DYSMENORRHEA
Valerie Robinson D.O.
DEFINITION
• Dysmenorrhea – painful menstruation
• Symptoms – Recurrent episodes of uterine cramps and lower abdominal
pain during menstrual cycle.
• Primary dysmenorrhea – occurs in the absence of a disease process.
Common in adolescents and nulliparous women
• Secondary dysmenorrhea – occurs with a disorder causing the symptoms.
More common in women in their 30s-40s
PRIMARY DYSMENORRHEA
• Multiple risk factors may include
• Protective factors may include
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Age less than 30
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Young age at first childbirth
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BMI less than 20
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High parity
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Smoking
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Advancing age
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Menarche before age 12
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Longer menstrual cycles/bleeding
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Irregular or heavy cycles
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History of sexual assault
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Family history of dysmenorrhea
PRIMARY DYSMENORRHEA
SYMPTOMS
• Recurrent episodes of uterine cramps, lower abdominal pain, nausea,
vomiting, diarrhea, headache, backache during menstrual cycle.
• Usually begins in adolescence after ovulatory cycles begin.
(Usually 2-5 years after menarche)
• Prevalence is 60-93% in adolescents
• The defining symptom is crampy pelvic pain that is intermittently intense
and may range from mild to severe pain.
• Pain occurs with most or all menstrual cycles and may begin 1-2 days before
bleeding starts.
• Pain occurs midline and may radiate to back or thighs.
PRIMARY DYSMENORRHEA
PATHOGENESIS
• At the beginning of the menstrual cycle, the sloughing endometrial lining
releases prostaglandins, specifically E2 and F2-alpha
• The prostaglandins stimulate uterine contractions
• Prostaglandins also stimulate the GI tract, causing nausea, vomiting, diarrhea
• Contractions are frequent and uncoordinated and result in high intrauterine
pressures
• When the intrauterine pressure exceeds the arterial pressure, uterine
ischemia develops
• Ischemia of uterine tissue causes it to form anaerobic metabolites that in
turn stimulate pain fibers.
PRIMARY DYSMENORRHEA
DIAGNOSIS
• Rule out likely causes of secondary dysmenorrhea
(PID, endometriosis, adenomyosis, fibroids)
• Does it respond to treatment? If no relief after 3 months of tx, start
thinking secondary.
PRIMARY DYSMENORRHEA
TREATMENT
• NSAIDs – are prostaglandin synthetase inhibitors
• Patients with severe symptoms should take NSAIDs prior to menses
• Hormonal contraceptives – suppress ovulation, thin endometrium, and
thereby decrease prostaglandin production
• Copper IUDs may increase dysmenorrhea
• Adjunct tx – heat packs, exercise, relaxation techniques, TENS unit
•
Nitrates, calcium channel blockers and magnesium are under study d/t tocolysis
SECONDARY DYSMENORRHEA
SYMPTOMS
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May occur well after menarche
Abnormal uterine bleeding
Pain may not be midline
Absence of nausea, vomiting, diarrhea, and back pain
Dyspareunia
Dyschezia
Progression of symptoms
SECONDARY DYSMENORRHEA
CAUSES
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PID
Endometriosis
Adenomyosis
Fibroids
Ovarian cysts
Adhesions
Obstructive endometrial polyps
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Obstructive congenital malformation
Cervical stenosis
IUD
Pelvic congestion
IBS
IBD
Psychogenic
SECONDARY DYSMENORRHEA
DIAGNOSIS
• PID: pelvic pain, occurs during or shortly after menses, dyspareunia, AUB,
vaginal or urethral discharge, cervical motion tenderness, adnexal tenderness
• Endometriosis: premenstrual spotting, dyspareunia, dyschezia, progressive
course. Uterosacral ligament nodularity, thickening, or tenderness, cervical
stenosis, adnexal mass
• Adenomyosis: typically after age 35, may be related or unrelated to cycle, bulky,
mildly tender uterus
• Fibroids: more common in women >30. Dyspareunia, noncyclic pain,
menorrhagia, enlarged and irregularly shaped uterus, usually nontender
• Testing is based on suspicion
• Urine HCG if new-onset
• Culture for GC/CT
• Pelvic ultrasound
• Rarely, diagnostic laparoscopy
SECONDARY DYSMENORRHEA
TREATMENT
• PID – tx the STD. May need laproscopic lysis of adhesions
• Endometriosis – Progesterone IUD, GnRH agonist (nafarelin or leuprolide)
• Adenomyosis –progesterone IUD, GnRH agonist, aromatase inhibitors,
hysterectomy
• Fibroids – watch and wait, NSAIDs, hormonal contraception, GnRH
agonists, antiprogestin (mifepristone), myomectomy, hysterectomy
• Ovarian cysts, Adhesions, Obstructive endometrial polyps, IUD – Remove
• IBS/IBD – treat the cause
• Psychogenic - psychotherapy
REFERENCES
• Banikarim, Chantay, MD, MPH. “Primary dysmenorrhea in adolescents.”
UpToDate. Updated August 28, 2012
• Smith, Roger P., MD and Andrew M. Kaunitz MD. “Primary dysmenorrhea
in adult women: Clinical features and diagnosis.” UpToDate. Updated March
1, 2012.
• Smith, Roger P., MD and Andrew M. Kaunitz MD. “Treatment of primary
dysmenorrhea in adult women.” UpToDate. Updated April 24, 2012.
• Stewart, Elizabeth A., MD. “Overview of treatment of uterine leiomyomas
(fibroids).” UpToDate. Updated February 27, 2012.
• Stewart, Elizabeth A., MD. “Uterine adenomyosis.” UpToDate. Updated
September 6 2011.
COLLOQUIALISMS