Dysmenorrhea

Background

• Dysmenorrhea is the most common gynecologic problem in women of all ages and races.
• Symptoms of recurrent lower abdominal cramping with menstruation may be due to myometrial activity resulting in increased intensity of uterine contractions (primary dysmenorrhea), or due to an underlying physiologic or pathologic condition (secondary dysmenorrhea, which may occur due to endometriosis, adenomyosis, or uterine fibroids).
• Lower abdominal cramping typically occurs with the onset of menstruation and peaks with maximal menstrual flow. Pain may persist up to 2-3 days and radiate to the lower back, groin, and upper thighs.
• Peak onset of primary dysmenorrhea occurs during the late teens and early twenties with prevalence decreasing progressively after age 30 years. Risk factors include irregular menstrual cycles, low body mass index, tubal sterilization, sexual abuse, and family history of endometriosis.
• Risk factors for severe dysmenorrhea may include menarche at < 12 years old, increased duration and amount of menstrual flow, low fish consumption, smoking, or passive smoke exposure. Severe symptoms may result in school and work absenteeism and/or limitations on social, academic, and sports activities.

Evaluation

• Diagnosis of primary dysmenorrhea is based on clinical history and physical exam. Pelvic exam is usually normal in patients with primary dysmenorrhea and is not necessary in adolescents with suspected primary dysmenorrhea who are not sexually active.
• Suspect secondary dysmenorrhea in women > 30 years old with no history of dysmenorrhea and in all patients refractory to first-line medical therapy (Strong recommendation).
• Additional testing for diagnosis of secondary dysmenorrhea in women in mid- to late 20s or older with no history of dysmenorrhea, or in women refractory to first-line medical treatment may include
  • blood or urine test to exclude pregnancy
  • additional blood tests to help determine the underlying cause
  • transvaginal ultrasound to rule out other causes of pelvic pain if lab tests are inconclusive or negative
  • additional testing, based on clinical suspicion to rule out malignancy after inconclusive or negative findings on transvaginal ultrasound
  • laparoscopy, if results on noninvasive testing is inconclusive

Management

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment for primary dysmenorrhea unless there is a contraindication to their use. Cyclooxygenase (COX)-2 selective inhibitors may reduce pain in women with dysmenorrhea and may have fewer adverse gastrointestinal effects than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) (Strong recommendation).
• A heat patch on the lower abdomen may be a more effective treatment for dysmenorrhea than over-the-counter analgesics.
• Oral contraceptives may help relieve symptoms of primary dysmenorrhea and may be considered first-line treatment for women with dysmenorrhea who desire contraception (Strong recommendation). Consider continuous or extended use of contraceptives to avoid withdrawal bleeding and associated dysmenorrhea. Other hormonal contraceptives may also be used for the first-line treatment of primary dysmenorrhea (Strong recommendation).
• Exercise and a low-fat vegetarian diet may decrease symptoms in women with primary dysmenorrhea.
• Some vitamins, minerals, and supplements may be effective for the treatment of dysmenorrhea, including ginger, fenugreek, valerian, vitamin B1 alone, fish oil alone, fish oil/vitamin B1 combination, zataria, and zinc sulphate (Weak recommendation).
• Surgical intervention may be indicated to treat dysmenorrhea refractory to medical management (Weak recommendation).
• Treatment options for secondary dysmenorrhea vary and are based on treatment of the underlying cause.