Dysmenorrhea Zeev Harel MD Paula J.

Adams Hillard MD Basics Description Dysmenorrhea is the most common gynecologic complaint and the leading cause of recurrent short-term school or wor a!senteeism among female adolescents and young adults. "he ma#ority of dysmenorrhea is primary $or functional% and is associated with normal ovulatory cycles and with no pelvic pathology.

&n '()* of adolescents and young adults with severe dysmenorrhea+ pelvic a!normalities such as endometriosis and uterine anomalies may !e found $secondary dysmenorrhea%.

Age-,elated -actors Dysmenorrhea is not common in the (st ./0 years after menarche+ when most menstrual cycles are anovulatory. Dysmenorrhea !ecomes more prevalent with the esta!lishment of ovulatory menstrual cycles during mid and late adolescence.

"he incidence of primary dysmenorrhea decreases with age+ parity+ and the use of hormonal contraceptives. 1econdary dysmenorrhea increases with age.

2pidemiology Prevalence '3)* of adolescents e4perience dysmenorrhea5 (6* have severe symptoms. Among women in their .)s+ 73* e4perience dysmenorrhea5 ()* have severe symptoms.

1econdary dysmenorrhea depends on cause.

,is -actors Primary8 o 9ulliparity

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Heavy menstrual flow :igarette smo ing ;ow fish inta e Depression<An4iety<1e4ual a!use and poor school<wor performance are wea er factors.

1econdary8
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Pelvic infection<1"Ds 2ndometriosis

-amily history of endometriosis $ris factor for secondary dysmenorrhea% 9onmedicated &=D use =terine fi!roids

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>enetics 2ndometriosis is a genetic disorder of polygenic<multifactorial inheritance with 6/3* ris in (st-degree relatives. Pathophysiology Primary dysmenorrhea8 o After ovulation a !uildup of fatty acids occur in the phospholipids of the cell mem!ranes. "he high inta e of ?-7 fatty acids in the @estern diet results in a predominance of ?-7 fatty acids in the cell wall phospholipids.
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After the onset of progesterone withdrawal !efore menstruation+ these ?-7 fatty acids+ particularly arachidonic acid+ are released+ and a cascade of prostaglandins $P>% and leu otrienes $;"% is initiated in the uterus. "he inflammatory response+ mediated !y these P>s and ;"s+ produces !oth cramps and systemic symptoms such as nausea+ vomiting+ and headaches. &n particular+ the prostaglandin -.a+ :AB meta!olite of arachidonic acid+ causes potent vasoconstriction and myometrial contractions+ leading to ischemia and pain.

1econdary dysmenorrheaCpelvic pathology8

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24ternal to uterus

2ndometriosis $see topic% "umors Pelvic adhesions

=terine8

A!structing uterovaginal anomaly in teens Adhesions Pelvic inflammatory disease Adenomyosis =terine leiomyomas :ervical stenosis =terine polyps 9onhormonal &=Ds

Associated :onditions 1ymptoms of PMDD or PM1 may overlap. Menstrual molimina $unpleasant symptoms accompanying menstruation%+ including !loating+ !reast tenderness+ headaches+ nausea+ vomiting+ diarrhea Diagnosis 1igns and 1ymptoms Primary dysmenorrhea8 o 1ymptoms of lower a!dominal and pelvic pain typically accompany the start of menstrual flow or occur within a few hours !efore or after onset+ and last .D/3. hours.
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Pain may radiate to !ac or thighs.

1econdary dysmenorrhea8
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Pain may occur (/. wee s !efore menses $chronic pelvic pain or mid cycle pain% as well as dyspareunia5 pain typically throughout menstrual flow

History

:omplete menstrual+ gynecologic+ pain history Menstrual history8

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@hen was menarcheE -reFuency+ duration+ and amount of flow -reFuency of dysmenorrhea

Pain history8
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Anset+ duration+ intensity of pain $rate )/()% Does the pain occur at times other than menstruationE Medications ta en+ including A":5 dose+ freFuency+ efficacy Ather menstruation associated symptomsE

>ynecologic history<procedures8
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1e4ual history5 dyspareunia5 1"D history :ontraception

History of physical or se4ual a!use Past medical history8

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HospitaliGations 1urgeries :hronic medical conditions

-amily history8
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2ndometriosis =terine fi!roids Dysmenorrhea Hysterectomy

"o!acco use

,eview of 1ystems 1pecial attention to >& and >= systems 1pecial attention to contraindications to hormonal contraception Physical 24am @omen with primary dysmenorrhea have a normal physical e4am. @omen with secondary dysmenorrhea often have a normal e4am+ !ut the clinician may find8
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=terine+ adne4al+ or rectovaginal tenderness =terine enlargement+ adne4al masses :ervical displacement =terosacral nodularity :ervical stenosis

"ests

Most patients do not reFuire e4tensive evaluation. A trial of 91A&Ds is an important component of the evaluation !ecause secondary dysmenorrhea is less li ely to respond to 91A&Ds than is primary dysmenorrhea.

;a!s :urrently+ no la!oratory tests can distinguish !etween primary and secondary dysmenorrhea. &maging =ltrasound5 transvaginal if possi!le8 o Aids in the characteriGation of physical e4am a!normalities
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Allows the detection of uterine and adne4al lesions that may not !e detecta!le on e4am

Pelvic M,& study is indicated in adolescents when the e4am or ultrasound suggests o!structive anomaly.

P.0(

Differential Diagnosis &nfection P&D ="& "umor<Malignancy 2ndometrial polyp =terine or ovarian neoplasm

:ervical cancer

Ather<Miscellaneous :ongenital anomalies of the uterus or vagina :omplications of pregnancy

Missed or incomplete a!ortion 2ctopic pregnancy 2ndometriosis Adenomyosis Pelvic adhesions >& pathology :omplications of intrauterine device

Management >eneral Measures Assess the patientHs degree of symptoms. Assess whether the patient has already ta en A": medication $type+ dose%. 1pecial "herapy :omplementary and Alternative "herapies "opical heat therapy8 o Better pain relief than acetaminophen alone
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1imilar to the relief o!tained !y low-dose i!uprofen.

&nterventions such as her!al preparations+ transcutaneous nerve stimulation+ and acupuncture have !een reported to improve dysmenorrhea in some studies. 1ome evidence suggests that a low-fat vegetarian diet may help some women. High inta e of fish rich in ?-0 fatty acids has !een correlated with less dysmenorrhea symptoms. 1ome women o!tain relief with aero!ic e4ercise+ although other women o!tain no !enefit.

Medication $Drugs% 91A&Ds8 o Decrease prostaglandin production+ there!y decreasing the discomfort of uterine contractions
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'3)* e4perience partial or total pain relief+ compared to (6* with place!o &!uprofen+ napro4en+ and mefenamic acid are used commonly for the treatment of dysmenorrhea. A loading dose of 91A&D $typically twice the regular does% should !e used as initial treatment+ followed !y a regular dose as needed. A :AB-. inhi!itor $:eleco4i!% may !e considered in patients with a history of peptic ulcer or with a history of conventional 91A&D >& adverse effects.

Hormonal therapy8
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:om!ined A:Ps $may !e considered for first-line of therapy in a se4ually active female% .(<3 or e4tended cycle DMPA $Depo-Provera% ;evonorgestrel intrauterine system $Mirena%

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Ather therapies for secondary dysmenorrhea8

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>n,H agonists such as ;euprolide acetate $;upron% I<- add !ac se4 steroid therapy Aromatase inhi!itors Ather therapies specific to cause $e.g.+ anti!iotics for P&D%

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1urgery Persistent dysmenorrhea despite appropriate dose and freFuency of 91A&Ds and after a trial of oral contraceptives should prompt a reconsideration of the diagnosis of primary dysmenorrhea and consideration of diagnostic laparoscopy. 1urgical correction of o!structing anomalies

&n select women+ lysis of adhesions or a!lation therapy for endometriosis may !e indicated. Alder women with disa!ling symptoms of adenomyosis or severe endometriosis may infreFuently reFuire hysterectomy.

-ollowup Patients should have an initial follow up visit in ./0 months and periodic reassessment after. Disposition

&ssues for ,eferral &f a secondary cause of dysmenorrhea or if another source of chronic pelvic pain is suspected+ the patient may !enefit from referral to a gynecologist with e4pertise in dealing with pelvic pain. &f o!structing anomalies are present+ referral to a gynecologist with e4perience in these conditions is indicated. Prognosis Primary8 &mproves with age and parity 1econdary8 ;i ely to reFuire therapy !ased on underlying cause Patient Monitoring &n rare cases+ hospitaliGation may !e needed for pain control or rehydration. &f symptoms of depression or an4iety+ reassess during a painfree period+ as they may !e independently present. Bi!liography A in M+ et al. :ontinuous+ low-level topical heat in the treatment of primary dysmenorrhea. A!stet >ynecol. .))(5J380D0. Amsterdam ;;. AnastraGole and oral contraceptives8 A novel treatment for endometriosis. -ertil 1teril. .))65KD80)). :oo A1+ et al. ,ole of laparoscopy in the treatment of endometriosis. -ertil 1teril. (JJ(5668770. Deutch B. Menstrual pain in Danish women correlated with low n-0 polyunsaturated fatty acid inta e. 2ur J :lin 9utr. (JJ65DJ86)K. Helms JM. Acupuncture for the management of primary dysmenorrhea. A!stet >ynecol. (JK357J86(. Horns!y PP+ et al. :igarette smo ing and distur!ance of menstrual function. 2pidemiology. (JJK5J8(J0. Lotani 9+ et al. Analgesic effect of an her!al medicine for treatment of primary dysmenorrheaCa dou!le !lind study. Am J :hin Med. (JJ35.68.)6. Awen P,. Prostaglandin synthetase inhi!itors in the treatment of primary dysmenorrhea. Am J A!stet >ynecol. (JKD5(DK8J7. Proctor M;+ et al. :om!ined oral contraceptive pill $A:P% as treatment for primary dysmenorrhea. :ochrane Data!ase 1yst ,ev. .))(. ,ees M:P+ et al. Prostaglandins in menstrual fluid in menorrhagia and dysmenorrhea. Br J A!stet >ynaecol. (JKD5J(8730. 1undell >+ et al. -actors influencing the prevalence and severity of dysmenorrhea in young women. Br J A!stet >ynaecol. (JJ)5J386KK. Miscellaneous 1ynonym$s% Menstrual cramps :linical Pearls M Adolescents with a clinical history suggestive of primary dysmenorrhea can !e evaluated with a careful history and managed with 91A&Ds. M Dysmenorrhea unrelieved !y 91A&Ds should prompt consideration of :A:s. M Persistent dysmenorrhea after 91A&Ds and :A:s should prompt further evaluation. A!!reviations M :A:C:om!ination oral contraceptive M :ABC:ycloo4ygenase

M >n,HC>onadotropin-releasing hormone M A:PCAral contraceptive pill M P&DCPelvic inflammatory disease M PMDDCPremenstrual dysphoric disorder M PM1CPremenstrual syndrome M ="&C=rinary tract infection :odes &:DJ-:M M 7.6.0 Dysmenorrhea M 7.6.J Pelvic pain Patient "eaching M :are providers should e4plain the physiologic etiology of dysmenorrhea. M A review of effective treatment options should !e provided. M Discuss evidence regarding her!al+ dietary+ and alternative therapies. ,egular e4ercise and heat may !e !eneficial. M ,eassure patient that primary dysmenorrhea is treata!le with use of 91A&Ds and<or A:Ps+ and that normal activities during menses should !e the goal. M 2ncourage use of 91A&Ds $over-the-counter or prescription% ta en prophylactically prior to e4pected menses on a scheduled !asis. M Discourage use of A":s without proven efficacy. M A:A> Patient 2ducation pamphlet availa!le at http8<<www.acog.org. Prevention M Primary dysmenorrhea8 9ot well esta!lished M 1econdary dysmenorrhea8 ,educe ris of 1"Ds