Evaluation of dysmenorrhea

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

Evidence last reviewed: 21 Jul 2026

Topic last updated: 06 Aug 2026

Dysmenorrhea is one of the most common gynecological symptoms affecting the quality of life of women who menstruate.[1][2][3][4] People with dysmenorrhea typically experience lower abdominal pain or uterine cramps that occur in the days prior to and/or during menstruation, and subside by 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 true prevalence of dysmenorrhea is difficult to determine, as studies use varying definitions and diagnostic criteria. In some studies, even mild menstrual pain has been considered sufficient to define dysmenorrhea, while others have considered dysmenorrhea as menstrual pain associated with the need for drug and the inability to function normally. Also, dysmenorrhea is often underestimated and undertreated.[5][6] One systematic review and meta-analysis examining data from 70 countries reported a pooled global prevalence of dysmenorrhea of 71%.[7] A greater prevalence is generally observed in young women compared with older women, with estimates ranging from 55.1% to 89.0% for those ages 14-19 years.[8][9][10] Estimates of the prevalence in women age 18 and over also vary, ranging from 60% to 96%.[11][12][13] Dysmenorrhea can lead to absenteeism from work or school, with 50% of women with primary dysmenorrhea reporting at least one episode of absence, and 5% to 14% reporting frequent absence due to their symptoms.[12]

Factors that correlate positively with dysmenorrhea are smoking, early menarche, nulliparity, and family history.[14][15] Dysmenorrhea is not associated with the duration of the menstrual cycle, but often coexists with heavy menstrual bleeding. Many women experience delays in diagnosis and management.[16] A survey of more than 7500 women and girls in the UK found that one half of respondents felt their symptoms related to menstruation had been dismissed by friends, family, colleagues, and even health care professionals.[13] Validated questionnaires such as the Women’s Health Questionnaire, or the Menstrual Distress Questionnaire may be useful in the initial assessment of dysmenorrhea and in assessing response to treatment.[17]

Primary dysmenorrhea

Primary dysmenorrhea often begins in adolescence once ovulatory cycles have been established, 6-24 months after the menarche.[18]

Pain due to primary dysmenorrhea is usually lower abdominal and cramping in nature and may radiate to the back and inner thighs. 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 is commonly associated with other systemic symptoms such as vomiting, nausea, diarrhea, fatigue, and headache.[6] Patients may also have increased sensitivity to pain.[4] The diagnosis can be made clinically after available investigations fail to reveal an underlying pelvic pathology.

Secondary dysmenorrhea

Secondary dysmenorrhea often occurs several years after the onset of menarche. It may arise as a new symptom in the third or fourth decade, associated with identifiable pelvic pathology or disease. The pain may not be consistently related to menstruation alone, and may occur throughout the menstrual cycle. It may also worsen as menstruation progresses rather than being confined to the first 24-48 hours. 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 (IUD) is a potential iatrogenic cause. Less common causes include congenital uterine abnormalities, cervical stenosis, and 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

Alaina R. Francis, BSC, MHSc, MD

FRANZCOG trainee and Gynaecology Fellow

Royal Women’s Hospital

Parkville

Victoria

Australia

Disclosures

AF declares that she has no competing interests.

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

Professor

Department of Obstetrics, Gynaecology and Newborn Health

University of Melbourne

Parkville

Victoria

Australia

Head of Menopause Services

The Women’s Hospital

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 is listed as coinventor on a patent application (UK Patent App No. 2217921.2, International Patent App No. PCT/GB2023/053076) relating to a predictive test to determine the efficacy of gabapentin for chronic pelvic pain treatment. His institution has received honoraria for consultancy from Roche Diagnostics, Gesynta, and Joii and grant funding from Roche Diagnostics. AWH has received lecture fees from Theramex and Gedeon Richter and grant funding from the EU (Horizon), NIHR, CSO, UKRI, and Wellbeing of Women.

Michelle Cooper, MBChB, MRCOG, MFSRH, DipGUM

Consultant in Gynaecology and Sexual Health

Chalmers Centre

NHS Lothian

Edinburgh

Disclosures

MC declares that she has received research grant funding from the Chief Scientist Office (Scottish Government) and serves as a member of the BMJ SRH Editorial board.

Acknowledgements

Dr Alaina Francis, 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

Bradley Bruggeman, MD

Assistant Professor

Division of Academic Specialists in General Obstetrics and Gynecology

University of Florida College of Medicine

Gainesville, FL

Disclosures

BB 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.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Burnett M. Guideline no. 345: primary dysmenorrhea. J Obstet Gynaecol Can. 2025 May;47(5):102840. Abstract

Kho KA, Shields JK. Diagnosis and management of primary dysmenorrhea. JAMA. 2020 Jan 21;323(3):268-9. Abstract

Singh SS, Allaire C, Al-Nourhji O, et al. Guideline no. 449: diagnosis and impact of endometriosis - a Canadian guideline. J Obstet Gynaecol Can. 2024 May;46(5):102450. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Evaluation of dysmenorrhea

Summary

Primary dysmenorrhea

Secondary dysmenorrhea

Differentials

Common

Uncommon

Contributors

Authors

Alaina R. Francis, BSC, MHSc, MD

Disclosures

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

Bradley Bruggeman, MD

Disclosures

Peter Reid, BSc, MD, FRCOG, FRANZCOG

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Patient information

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