Diagnosis and Initial Management of Dysmenorrhea



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Am Fam Physician. 2014 Mar 1;89(5):341-346.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/dysmenorrhea/treatment.html.

Author disclosure: No relevant financial affiliations.

Dysmenorrhea is one of the most common causes of pelvic pain. It negatively affects patients' quality of life and sometimes results in activity restriction. A history and physical examination, including a pelvic examination in patients who have had vaginal intercourse, may reveal the cause. Primary dysmenorrhea is menstrual pain in the absence of pelvic pathology. Abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and duration of pain, and abnormal pelvic examination findings suggest underlying pathology (secondary dysmenorrhea) and require further investigation. Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected. Endometriosis is the most common cause of secondary dysmenorrhea. Symptoms and signs of adenomyosis include dysmenorrhea, menorrhagia, and a uniformly enlarged uterus. Management options for primary dysmenorrhea include nonsteroidal anti-inflammatory drugs and hormonal contraceptives. Hormonal contraceptives are the first-line treatment for dysmenorrhea caused by endometriosis. Topical heat, exercise, and nutritional supplementation may be beneficial in patients who have dysmenorrhea; however, there is not enough evidence to support the use of yoga, acupuncture, or massage.

Dysmenorrhea, defined as painful cramps that occur with menstruation, is the most common gynecologic problem in women of all ages and races,1 and one of the most common causes of pelvic pain.2 Estimates of the prevalence of dysmenorrhea vary widely (16.8% to 81%3), and rates as high as 90% have been recorded.4 Symptoms typically begin in adolescence and may lead to school and work absenteeism, as well as limitations on social, academic, and sports activities.5

Dysmenorrhea is considered primary in the absence of underlying pathology. Onset is typically six to 12 months after menarche, with peak prevalence occurring in the late teens or early twenties. Secondary dysmenorrhea results from specific pelvic pathology. It should be suspected in older women with no history of dysmenorrhea until proven otherwise.6 Symptoms include menorrhagia, intermenstrual bleeding, dyspareunia, postcoital bleeding, and infertility.

Endometriosis is the most common cause of secondary dysmenorrhea.7 The incidence is highest among women 25 to 29 years of age and lowest among women older than 44 years. Black women have a 40% lower incidence of endometriosis compared with white women.8  Table 1 lists risk factors for the development of dysmenorrhea; protective factors include regular exercise, oral contraceptive use, and early childbirth.6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

A pelvic examination should be performed in all sexually active patients with dysmenorrhea and in those in whom endometriosis is suspected.

C

11, 20

Nonsteroidal anti-inflammatory drugs should be used as first-line treatment for primary dysmenorrhea.

A

22

Oral contraceptives may be effective for relieving symptoms of primary dysmenorrhea, but evidence is limited.

B

27

Combined hormonal contraceptives and intramuscular, intrauterine, and subcutaneous progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis.

B

11, 25, 28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

A pelvic examination should be performed in all sexually active patients with dysmenorrhea and in those in whom endometriosis is suspected.

C

11, 20

Nonsteroidal anti-inflammatory drugs should be used as first-line treatment for primary dysmenorrhea.

A

22

Oral contraceptives may be effective for relieving symptoms of primary dysmenorrhea, but evidence is limited.

B

27

Combined hormonal contraceptives and intramuscular, intrauterine, and subcutaneous progestin-only contraceptives are effective treatments for dysmenorrhea caused by endometriosis.

B

11, 25, 28


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Risk Factors for Dysmenorrhea

Risk factorOdds ratio

Heavy menstrual loss

4.7

Premenstrual symptoms

2.4

Irregular menstrual cycles

2.0

Age younger than 30 years

1.9

Clinically suspected pelvic inflammatory disease

1.6

Sexual abuse

1.6

Menarche before 12 years of age

1.5

Low body mass index

1.4

Sterilization

1.4


Information from reference

The Authors

AMIMI S. OSAYANDE, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center in Dallas.

SUARNA MEHULIC, MD, was a resident in the Department of Family and Community Medicine at the University of Texas Southwestern Medical Center at the time the article was written.

Address correspondence to Amimi S. Osayande, MD, University of Texas Southwestern Medical Center, 5920 Forest Park Rd., Ste. 651, Mail code 9165, Dallas, TX 75235 (e-mail: amimi.osayande@utsouthwestern.edu). Reprints are not available from the authors.

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