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Dysmenorrhea
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Dysmenorrhea
, Menstrual Cramps, Painful Menses
See Also
Primary Dysmenorrhea
Secondary Dysmenorrhea
Acute Pelvic Pain
Chronic Pelvic Pain
Definition
Dysmenorrhea: Painful Menses
Translation: Difficult Monthly Flow
Epidemiology
Menstruating women who experience Dysmenorrhea: 50-75%
Women with severe Dysmenorrhea: 10%
Highest
Incidence
in adolescents
Risk Factors
Menorrhagia
or heavy
Menses
(4.7
Odds Ratio
)
Premenstrual symptoms (2.4
Odds Ratio
)
Metrorrhagia
or irregular
Menses
(2.0
Odds Ratio
)
Age under 30 years old, especially under age 20 years old (1.9
Odds Ratio
)
Pelvic Inflammatory Disease
(1.6
Odds Ratio
)
Sexual abuse (1.6
Odds Ratio
)
Early
Menarche
prior to age 12 years (1.5
Odds Ratio
)
Low
Body Mass Index
or dieting (1.4
Odds Ratio
)
Tubal Ligation
(1.4
Odds Ratio
)
Tubal Ligation
(1.4
Odds Ratio
)
Tobacco Abuse
Mood Disorder
(
Major Depression
or
Anxiety Disorder
)
Nulliparity
References
Latthe (2006) BMJ 332(7544): 749-55 [PubMed]
Types
Primary Dysmenorrhea
(90%)
Onset occurs within 6 to 12 months of
Menarche
Lifetime
Prevalence
of severe Dysmenorrhea: 50-60%
Women incapacitated for 1-3 days of each cycle: 10%
Idiopathic with no clear pelvic pathology
Secondary Dysmenorrhea
: Acquired organic pelvic disease
Emergent causes
Ectopic Pregnancy
Most common causes
Endometriosis
(most common)
Pelvic Pain
variable in timing and intensity
Dyspareunia
Pelvic Inflammatory Disease
(PID)
Dyspareunia
Sexually Transmitted Infection
Vaginal Discharge
Other Common causes
Uterine Myoma
ta (
Uterine Fibroid
s)
Menorrhagia
Adenomyosis
(
Endometriosis of Uterus
)
Menorrhagia
Interstitial Cystitis
Non-cyclical
Suprapubic Pain
with urinary tract symptoms
Chronic Pelvic Pain
Non-cyclical
Pelvic Pain
Miscellaneous causes
Postsurgical adhesions
Endometrial Polyp
s
Cervical stenosis
Congenital uterine anomaly
Intrauterine Device
(IUD)
Etiology
Primary Dysmenorrhea
Prostaglandin-mediated high intensity contractions
Vasopressin
-mediated contractions
Reduces uterine
Blood Flow
via
Vasocon
striction
May result in ischemic pain
Prostaglandin mediated nerve terminal
Hypersensitivity
History
Findings suggestive of
Secondary Dysmenorrhea
Changed Dysmenorrhea character, location or intensity
History of prior
Sexually Transmitted Disease
Prior abdominal or pelvic surgery
Pelvic Pain
persisting throughout cycle
Infertility
Abnormal
Menstrual Bleeding
Endometriosis
type
Rectal Pain
or
Dyspareunia
Family History
of
Endometriosis
(in a first degree relative)
Symptoms
Cramping or colicky suprapubic, lower abdominal or
Pelvic Pain
Pain begins within a few hours of menstrual flow
Radiation of pain to lower back and thighs
Gastrointestinal symptoms
Nausea
or
Vomiting
Abdominal Bloating
Diarrhea
Other associated symptoms
Weakness
Fatigue
Headache
Palliative factors
Oral Contraceptive
use
Following childbirth
Signs
Normal Pelvic exam
Suggests
Primary Dysmenorrhea
Uterosacral nodularity (and reduced uterine mobility)
Suggests
Endometriosis
Thickened
Adnexal Mass
with mucopurulent cervical discharge and cervical motion tenderness
Suggests
Pelvic Inflammatory Disease
Enlarged, irregular
Uterus
Suggests
Uterine Fibroid
s
Enlarged, boggy
Uterus
Suggests
Adenomyosis
Exam
Pelvic Examination
May forego initial pelvic examination if patient has never been sexually active
Should be performed on subsequent
Secondary Dysmenorrhea
evaluation
Perform both pelvic exam and rectovaginal exam if
Endometriosis
is suspected
Labs
Initial presentation
Urine Pregnancy Test
Secondary Dysmenorrhea
evaluation
Urinalysis
Pelvic Inflammatory Disease
evaluation (with acute phase reactants)
Complete Blood Count
Erythrocyte Sedimentation Rate
or
C-Reactive Protein
Vaginal Wet Prep
If indicated for
Vaginal Discharge
Sexually Transmitted Disease
screening
Gonorrhea
PCR
Chlamydia
PCR
Other testing
Update
Cervical Cytology
for
Pap Smear
if due
Imaging
Pelvic
Ultrasound
findings related to Dysmenorrhea
Ovarian Cyst
s
Uterine Fibroid
s
Advanced
Endometriosis
(Stage 3 or 4)
Management
Approach
Step 1: Initial Dysmenorrhea Evaluation
Obtain history (including red flags suggestive of
Secondary Dysmenorrhea
)
Perform pelvic examination
Urine Pregnancy Test
Step 2: Empiric
Primary Dysmenorrhea
Management
Treat with
NSAID
S (see below)
Consider
Oral Contraceptive
s (see below)
Consider general measures listed below
Reevaulate every 6 months if symptoms controlled
Step 3:
Secondary Dysmenorrhea
evaluation (if refractory
Pelvic Pain
to above measures)
Obtain
Secondary Dysmenorrhea
evaluations as above (
Urinalysis
, CBC, ESR or CRP, STD testing)
Consider pelvic
Ultrasound
Treat
Pelvic Inflammatory Disease
if present
Step 4: Refractory Dysmenorrhea (with negative or nondiagnostic evaluation in step 3)
Consider additional abdominal imaging (e.g. MRI or
CT Abdomen and Pelvis
)
MRI
Abdomen
and
Pelvis
may be considered for
Adenomyosis
or deep pelvic
Endometriosis
evaluation (if pelvic
Ultrasound
negative)
Consider Laparoscopy
Consider Hysteroscopy
Manage as
Chronic Pelvic Pain
Management
Gene
ral measures
Precautions
No general measure is supported by high quality, large randomized trial
Supplements that have been used historically in the past (limited to no evidence to support)
Thiamine
100 mg PO daily
Vitamin E
2500 IU daily
Started 2 days before
Menses
and continued for 5 days
Omega-3 Fatty Acid Supplement
2 grams daily
Harel (1996) Am J Obstet Gynecol 174:1335-8 [PubMed]
Toki-shakuyakusan (TSS): Japanese herbal supplement
Acupuncture
or Acupressure
Helms (1987) Obstet Gynecol 69:51-6 [PubMed]
Trancutaneous Electric Nerve Stimulation (
TENS
)
Low level heat patch placed inside underwear
Complete relief in 70% of patients (35% with
Placebo
)
Akin (2001) Obstet Gynecol 97:343-9 [PubMed]
Management
Medications
Nonsteroidal Anti-inflammatory
drugs (
NSAID
s)
No
NSAID
has proven efficacy better than another in Dysmenorrhea
Start
NSAID
at scheduled dosing 1-2 days before anticipated menstrual period and continue for 2-3 days into the menstrual perior
Ibuprofen
400 to 600 mg orally four times daily
Naproxen
(
Naprosyn
) 500 mg orally twice daily, then 250 mg orally four times daily
Naproxen
Sodium
(
Anaprox
) 275 mg orally four times daily
Mefenamic acid (
Pons
tel)
Option 1: 500 mg for first dose, then 250 mg orally four times daily
Option 2: 500 mg orally three times daily
NSAID
S are highly effective in Dysmenorrhea
Zhang (1998) Br J Obstet Gynaecol 105:780-9 [PubMed]
COX-2 Inhibitor
Celecoxib
(
Celebrex
) 200 mg twice daily
Hormonal Contraceptive use
Estrogen
and
Progesterone
options
Standard
Oral Contraceptive
s
Ortho Cyclen
(
Norgestimate
0.25 mg and
Ethinyl Estradiol
0.035 mg)
Ortho Novum 1/35
(
Norethindrone
1 mg and
Ethinyl Estradiol
0.035 mg)
Seasonal Oral Contraceptive Cycle
(extended cycle
Oral Contraceptive
s)
Seasonique
(
Levonorgestrel
0.15 mg and
Ethinyl Estradiol
0.03 mg)
Amethyst
(
Levonorgestrel
0.09 mg and
Ethinyl Estradiol
0.02 mg)
Intravaginal device
NuvaRing
(Etonogestrel 0.12 mg and
Ethinyl Estradiol
0.015 mg)
Contraceptive Patch
is not as effective as OCPs
Audet (2001) JAMA 285:2347-54 [PubMed]
Progesterone
only options
Depo Provera
(
Medroxyprogesterone
) 150 mg every 3 months
Levonorgestrel
IUD (
Mirena
)
Baldaszti (2003) Contraception 67:87-91 [PubMed]
Etonogestrel Implant (
Nexplanon
)
Other medications that have been used anecdotally for Dysmenorrhea
Nifedipine
orally
Terbutaline
IV
Management
Refractory cases
See
Endometriosis
See
Chronic Pelvic Pain
Consider gynecology
Consultation
for laparoscopy
Evaluation for
Secondary Dysmenorrhea
cause (e.g.
Endometriosis
)
Medications that have been used in severe cases (Gynecology prescribed)
Danazol
Leuprolide
References
French (2005) Am Fam Physician 71(2):285-91 [PubMed]
Osayande (2014) Am Fam Physician 89(5): 341-6 [PubMed]
Proctor (2002) Clin Evid 7:1639-53 [PubMed]
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