Evaluation of dysmenorrhea

Overview 
Theory 
Emergencies 
Diagnosis 
Resources 

Last reviewed: 5 Oct 2024

Last updated: 28 Sep 2023

Dysmenorrhea is one of the most common gynecological symptoms affecting the quality of life of menstruating women.[1][2][3][4] It is experienced as lower abdominal pain or uterine cramps that occur during the few days prior to and/or during menstruation, and usually subsides at the end of menstruation.

Dysmenorrhea is subcategorized into primary and secondary, although it is not always easy to distinguish between the two based on history and exam alone:

Primary dysmenorrhea occurs in the absence of pelvic pathology
Secondary dysmenorrhea occurs in the presence of pelvic pathology.

The prevalence is difficult to determine because different definitions and criteria are used, and dysmenorrhea is often underestimated and undertreated.[5][6] The reported prevalence of dysmenorrhea varies substantially.[7] According to a systematic review by the World Health Organization in 2006, the prevalence of dysmenorrhea in menstruating women is between 16.8% and 81%.[8] A greater prevalence is generally observed in young women, with estimates ranging from 67% to 90% for those aged 17-24 years.[7][9][10] An Australian study found that a higher proportion, 93%, of teenagers reported menstrual pain.[11] Studies in adult women are less consistent, with rates varying from 15% to 75%.[7][9] Dysmenorrhea can lead to absenteeism from work or school, with up to 50% reporting at least one episode of absence, and 5% to 14% reporting frequent absence.[12]

Factors that correlate positively with dysmenorrhea are smoking, early menarche, nulliparity, and family history.[13][14] Dysmenorrhea is not associated with the duration of the menstrual cycle, but it usually coexists with heavy menstrual bleeding. Many women experience delays in diagnosis and management.[15] Validated questionnaires of patient reported outcomes may be useful in the initial assessment of dysmenorrhea and in assessing response to treatment.[16]

Primary dysmenorrhea

Primary dysmenorrhea often occurs in the 6-12 months following menarche, once ovulatory cycles have been established.[17] It is more common in adolescents and women under 30 years, although underlying pathology may still be present. Endometriosis is common in adolescents, with a mean prevalence of 64% in girls with dysmenorrhea at laparoscopy.[18]

Pain due to primary dysmenorrhea is usually lower abdominal and cramping in nature, and may radiate to the back and inner thigh. It usually occurs at the onset of menstruation, or precedes it by only a few hours, and typically lasts between 8 and 72 hours. The pain may be associated with other systemic symptoms such as vomiting, nausea, diarrhea, fatigue, and headache. There may also be increased sensitivity to pain.[4] The diagnosis can be made clinically. Investigations fail to reveal an underlying pelvic pathology.

Secondary dysmenorrhea

By contrast, secondary dysmenorrhea often occurs several years after the onset of menarche. It may arise as a new symptom when the woman is in her 30s or 40s in the setting of an identifiable pelvic disease. The pain is not consistently related to menstruation alone, and may occur throughout the luteal phase of the menstrual cycle. It may also worsen as menses progresses rather than being confined to the first 24-48 hours of menstruation. Accompanying symptoms, such as irregular or heavy bleeding, vaginal discharge and dyspareunia can be suggestive of an underlying pelvic pathology.[19]

Common causes of secondary dysmenorrhea are endometriosis, chronic pelvic inflammatory disease, adenomyosis, intrauterine polyps and fibroids. The presence of an intrauterine contraceptive device (IUCD) is a potential iatrogenic cause. Less common causes include congenital uterine abnormalities, cervical stenosis, and an ovarian pathology.

Differentials

Common

Primary dysmenorrhea
Pelvic inflammatory disease
Endometriosis
Adenomyosis
Uterine leiomyoma (fibroids)
Uterine polyps

Full details

Uncommon

Ovarian cyst with hemorrhage
Ovarian torsion
Obstructive Mullerian duct anomalies
Cervical stenosis
Intrauterine devices
Asherman syndrome
Pelvic congestion syndrome

Full details

Contributors

Authors

Martha Hickey, BA Hon, MSc (Clinical Psychology), MBChB, FRCOG, FRANZCOG, MD

Professor and Deputy Head

Department of Obstetrics and Gynaecology

University of Melbourne

Parkville

Victoria

Australia

Disclosures

MH declares that she has no competing interests.

Andrew Wemyss Horne, MB ChB, PhD, FRCOG, FRCP Edin

Professor of Gynaecology and Reproductive Sciences, Honorary Consultant Gynaecologist

MRC Centre for Reproductive Health

University of Edinburgh

Edinburgh

Disclosures

AWH declares that the MRC Centre for Reproductive Health has received grant funding from the NIHR, MRC, Chief Scientist’s Office, Wellcome Trust, Wellbeing of Women, Ferring and Roche to investigate treatments for endometriosis. The MRC Centre for Reproductive Health has received honoraria for consultancy work that AWM has carried out on endometriosis diagnosis and management for Ferring, Roche Diagnostics, Nordic Pharma and Abbvie. AWH receives royalties for his book "Endometriosis: an experts' guide to live well and manage your symptoms."

Michelle Cooper, MBChB, MRCOG, MFSRH, DipGUM

Consultant in Gynaecology and Sexual Health

Chalmers Centre

NHS Lothian

Edinburgh

Disclosures

MC declares that she has no competing interests.

Acknowledgements

Professor Martha Hickey, Professor Andrew Wemyss Horne, and Dr Michelle Cooper would like to gratefully acknowledge Dr Mary Ann Lumsden, Dr Stamatina Iliodromiti, Dr Suketu M. Mansuria, and Dr Linda C. Lang, the previous contributors to this topic.

Disclosures

MAL, SI, SMM, and LCL declare that they have no competing interests.

Peer reviewers

Vani Dandolu, MD, MPH

Associate Professor

Ob/Gyn and Urology

Director

Division of Urogynecology

Associate Residency Program Director

Temple University Hospital

Philadelphia

Disclosures

VD declares that he has no competing interests.

Mohamed Mitwally, MD, HCLD, FACOG

Medical Director

Reproductive Endocrinology & Infertility Department

Baptist Medical Center

Odessa Reproductive Medicine

San Antonio

Disclosures

MM declares that he has no competing interests.

Robert Shaw, MD

Professor and Chair

Department of Neurology

Wake Forest University School of Medicine

Winston-Salem

Disclosures

RS declares that he has no competing interests.

Peter Reid, BSc, MD, FRCOG, FRANZCOG

Specialist Gynaecologist

Peel Health Campus

Mandurah

Australia

Disclosures

PR declares that he has no competing interests.

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Evaluation of dysmenorrhea

Summary

Primary dysmenorrhea

Secondary dysmenorrhea

Differentials

Common

Uncommon

Contributors

Authors

Martha Hickey, BA Hon, MSc (Clinical Psychology), MBChB, FRCOG, FRANZCOG, MD

Disclosures

Andrew Wemyss Horne, MB ChB, PhD, FRCOG, FRCP Edin

Disclosures

Michelle Cooper, MBChB, MRCOG, MFSRH, DipGUM

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Vani Dandolu, MD, MPH

Disclosures

Mohamed Mitwally, MD, HCLD, FACOG

Disclosures

Robert Shaw, MD

Disclosures

Peter Reid, BSc, MD, FRCOG, FRANZCOG

Disclosures

Patient information

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