typically begins in adolescence; prevalent in mid- to late adolescence when menstrual cycles become ovulatory
- Less common in the first 2-3 years following menarche when cycles are anovulatory
- Secondary dysmenorrhea is more common later in adolescence and in young adults; it has been estimated that 15% of young adult women suffer from chronic pelvic pain, with up to 97% of these women having endometriosis.
Prevalence
- Very common gynecologic complaint that affects up to 90% of adolescents
- 15% of adolescents report that the pain is "severe,"¯ limiting their daily activities.
- Many adolescents with dysmenorrhea either do not seek medical attention or are undertreated.
Risk Factors
- Early menarche
- Increased duration and amount of menstrual flow
- Nulliparity
- Cigarette smoking
- Low fish consumption
- Family history of dysmenorrhea
Genetics
- Dysmenorrhea is more common in patients with a positive family history.
- Particularly, there is a hereditary predisposition to endometriosis; mode of inheritance is polygenic, multifactorial, with expression related to interaction with environmental factors.
Pathophysiology
- Ovulation leads to increased progesterone release in the second half of the menstrual cycle. With the drop in progesterone late in the menstrual cycle, arachidonic acid and other omega-6 fatty acids are released, triggering an inflammatory response cascade involving prostaglandins (PGs) and leukotrienes (LTs).
- Uterine PGs and LTs cause myometrial contractions and endometrial artery vasoconstriction, resulting in uterine ischemia and in ensuing pain.
- PGF2alpha is thought to stimulate the myometrium and cause vasoconstriction.
- Severity of dysmenorrhea is directly proportional to endometrial PGF2alpha concentrations.
- Vasopressin, also elevated among women with dysmenorrhea, may play a secondary role by potentiating uterine contractions and ischemic pain.
- PGs and LTs can affect other body systems/organs, leading to dysmenorrhea-associated symptoms such as nausea/vomiting, diarrhea, and headaches.
- In endometriosis lesions, there is an inappropriate local aromatase activity, leading to a local rise in estrogen, which induces transcription of cyclooxygenase (COX)-2 and synthesis of PGE2. Aberrant expression of cytokines also mediates inflammation/pain.
- The distinct possibility of a m ¼llerian anomaly must also be considered as a cause for secondary dysmenorrhea.
Diagnosis
- Primary dysmenorrhea
- Painful, often spasmodic cramps of varying severity in the lower abdomen or back, starting hours to a few days prior to menses and lasting up to 2-3 days after the start of menses
- Pain is strongest in intensity initially, waning by the end of menses. Referred pain to lower back or thighs may occur.
- Secondary dysmenorrhea
- More likely to present with both cyclic and acyclic pain (chronic pelvic pain), metrorrhagia, and dyspareunia
History
- Given the high prevalence, screen all adolescent females for dysmenorrhea.
- Pain
- Ask about quality and intensity of pain (use pain scales); constant or intermittent occurrence; location; onset, timing, and duration; aggravating or alleviating factors; extent to which the pain limits activities (work, school, sports, social).
- Menstrual history
- Age at menarche: Dysmenorrhea is more common in girls with earlier menarche.
- Menstrual flow: Dysmenorrhea is more common in women with heavy/long menstrual flow.
- Last menstrual period (and previous one, if known)
- Cycle regularity
- Sexual history
- Parity, current sexual activity, contraception, and history of sexually transmitted infections (STIs) or pelvic inflammatory disease (PID). Adhesions may cause painful menses.
- Menstruation-associated symptoms: nausea, vomiting, diarrhea, headache, irritability, fatigue, breast tenderness, dizziness, bloating, and acne exacerbation
- History of sexual, physical, or emotional abuse
- Family history of gynecologic (GYN) diseases, including endometriosis, GYN or breast cancer, and complications with oral contraceptive pills (OCPs) including deep vein thrombosis (DVT), stroke, or myocardial infarction
- Medications: response to analgesic medications including name, dose, and perceived effectiveness
- Diet: Higher intake of omega-6 polyunsaturated fatty acids correlates with increased dysmenorrhea symptoms.
Alert
- The adolescent health care provider should screen for menstrual symptoms at every encounter with the adolescent female.
- Menstrual pain that started at menarche or immediately after menarche is unlikely to be primary dysmenorrhea, as most girls are still having anovulatory cycles.
- Cigarette smoking may increase duration of dysmenorrhea.
- Consider a workup of endometriosis for hard to manage dysmenorrhea.
Physical Exam
- Abdominal exam
- Lower abdomen/suprapubic tenderness
- Enlarged uterus can be palpated in vaginal outlet obstruction.
- Inspection of external genitalia: A cotton-tipped swab can be inserted into the vagina to evaluate for the presence of a transverse vaginal septum or vaginal agenesis.
- Pelvic exam
- Defer in younger girls with mild, classic symptoms and normal external genitalia who have never been sexually active.
- Perform in girls with history suggesting secondary dysmenorrhea, particularly if the patient failed treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
Diagnostic Tests & Interpretation
- Lab studies are generally not warranted.
- Consider testing for pregnancy, STIs, and PID as indicated by history and physical exam.
Imaging
- Consider pelvic ultrasound (US) for patients who fail a trial of NSAIDs.
- US can rule out genital tract abnormalities and ovarian pathologies.
- Pelvic US or pelvic magnetic resonance imaging (MRI) may be indicated, particularly to exclude obstructive anomalies.
- Although US and MRI can detect ovarian, vaginal, and bladder endometriosis and deeply infiltrative lesions, there are no good imaging modalities to detect intraperitoneal endometriosis lesions.
Diagnostic Procedures/Other
Consider a diagnostic laparoscopy with resection/ablation of lesions if indicated in patients with dysmenorrhea refractory to treatments with NSAIDs and OCPs, particularly if they have a 1st-degree relative with endometriosis.
Differential Diagnosis
Primary dysmenorrhea is a diagnosis of exclusion; secondary dysmenorrhea should be ruled out based on history, physical exam, response to initial treatment, and imaging if warranted.
- Causes of secondary dysmenorrhea
- Endometriosis, congenital vaginal or uterine anomalies, adenomyosis, ectopic pregnancy, ovarian cysts or tumors, pelvic adhesions, PID, uterine adhesions, fibroids, or polyps
- Other diagnoses to rule out:
- Gastrointestinal: constipation, diverticulitis, inflammatory bowel disease, irritable bowel syndrome
- Urologic: interstitial cystitis, kidney stones, urinary tract infection
- Neurologic: fibromyalgia, herniated disk, lower back pain
Treatment
Medication
First Line
- NSAIDs
- Conventional PG synthetase (COX) inhibitors
- If a patient fails to respond to the first choice at a therapeutic level, try a different NSAID.
- A COX-2 inhibitor should be considered in patients with prior history of peptic ulcer or gastrointestinal bleeding.
- 90% of patients have relief with proper dosing.
- Most effective when used on a regular basis for the first 2-3 days of menses
- If possible, start 1 day prior or at the onset of menses.
- Choices
- Ibuprofen: 800 mg initially, followed by 400-800 mg PO q8h as needed
- Naproxen sodium: 440-550 mg initially, followed by 220-550 mg PO q12h as needed
- Mefenamic acid: 500 mg PO initially, followed by 250 mg PO q6h as needed
- Celecoxib: 400 mg initially, followed by 200 mg q12h as needed (COX-2 inhibitor approved for girls ≥18 years)
- Side effects of conventional NSAIDs
- Black box warnings: increased risk of adverse cardiovascular events, including myocardial infarction, stroke, and new-onset or worsening of preexisting hypertension; increased risk of gastrointestinal irritation, ulceration, bleeding, and perforation
Second Line
- OCPs
- OCPs suppress ovulation and decrease uterine PG secretion following reduction in progesterone levels.
- Good choice for patients who fail NSAIDs as monotherapy, desire pregnancy prevention, or who have acne
- Patients may need 3 months to see improvement.
- Extended cycling OCPs: can prescribe formulation for a 91-day cycle (e.g., Seasonale, Seasonique) or use multiple OCP packs to achieve same effect
- Side effects: nausea, vomiting, breast tenderness, breakthrough menstrual bleeding, headaches from the estrogen; rare: DVT, stroke, myocardial infarction
- Long-acting hormonal contraceptives
- Long-acting combined estrogen and progestin hormonal contraceptives such as the transdermal patch and the vaginal ring as well as long-acting progestin-only hormonal contraceptives such as the injectable depot-medroxyprogesterone acetate, etonorgestrel subdermal implant, and the levonorgestrel-releasing intrauterine system can also alleviate dysmenorrhea symptoms.
- Secondary dysmenorrhea is treated by addressing the underlying cause. Extended OCP regimen is the first line of treatment for endometriosis. Medical management in patients refractory to noncyclic OCP may proceed to treatment with a gonadotropin-releasing hormone (GnRH) agonist.
Issues for Referral
Consider referral to adolescent gynecologist for possible laparoscopy or management of endometriosis.
Complementary & Alternative Therapies
- Supplementation with vitamin B1, magnesium, or omega-3 fatty acids have been shown to alleviate dysmenorrhea symptoms.
- Transcutaneous electrical nerve stimulation (TENS): Electrodes on the skin stimulate nerves at different current frequencies and intensities. Better results are reported with high frequency than with low frequency.
- Exercise may help to reduce symptoms of dysmenorrhea (due to release of endorphins).
- Acupuncture, yoga, and heat therapy may also reduce dysmenorrhea symptoms.
Surgery/Other Procedures
Laparoscopic techniques for interruption of the uterosacral nerves may be used as treatment for primary dysmenorrhea when other modalities have failed.
- Laparoscopic uterine nerve ablation (LUNA) is effective for long-term (≥12 months) pain relief in primary dysmenorrhea.
- Laparoscopic presacral neurectomy is more effective than LUNA for pain relief at ≥6 months follow-up but has significant side effects especially constipation; it should only be performed by pelvic laparoscopic surgeons with special training.
Alert
- There are a number of over-the-counter medicines that are marketed for treating cramps in women. Only those formulations that contain NSAIDs are effective in treating dysmenorrhea.
- Start an adequate dose of pain medication at first awareness of approaching menses.
- Estrogen and progestin hormones are also used for treatment of dysmenorrhea and do not lead to adolescent sexual activity.
Ongoing Care
Diet
Encourage patients to increase consumption of fish rich in omega-3 fatty acids.
Patient Education
- Stress to patients the importance of keeping a pain diary indicating days of menses, days of pain, pain ratings (0-10 scale), days of limited activities (school or work) due to pain, and associated symptoms.
- Web site for patient education materials
- American College of Obstetricians and Gynecologists. Dysmenorrhea. http://www.acog.org/~/media/For%20Patients/faq046.pdf?dmc=1&ts=20121119T1244369567
Prognosis
Improvement in dysmenorrhea symptoms may occur after childbirth.
Complications
Missed school or work, decreased academic performance, sports participation, and peer socialization
Additional Reading
- Falcone T, Lebovic DI. Clinical management of endometriosis. Obstet Gynecol. 2011;118(3):691-705. [View Abstract]
- Harel Z. Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies. Expert Opin Pharmacother. 2012;13(15):2157-2170.
- Harel Z. Dysmenorrhea in adolescents and young adults: from pathophysiology to pharmacological treatments and management strategies. Expert Opin Pharmacother. 2008;9(15):1-12.
Codes
ICD09
ICD10
- N94.6 Dysmenorrhea, unspecified
- N94.4 Primary dysmenorrhea
- N94.5 Secondary dysmenorrhea
SNOMED
- 266599000 Dysmenorrhea (disorder)
- 65754002 Primary dysmenorrhea (disorder)
- 32096006 Secondary dysmenorrhea
FAQ
- Q: What percentage of patients report dysmenorrhea?
- A: Although dysmenorrhea affects up to 90% of adolescents, fewer than 15% will seek medical care. It is important to screen all adolescent women for dysmenorrhea. Barriers to seeking physician advice include fears of pelvic exam and lack of knowledge of effective treatments.
- Q: When to refer a patient with dysmenorrhea to laparoscopy?
- A: Although pelvic US and MRI can detect some endometriosis lesions, there are no good imaging modalities to detect intraperitoneal endometriosis lesions. Therefore, a diagnostic laparoscopy with resection/ablation of lesions is indicated in patients with dysmenorrhea refractory to treatments with NSAIDs and hormones.