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Dysmenorrhea
Taiwona Elliott, DO
image BASICS
DESCRIPTION
  • Pelvic pain occurring at/around time of menses; a leading cause of absenteeism for women <30 years old
  • Primary dysmenorrhea: pelvic pain without pathologic physical findings
  • Secondary dysmenorrhea: often more severe, results from specific pelvic pathology. Severity based on activity impairment
    • Mild: painful, rarely limits daily function, or requires analgesics
    • Moderate: daily activity affected, rare absenteeism, and requires analgesics
    • Severe: daily activity affected, likelihood absenteeism, limited benefit from analgesics
  • System affected: reproductive
  • Synonym(s): menstrual cramps
EPIDEMIOLOGY
  • Predominant age
    • Primary: onset 6 to 12 months after the start of menarche, teens to early 20s
    • Secondary: 20s to 30s
  • Predominant sex: women only
Prevalence
  • Up to 90% of menstruating females have experienced primary dysmenorrhea.
  • Up to 42% lose days of school/work monthly due to dysmenorrhea.
  • Up to 20% reported impairment in daily activities.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Primary: Elevated prostaglandin (PGF2&agr;) production through indirect hormonal control (stimulation of production by estrogen) causes nonrhythmic hypercontractility and increased uterine muscle tone with vasoconstriction and resultant uterine ischemia. Ischemia results in hypersensitization of type C pain nerve fibers. Intensity of cramps directly proportional to amount of PGF2&agr; released.
  • Secondary
    • Endometriosis (most common cause)
    • Congenital abnormalities of uterine/vaginal anatomy
    • Cervical stenosis
    • Pelvic inflammatory disease
    • Adenomyosis
    • Ovarian cysts
    • Pelvic tumors, especially leiomyomata (fibroids) and uterine polyps
Genetics
Not well studied
RISK FACTORS
  • Primary (1)
    • Cigarette smoking
    • Alcohol use
    • Early menarche (age <12 years)
    • Age <30 years
    • Irregular/heavy menstrual flow
    • Nonuse of oral contraceptives
    • Sexual abuse
    • Psychological symptoms (depression, anxiety, increased stress, etc.)
    • Nulliparity
  • Secondary (10%)
    • Pelvic infection
    • Use of intrauterine device (IUD)
    • Structural pelvic malformations
    • Family history of endometriosis in first-degree relative
GENERAL PREVENTION
  • Primary: Choose a diet low in animal fats.
  • Secondary: Reduce risk of sexually transmitted infections (STIs).
Pediatric Considerations
Onset with first menses raises probability of genital tract anatomic abnormality (i.e., transverse vaginal septum, imperforate or minimally perforated hymen, uterine anomalies).
COMMONLY ASSOCIATED CONDITIONS
  • Irregular/heavy menstrual periods
  • Longer menstrual cycle length/duration of bleeding
  • Endometriosis
image DIAGNOSIS
Based on characteristic history of suprapubic/low back cramping/pain occurring at or near menstrual flow onset lasting for 8 to 72 hours (2).
PHYSICAL EXAM
  • Primary: Physical exam typically is normal. Examine to rule out secondary dysmenorrhea. Pelvic exam is recommended if sexually active to rule out infection.
  • Secondary: Evaluate for cervical discharge, uterine enlargement, tenderness, irregularity, or fixation.
DIFFERENTIAL DIAGNOSIS
  • Primary: History is characteristic.
  • Secondary
    • Pelvic/genital infection
    • Complication of pregnancy
    • Missed/incomplete abortion
    • Ectopic pregnancy
    • Uterine/ovarian neoplasm
    • Endometriosis
    • UTI
    • Complication with IUD use
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Pregnancy test
  • Urine testing for infection
  • Gonorrhea/chlamydia cervical testing, especially in women age <25 years and in high-prevalence areas.
  • Primary: Consider pelvic ultrasound to rule out secondary abnormalities if history is not characteristic or suspected abnormality on exam.
  • Secondary: Ultrasound/laparoscopy to define anatomy for severe/refractory cases. MRI may be useful as second-line noninvasive imaging if ultrasound is nondiagnostic and torsion, deep endometriosis, or adenomyosis suspected.
Follow-Up Tests & Special Considerations
Counsel regarding appropriate preventive measures for STI and pregnancy.
Diagnostic Procedures/Other
Laparoscopy is rarely needed.
Test Interpretation
  • Primary: none
  • Secondary: Specific anatomic abnormalities may be noted (see “Differential Diagnosis”).
Pregnancy Considerations
Consider ectopic pregnancy when pelvic pain occurs with vaginal bleeding.
image TREATMENT
  • Reassure the patient that treatment success is very likely with adherence to recommendations.
  • Relief may require the use of several treatment modalities at the same time.
GENERAL MEASURES
  • Exercise and local heat are noninvasive general measures to relieve pain.
  • High-frequency transcutaneous electrical nerve stimulation (TENS) has been found to be beneficial. There is conflicting evidence for low-frequency TENS.
  • Secondary dysmenorrhea: Treatment of infections; suppression of endometrium if endometriosis suspected; remove IUD if contributing factor.
MEDICATION
First Line
  • NSAIDs: No NSAID has been found to be superior to others. Medication should be taken on scheduled dosing 1 to 2 days prior to onset of menses and continued for 2 to 3 days (2,3)[A]. If one NSAID preparation does not work, another NSAID preparation should be tried.
    • Ibuprofen 400 mg q8h
    • Naproxen sodium 500 mg BID
    • Celecoxib 400 mg × 1, then 200 mg q12h
    • Mefenamic acid 500 mg × 1, then 250 mg q6h
  • Hormonal contraceptives: recommended for primary dysmenorrhea in women desiring contraception (2)[B]. Directly limits endometrial growth resulting in reduced prostaglandin production and intrauterine pressure. Continuous rather than cyclic dosing may initially be more effective at reducing pain, however, may have similar benefit after 6 months (4)[B]. Estrogen-containing contraceptives are recommended as first-line for secondary dysmenorrhea due to endometriosis, although progestin-only methods have also been shown to be beneficial (2)[B].
  • Levonorgestrel IUDs can decrease primary dysmenorrhea (5)[B].
  • Potential contraindications to NSAIDs and combined oral contraceptives (COCs)
    • Platelet disorders
    • Gastric ulceration or gastritis
    • P.321

    • Thromboembolic disorders
    • Vascular disease
    • Migraine with aura
  • Precautions
    • GI irritation
    • Lactation
    • Coagulation disorders
    • Impaired renal function
    • Heart failure
    • Liver dysfunction
  • Significant possible interactions
    • Coumadin-type anticoagulants
    • Aspirin with other NSAIDs
Second Line
  • Local heat can help relieve pain and may be as effective as NSAIDs (2)[B].
  • Exercise may have beneficial effects in relieving pain (6)[B].
  • &bgr;2-adrenoceptor agonists have not definitively been shown to relieve pain in dysmenorrhea (7)[B].
  • Behavioral interventions, such as relaxation exercises, may help alleviate pain in primary dysmenorrhea.
SURGERY/OTHER PROCEDURES
Laparoscopic uterosacral nerve ablation has been shown to relieve pain at >12 months postoperatively.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Spinal manipulation has not been shown to be effective in treating pain (8)[A].
  • Chinese herbal medicine shows promising evidence of decreasing pain, but more evidence is needed.
  • Acupuncture treatments have been shown to decrease pain in dysmenorrhea, but further randomized, well-designed studies are needed (2,9)[B].
  • Acupoint stimulation, particularly noninvasive stimulation (acupressure), can relieve pain (10)[B].
  • Aromatherapy abdominal massage performed daily for 10 minutes, 7 days prior to onset of menses can decrease primary dysmenorrhea (11)[B].
  • Further research needed to determine benefit and safety for use of oral fennel, extracorporeal magnetic innervation, vitamin K1 injection into the spleen-6 acupuncture point, use of high-frequency vibratory stimulation tampon, and vaginal sildenafil.
INPATIENT CONSIDERATIONS
Both primary and secondary dysmenorrhea are usually managed in the outpatient setting.
Admission Criteria/Initial Stabilization
  • Primary: outpatient care
  • Secondary: usually outpatient care
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Normal
DIET
  • Vitamin B1 100 mg daily, omega-3 fatty acid, and fish oil supplementation may be beneficial (12)[B].
  • Magnesium has been shown to be useful, but the correct dosage has not been determined.
  • Insufficient evidence to show usefulness of zinc and vitamin E at this time
  • Low-fat vegetarian diet can be helpful in some patients (12).
PATIENT EDUCATION
Reassure the patient that primary dysmenorrhea is treatable with the use of NSAIDs, COCs, IUD, or local heat; and that it will usually abate with age and parity.
PROGNOSIS
  • Primary: reduced with age and parity
  • Secondary: likely to require therapy based on underlying cause
REFERENCES
1. Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-113.
2. Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014;89(5):341-346.
3. Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(1):CD000400.
4. Dmitrovic R, Kunselman AR, Legro RS. Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstet Gynecol. 2012;119(6):1143-1150.
5. Lindh I, Milsom I. The influence of intrauterine contraception on the prevalence and severity of dysmenorrhea: a longitudinal population study. Hum Reprod. 2013;28(7):1953-1960.
6. Brown J, Brown S. Exercise for dysmenorrhoea. Cochrane Database Syst Rev. 2010;(2):CD004142.
7. Fedorowicz Z, Nasser M, Jagannath VA, et al. Beta2-adrenoceptor agonists for dysmenorrhoea. Cochrane Database Syst Rev. 2012;(5):CD008585.
8. Kannan P, Claydon LS. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review. J Physiother. 2014;60(1):13-21.
9. Reyes-Campos MD, Díaz-Toral LG, Verdín-Terán SL, et al. Acupuncture as an adjunct treatment for primary dysmenorrhea: a comparative study. Med Acupunct. 2013;25(4):291-294.
10. Chen MN, Chien LW, Liu CF. Acupuncture or acupressure at the Sanyinjiao (SP6) Acupoint for the treatment of primary dysmenorrhea: a meta-analysis. Evid Based Complement Alternat Med. 2013;2013:493038.
11. Marzouk TM, El-Nemer AM, Baraka HN. The effect of aromatherapy abdominal massage on alleviating menstrual pain in nursing students: a prospective randomized cross-over study. Evid Based Complement Alternat Med. 2013;2013:742421.
12. Hansen SO, Knudsen UB. Endometriosis, dysmenorrhoea and diet. Eur J Obstet Gynecol Reprod Biol. 2013;169(2):162-171.
Additional Reading
&NA;
  • Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol. 2001;97(3):343-349.
  • Allen LM, Lam AC. Premenstrual syndrome and dysmenorrhea in adolescents. Adolesc Med State Art Rev. 2012;23(1):139-163.
  • Altunyurt S, Göl M, Altunyurt S, et al. Primary dysmenorrhea and uterine blood flow: a color Doppler study. J Reprod Med. 2005;50(4):251-255.
  • Bayer LL, Hillard PJ. Use of levonorgestrel intrauterine system for medical indications in adolescents. J Adolesc Health. 2013;52(4 Suppl):S54-S58.
  • Cho SH, Hwang EW. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG. 2010;117(5):509-521.
  • Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428-441.
  • Eby GA. Zinc treatment prevents dysmenorrhea. Med Hypotheses. 2007;69(2):297-301.
  • Kannan P, Claydon LS, Miller D, et al. Vigorous exercises in the management of primary dysmenorrhea: a feasibility study. Disabil Rehabil. 2015:37(15):1334-1339.
  • Khan KS, Champaneria R, Latthe PM. How effective are non-drug, non-surgical treatments for primary dysmenorrhoea? BMJ. 2012;344:e3011.
  • Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749-755.
  • Polat A, Celik H, Gurates B, et al. Prevalence of primary dysmenorrhea in young adult female university students. Arch Gynecol Obstet. 2009;279(4):527-532.
  • Proctor M, Farquhar C. Diagnosis and management of dysmenorrhea. BMJ. 2006:332(7550):1134-1138.
  • Zahradnik HP, Hanjalic-Beck A, Groth K. Non-steroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: a review. Contraception. 2010;81(3):185-196.
  • Zannoni L, Giorgi M, Spagnolo E, et al. Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol. 2014;27(5):258-265.
  • Zhu X, Proctor M, Bensoussan A, et al. Chinese herbal medicine for primary dysmenorrhoea. Cochrane Database Syst Rev. 2008;(2):CD005288.
See Also
&NA;
  • Endometriosis
  • Dyspareunia
  • Menorrhagia
  • Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)
  • Algorithm: Pelvic Pain
Codes
&NA;
ICD10
  • N94.6 Dysmenorrhea, unspecified
  • N94.4 Primary dysmenorrhea
  • N94.5 Secondary dysmenorrhea
Clinical Pearls
&NA;
  • Dysmenorrhea is a leading cause of absenteeism for women age <30 years.
  • In women who desire contraception, hormonal contraceptives are the preferred treatment.
  • All NSAIDs studied have been found to be equally effective in the relief of dysmenorrhea and should be initiated 1 to 2 days prior to onset of menses with scheduled dosing.