Dysmenorrhea

Aka: Dysmenorrhea, Menstrual Cramps, Painful Menses, Menstrual Pain, Painful Menstrual Period

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II. Definitions

  1. Dysmenorrhea
    1. Painful Menses or Menstruation

III. Epidemiology

  1. Menstruating women who experience Dysmenorrhea: 50-75%
  2. Women with severe Dysmenorrhea: 10%
  3. Highest Incidence in adolescents

IV. Risk Factors

  1. Menorrhagia or heavy Menses (4.7 Odds Ratio)
  2. Premenstrual Syndrome (2.4 Odds Ratio)
  3. Metrorrhagia (esp. longer Menstrual Cycles) or irregular Menses (2.0 Odds Ratio)
  4. Age under 30 years old, especially under age 20 years old (1.9 Odds Ratio)
  5. Pelvic Inflammatory Disease (1.6 Odds Ratio)
  6. Sexual abuse (1.6 Odds Ratio)
  7. Early Menarche prior to age 12 years (1.5 Odds Ratio)
  8. Low Body Mass Index <20 kg/m2 or dieting (1.4 Odds Ratio)
  9. Tubal Ligation (1.4 Odds Ratio)
  10. Tobacco Abuse
  11. Mood Disorder (Major Depression or Anxiety Disorder)
  12. Nulliparity
  13. References
    1. Latthe (2006) BMJ 332(7544): 749-55 [PubMed]

V. Types

  1. Primary Dysmenorrhea (90%)
    1. Onset occurs within 6 to 12 months of Menarche
    2. Lifetime Prevalence of severe Dysmenorrhea: 50-60%
    3. Women incapacitated for 1-3 days of each cycle: 10%
    4. Hormonal and inflammatory level increases with no clear pelvic pathology
      1. Associated with increased Prostaglandin and Leukotriene levels
      2. Resulting inflammation with uterine contractility and cramping
  2. Secondary Dysmenorrhea: Acquired organic pelvic disease (10% of cases)
    1. See Secondary Dysmenorrhea for a complete list
    2. Emergent causes
      1. Ectopic Pregnancy
    3. Most common causes
      1. Endometriosis (most common)
        1. Pelvic Pain variable in timing and intensity
        2. Dyspareunia
      2. Pelvic Inflammatory Disease (PID)
        1. Dyspareunia
        2. Sexually Transmitted Infection
        3. Vaginal Discharge
    4. Other Common causes
      1. Uterine Myomata (Uterine Fibroids)
        1. Menorrhagia
      2. Adenomyosis (Endometriosis of Uterus)
        1. Menorrhagia
      3. Interstitial Cystitis
        1. Non-cyclical Suprapubic Pain with urinary tract symptoms
      4. Chronic Pelvic Pain
        1. Non-cyclical Pelvic Pain
    5. Miscellaneous causes
      1. See Chronic Pelvic Pain in Women
      2. Postsurgical adhesions
      3. Endometrial Polyps
      4. Cervical stenosis
      5. Congenital uterine anomaly
      6. Intrauterine Device (IUD)

VI. History: Findings suggestive of Secondary Dysmenorrhea

  1. Changed Dysmenorrhea character, location or intensity
  2. History of prior Sexually Transmitted Disease
  3. Prior abdominal or pelvic surgery
  4. Pelvic Pain persisting throughout cycle
  5. Infertility
  6. Abnormal Menstrual Bleeding
  7. Endometriosis type Rectal Pain or Dyspareunia
  8. Family History of Endometriosis (in a first degree relative)

VII. Symptoms

  1. Cramping or colicky suprapubic, lower abdominal or Pelvic Pain
    1. Pain begins within a few hours of menstrual flow
    2. Duration typically 8 to 72 hours
    3. Radiation of pain to lower back and thighs
    4. Severity is of moderate intensity in nearly half of patients (severe in <20% of patients)
  2. Gastrointestinal symptoms
    1. Nausea or Vomiting
    2. Abdominal Bloating
    3. Diarrhea
  3. Other associated symptoms
    1. Weakness
    2. Fatigue
    3. Headache
    4. Myalgias
    5. Low Back Pain
    6. Insomnia
  4. Palliative factors
    1. Oral Contraceptive use
    2. Following childbirth

VIII. Signs

  1. Normal Pelvic exam
    1. Suggests Primary Dysmenorrhea
  2. Uterosacral nodularity (and reduced uterine mobility)
    1. Suggests Endometriosis
  3. Thickened Adnexal Mass with mucopurulent cervical discharge and cervical motion tenderness
    1. Suggests Pelvic Inflammatory Disease
  4. Enlarged, irregular Uterus
    1. Suggests Uterine Fibroids
  5. Enlarged, boggy Uterus
    1. Suggests Adenomyosis

IX. Exam: Pelvic Examination

  1. May forego initial pelvic examination if patient has never been sexually active (Primary Amenorrhea)
  2. Should be performed on subsequent Secondary Dysmenorrhea evaluation
  3. Perform both pelvic exam and rectovaginal exam if Endometriosis is suspected

X. Differential Diagnosis

  1. See Chronic Pelvic Pain in Women

XI. Labs

  1. Initial presentation
    1. Urine Pregnancy Test in all sexually active patients
  2. Secondary Dysmenorrhea evaluation
    1. Urinalysis
    2. Pelvic Inflammatory Disease evaluation (with acute phase reactants)
      1. Complete Blood Count
      2. Erythrocyte Sedimentation Rate or C-Reactive Protein
    3. Vaginal Wet Prep
      1. If indicated for Vaginal Discharge
    4. Sexually Transmitted Disease screening
      1. Gonorrhea PCR
      2. Chlamydia PCR
  3. Other testing
    1. Update Cervical Cytology for Pap Smear if due

XII. Imaging: Pelvic Ultrasound findings related to Dysmenorrhea

  1. Ovarian Cysts
  2. Uterine Fibroids
  3. Advanced Endometriosis (Stage 3 or 4)

XIII. Precautions

  1. Delayed diagnosis of Secondary Dysmenorrhea is common (5.4 years in teens, 1.9 years in adults)

XIV. Management: Approach

  1. Step 1: Initial Dysmenorrhea Evaluation
    1. Obtain history (including red flags suggestive of Secondary Dysmenorrhea)
    2. Perform pelvic examination
    3. Urine Pregnancy Test
  2. Step 2: Empiric Primary Dysmenorrhea Management
    1. Treat with NSAIDS (see below)
    2. Consider Oral Contraceptives (see below)
    3. Consider general measures listed below
    4. Reevaulate every 6 months if symptoms controlled
  3. Step 3: Secondary Dysmenorrhea evaluation (if refractory Pelvic Pain to above measures)
    1. Obtain Secondary Dysmenorrhea evaluations as above (Urinalysis, CBC, ESR or CRP, STD testing)
    2. Consider pelvic Ultrasound
    3. Treat Pelvic Inflammatory Disease if present
  4. Step 4: Refractory Dysmenorrhea (with negative or nondiagnostic evaluation in step 3)
    1. Consider additional abdominal imaging (e.g. MRI or CT Abdomen and Pelvis)
      1. MRI Abdomen and Pelvis indications (if pelvic Ultrasound negative)
        1. Evaluate for Adenomyosis or Deep pelvic Endometriosis evaluation
    2. Consider Laparoscopy
    3. Consider Hysteroscopy
    4. Manage as Chronic Pelvic Pain

XV. Management: General measures

  1. Precautions
    1. No general measure is supported by high quality, large randomized trial
  2. Regular Exercise
    1. Matthewman (2018) Am J Obstet Gynecol 219(3):255 +PMID: 29630882 [PubMed]
    2. Armour (2019) Cochrane Database Syst Rev (9):CD004142 +PMID: 31538328 [PubMed]
  3. Supplements that have been used historically in the past (limited to no evidence to support)
    1. Thiamine 100 mg PO daily
    2. Vitamin E 2500 IU daily
      1. Started 2 days before Menses and continued for 5 days
    3. Omega-3 Fatty Acid Supplement 2 grams daily
      1. Harel (1996) Am J Obstet Gynecol 174:1335-8 [PubMed]
    4. Toki-shakuyakusan (TSS): Japanese herbal supplement
  4. Self-Applied Accupressure (via smartphone app)
    1. Blödt (2018) Am J Obstet Gynecol 218(2):227 +PMID: 29155036 [PubMed]
  5. Acupuncture or Acupressure (variable evidence)
    1. Helms (1987) Obstet Gynecol 69:51-6 [PubMed]
  6. Trancutaneous Electric Nerve Stimulation (TENS)
    1. Bai (2017) Medicine (Baltimore) 96(36):e7959 +PMID: 28885348 [PubMed]
  7. Low level heat patch placed inside underwear
    1. Complete relief in 70% of patients (35% with Placebo)
    2. Akin (2001) Obstet Gynecol 97:343-9 [PubMed]

XVI. Management: Medications

  1. Nonsteroidal Anti-inflammatory drugs (NSAIDs)
    1. No NSAID has proven efficacy better than another in Dysmenorrhea
      1. Scheduled and adequate dosing of the NSAID is the most important factor for effectiveness
    2. Timing
      1. Start NSAID at scheduled dosing 1-2 days before anticipated menstrual period
      2. Continue for 2-3 days into the menstrual period
    3. Ibuprofen 400 to 600 mg orally four times daily
    4. Naproxen (Naprosyn) 500 mg orally twice daily, then 250 mg orally four times daily
    5. NaproxenSodium (Anaprox) 275 mg orally four times daily
    6. Mefenamic Acid (Ponstel)
      1. Option 1: 500 mg for first dose, then 250 mg orally four times daily
      2. Option 2: 500 mg orally three times daily
    7. NSAIDS are highly effective in Dysmenorrhea
      1. Zhang (1998) Br J Obstet Gynaecol 105:780-9 [PubMed]
  2. COX-2 Inhibitor
    1. Celecoxib (Celebrex) 200 mg twice daily
  3. Hormonal Contraceptive use
    1. Estrogen and Progesterone options
      1. Standard Oral Contraceptives
        1. Ortho Cyclen (Norgestimate 0.25 mg and Ethinyl Estradiol 0.035 mg)
        2. Ortho Novum 1/35 (Norethindrone 1 mg and Ethinyl Estradiol 0.035 mg)
      2. Seasonal Oral Contraceptive Cycle (extended cycle Oral Contraceptives)
        1. Seasonique (Levonorgestrel 0.15 mg and Ethinyl Estradiol 0.03 mg)
        2. Amethyst (Levonorgestrel 0.09 mg and Ethinyl Estradiol 0.02 mg)
      3. Intravaginal device
        1. NuvaRing (Etonogestrel 0.12 mg and Ethinyl Estradiol 0.015 mg)
      4. Contraceptive Patch is not as effective as OCPs
        1. Audet (2001) JAMA 285:2347-54 [PubMed]
        2. Imai (2014) Clin Exp Obstet Gynecol 41(5):495-8 +PMID: 25864246 [PubMed]
    2. Progesterone only options
      1. Depo Provera (Medroxyprogesterone) 150 mg every 3 months
      2. Levonorgestrel IUD (Mirena)
        1. Baldaszti (2003) Contraception 67:87-91 [PubMed]
      3. Etonogestrel Implant (Nexplanon)
  4. Other medications that have been used anecdotally for Dysmenorrhea
    1. Nifedipine orally
    2. Terbutaline IV

XVII. Management: Refractory cases

  1. See Endometriosis
  2. See Chronic Pelvic Pain
  3. Consider gynecology Consultation for laparoscopy
    1. Evaluation for Secondary Dysmenorrhea cause (e.g. Endometriosis)
  4. Medications that have been used in severe cases (Gynecology prescribed)
    1. Danazol
    2. Leuprolide

XVIII. Prognosis

  1. Dysmenorrhea tends to improve with age and increasing Parity

XIX. Complications

  1. Work or school absence in 50% of patients (frequent absences in 10-15% of patients)
  2. Depressed Mood
  3. Anxiety Disorder
  4. Infertility
    1. Associated with Secondary Dysmenorrhea (esp. Endometriosis)

XX. References

  1. French (2005) Am Fam Physician 71(2):285-91 [PubMed]
  2. McKenna (2021) Am Fam Physician 104(2): 164-70 [PubMed]
  3. Osayande (2014) Am Fam Physician 89(5): 341-6 [PubMed]
  4. Proctor (2002) Clin Evid 7:1639-53 [PubMed]

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