Dysmenorrhoea is one of the most common gynaecological symptoms affecting the quality of life of menstruating women. Its meaning, 'painful menstruation', is Greek in origin (dys meaning painful; meno meaning monthly; and rhoe meaning flow). 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.
Dysmenorrhoea is sub-categorised into primary and secondary, although it is not always easy to distinguish between the two based on history and examination alone:
Primary dysmenorrhoea occurs in the absence of pelvic pathology
Secondary dysmenorrhoea occurs in the presence of pelvic pathology.
The prevalence is difficult to determine because different definitions and criteria are used and dysmenorrhoea is often underestimated and undertreated. One systematic review of chronic pelvic pain and dysmenorrhoea quotes a prevalence of between 47% to 97%. A cross-sectional study reported dysmenorrhoea in 72% of young women at the age of 19 years, and in 15% of them, it was severe and affected daily activities. It 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.
Factors that correlate positively with dysmenorrhoea are smoking, early menarche, nulliparity, and family history. Dysmenorrhoea 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. Validated questionnaires of patient reported outcomes may be useful in the initial assessment of dysmenorrhoea and in assessing response to treatment.
Primary dysmenorrhoea often occurs in the 6 to 12 months following menarche, once ovulatory cycles have been established. It is more common in adolescents and women under 30 years, although underlying pathology may still be present. Endometriosis is common in adolescents, found in 70% of girls with dysmenorrhoea at laparoscopy.
Pain due to primary dysmenorrhoea 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, diarrhoea, fatigue, and headache. There may also be increased sensitivity to pain. The diagnosis can be made clinically. Investigations fail to reveal an underlying pelvic pathology.
By contrast, secondary dysmenorrhoea 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 to 48 hours of menstruation. Accompanying symptoms, such as irregular or heavy bleeding, vaginal discharge and dyspareunia can be suggestive of an underlying pelvic pathology.
Common causes of secondary dysmenorrhoea are endometriosis, chronic pelvic inflammatory disease, adenomyosis, intrauterine polyps, and fibroids. The presence of an intrauterine contraceptive devices (IUCD) is a potential iatrogenic cause. Less common causes include congenital uterine abnormalities, cervical stenosis, and an ovarian pathology.
- Primary dysmenorrhoea
- Pelvic inflammatory disease
- Uterine leiomyoma (fibroids)
- Uterine polyps
- Ovarian cyst with haemorrhage
- Ovarian torsion
- Obstructive Mullerian duct anomalies
- Cervical stenosis
- Intrauterine devices
- Asherman's syndrome
- Pelvic congestion syndrome
- Ectopic pregnancy and miscarriage: diagnosis and initial management
- Combined hormonal contraception
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