Am Fam Physician. 2021 Aug ;104(2):164-170.

  Patient information: See related handout on painful menstrual periods, written by authors of this article.

Author disclosure: No relevant financial affiliations.

Dysmenorrhea is common and usually independent of, rather than secondary to, pelvic pathology. Dysmenorrhea occurs in 50% to 90% of adolescent girls and women of reproductive age and is a leading cause of absenteeism. Secondary dysmenorrhea as a result of endometriosis, pelvic anatomic abnormalities, or infection may present with progressive worsening of pain, abnormal uterine bleeding, vaginal discharge, or dyspareunia. Initial workup should include a menstrual history and pregnancy test for patients who are sexually active. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives are first-line medical options that may be used independently or in combination. Because most progestin or estrogen-progestin combinations are effective, secondary indications, such as contraception, should be considered. Good evidence supports the effectiveness of some nonpharmacologic options, including exercise, transcutaneous electrical nerve stimulation, heat therapy, and self-acupressure. If secondary dysmenorrhea is suspected, nonsteroidal anti-inflammatory drugs or hormonal therapies may be effective, but further workup should include pelvic examination and ultrasonography. Referral to an obstetrician-gynecologist may be warranted for further evaluation and treatment.

Dysmenorrhea, which is defined as painful menstruation, affects up to 50% to 90% of adolescent girls and women of reproductive age.1,2 Nearly one-half of patients (45%) with symptoms of dysmenorrhea will present first to their primary care physician.3 Dysmenorrhea leads to decreased quality of life, absenteeism, and increased risk of depression and anxiety.4,5 Up to one-half of patients with dysmenorrhea miss school or work at least once, and 10% to 15% have regular absences during menses.68 A prospective longitudinal study of 400 patients with dysmenorrhea revealed that most have persistent symptoms throughout their years of menstruation, although some improvement in severity may occur, for example, after childbirth.9

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Clinical recommendationEvidence ratingComments

Empiric therapy should be initiated if the history is consistent with primary dysmenorrhea.1,19


Recommendation from consensus guidelines

Nonsteroidal anti-inflammatory drugs should be used as first-line treatment for primary dysmenorrhea.22


Systematic review of 80 randomized controlled trials

Combined estrogen-progestin oral contraceptives are an alternative first-line treatment or an adjunct to nonsteroidal anti-inflammatory drugs for primary dysmenorrhea.2628,30


Consistent findings from randomized controlled trials

The levonorgestrel-releasing intrauterine system (Mirena) is effective for the treatment of primary dysmenorrhea and secondary dysmenorrhea caused by endometriosis.31


Systematic review with consistent findings

Consider exercise, high-frequency transcutaneous electrical nerve stimulation, heat therapy, or self-acupressure as an alternative or adjunct to first-line therapies for dysmenorrhea.3237


Limited-quality evidence from randomized controlled trial and systematic review

Pelvic examination and ultrasonography should be completed if first-line therapy is ineffective or if symptoms of secondary dysmenorrhea are present.1,19


Recommendation from consensus guidelines

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 https://www.aafp.org/afpsort.

The Authors

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KATHRYN A. MCKENNA, MD, MPH, is associate director of the Penn Medicine Lancaster (Pa.) General Health Family and Community Medicine Residency Program....

COREY D. FOGLEMAN, MD, FAAFP, is deputy director of the Penn Medicine Lancaster General Health Family and Community Medicine Residency Program.

Address correspondence to Kathryn A. McKenna, MD, MPH, Penn Medicine Lancaster General Health Family and Community Medicine Residency Program, 540 N Duke St., 3rd Floor, Lancaster, PA 17604 (email: Kathryn.McKenna@pennmedicine.upenn.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

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