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

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

This clinical content conforms to AAFP criteria for CME.

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

Primary dysmenorrhea occurs in the absence of pelvic pathology. It is mediated by elevated prostaglandin and leukotriene levels, with inflammation causing uterine contractility and cramping pain.1,10

Secondary dysmenorrhea is due to pelvic pathology or a recognized medical condition and accounts for about 10% of cases of dysmenorrhea.1 The most common etiology is endometriosis. Other etiologies include congenital or acquired obstructive and nonobstructive anatomic abnormalities (e.g., müllerian malformations, uterine leiomyomas, adenomyosis), pelvic masses, and infection1 (Table 11,11 ).

Diagnosis*Characteristic signs and symptoms
EndometriosisInfertility; pain with intercourse, urination, or bowel movements
Ovarian cystsSudden onset and resolution; if twisted, can cause ovarian torsion
Uterine polypsIrregular vaginal bleeding
Uterine leiomyomasHeavy, prolonged periods; constipation or difficulty emptying the bladder possible; more common in older people
AdenomyosisHeavy bleeding, blood clots, pain with intercourse, abdominal tenderness; more common in older people
Pelvic inflammatory diseaseAbdominal pain, fever, vaginal discharge and odor, pain with intercourse, bleeding after intercourse
Congenital obstructive müllerian malformationsAmenorrhea, infertility, miscarriage
Pelvic adhesionsHistory of surgery, infertility, bowel obstruction, painful bowel movements, pain with change in position
Pelvic massesBloating, frequent urination, nausea
Cervical stenosisAmenorrhea, infertility

Risk Factors

Age younger than 30 years, body mass index less than 20 kg per m2, smoking, earlier menarche (younger than 12 years), longer menstrual cycles, heavy menstrual flow, and history of sexual abuse increase the risk of primary dysmenorrhea. Nulliparity, premenstrual syndrome, and a history of pelvic inflammatory disease are also associated with the disorder. Protective factors include increasing age, increasing parity, exercise, and oral contraceptive use.9,12

Secondary dysmenorrhea is associated with infertility, especially when caused by endometriosis.13 However, secondary dysmenorrhea associated with increasing gravidity, parity, and body mass index suggests a cause other than endometriosis.14

Clinical Presentation

Dysmenorrhea is typically described as cramping pain in the lower abdomen beginning at the onset of menstrual flow and lasting eight to 72 hours.15 It is often accompanied by nausea, vomiting, diarrhea, headaches, muscle cramps, low back pain, fatigue, and, in more severe cases, sleep disturbance.1,6 In a study of more than 400 patients with dysmenorrhea, 47% reported moderate pain, and 17% reported severe pain on a 0 to 10 visual analog scale.16

Primary dysmenorrhea begins an average of six to 12 months following menarche, corresponding with the initiation of ovulatory cycles, and tends to recur with every menstrual cycle.1

Symptoms of secondary dysmenorrhea may start immediately following menarche or may arise later in life.1 Symptoms more consistent with secondary dysmenorrhea include changes in or progressive worsening of pelvic pain, abnormal uterine bleeding, vaginal discharge, and dyspareunia.1,11

Diagnosis

Evaluation should begin with a complete medical, gynecologic, menstrual, family, and surgical history.1 The history should characterize whether pain coincides with menstruation and include which nonprescription therapies the patient has tried. A family history of similar symptoms may suggest endometriosis, and a history of pelvic surgery may suggest adhesions.1 Symptoms should be carefully elicited because many patients assume pain is a normal part of menstruation.8,17 In a study of more than 4,300 patients seeking care for symptoms of dysmenorrhea, nearly two-thirds were told nothing was wrong; this was even more likely when symptoms began during adolescence. 3 A substantial delay from symptom onset to diagnosis is common, ranging from 5.4 years in adolescents to 1.9 years in adults.3 In secondary dysmenorrhea, the time from onset of symptoms to surgically confirmed diagnosis may range from four to 11 years.18

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