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Dysmenorrhea

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Dysmenorrhea, Menstrual Cramps, Painful Menses

  • See Also
  1. Primary Dysmenorrhea
  2. Secondary Dysmenorrhea
  3. Acute Pelvic Pain
  4. Chronic Pelvic Pain
  • Definition
  1. Dysmenorrhea: Painful Menses
  2. Translation: Difficult Monthly Flow
  • Epidemiology
  1. Menstruating women who experience Dysmenorrhea: 50-75%
  2. Women with severe Dysmenorrhea: 10%
  3. Highest Incidence in adolescents
  • Risk Factors
  1. Menorrhagia or heavy Menses (4.7 Odds Ratio)
  2. Premenstrual symptoms (2.4 Odds Ratio)
  3. Metrorrhagia 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 or dieting (1.4 Odds Ratio)
  9. Tubal Ligation (1.4 Odds Ratio)
  10. Tubal Ligation (1.4 Odds Ratio)
  11. Tobacco Abuse
  12. Mood Disorder (Major Depression or Anxiety Disorder)
  13. Nulliparity
  14. References
    1. Latthe (2006) BMJ 332(7544): 749-55 [PubMed]
  • 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. Idiopathic with no clear pelvic pathology
  2. Secondary Dysmenorrhea: Acquired organic pelvic disease
    1. Emergent causes
      1. Ectopic Pregnancy
    2. 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
    3. 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
    4. Miscellaneous causes
      1. Postsurgical adhesions
      2. Endometrial Polyps
      3. Cervical stenosis
      4. Congenital uterine anomaly
      5. Intrauterine Device (IUD)
  1. Prostaglandin-mediated high intensity contractions
  2. Vasopressin-mediated contractions
    1. Reduces uterine Blood Flow via Vasoconstriction
    2. May result in ischemic pain
  3. Prostaglandin mediated nerve terminal Hypersensitivity
  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)
  • Symptoms
  1. Cramping or colicky suprapubic, lower abdominal or Pelvic Pain
    1. Pain begins within a few hours of menstrual flow
    2. Radiation of pain to lower back and thighs
  2. Gastrointestinal symptoms
    1. Nausea or Vomiting
    2. Abdominal Bloating
    3. Diarrhea
  3. Other associated symptoms
    1. Weakness
    2. Fatigue
    3. Headache
  4. Palliative factors
    1. Oral Contraceptive use
    2. Following childbirth
  • 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
  • Exam
  • Pelvic Examination
  1. May forego initial pelvic examination if patient has never been sexually active
  2. Should be performed on subsequent Secondary Dysmenorrhea evaluation
  3. Perform both pelvic exam and rectovaginal exam if Endometriosis is suspected
  • Labs
  1. Initial presentation
    1. Urine Pregnancy Test
  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
  • Imaging
  • Pelvic Ultrasound findings related to Dysmenorrhea
  1. Ovarian Cysts
  2. Uterine Fibroids
  3. Advanced Endometriosis (Stage 3 or 4)
  • 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 may be considered for Adenomyosis or deep pelvic Endometriosis evaluation (if pelvic Ultrasound negative)
    2. Consider Laparoscopy
    3. Consider Hysteroscopy
    4. Manage as Chronic Pelvic Pain
  • Management
  • General measures
  1. Precautions
    1. No general measure is supported by high quality, large randomized trial
  2. 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
  3. Acupuncture or Acupressure
    1. Helms (1987) Obstet Gynecol 69:51-6 [PubMed]
  4. Trancutaneous Electric Nerve Stimulation (TENS)
  5. 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]
  • Management
  • Medications
  1. Nonsteroidal Anti-inflammatory drugs (NSAIDs)
    1. No NSAID has proven efficacy better than another in Dysmenorrhea
    2. Start NSAID at scheduled dosing 1-2 days before anticipated menstrual period and continue for 2-3 days into the menstrual perior
    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. 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
  • 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
  • References
  1. French (2005) Am Fam Physician 71(2):285-91 [PubMed]
  2. Osayande (2014) Am Fam Physician 89(5): 341-6 [PubMed]
  3. Proctor (2002) Clin Evid 7:1639-53 [PubMed]