Dysmenorrhea is one of the most common gynecological 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.
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. One systematic review of chronic pelvic pain and dysmenorrhea quotes a prevalence of between 47% to 97%. A cross-sectional study reported dysmenorrhea 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 dysmenorrhea are smoking, early menarche, nulliparity, and family history. 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. Validated questionnaires of patient reported outcomes may be useful in the initial assessment of dysmenorrhea and in assessing response to treatment.
Primary dysmenorrhea 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 dysmenorrhea at laparoscopy.
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. The diagnosis can be made clinically. Investigations fail to reveal an underlying pelvic pathology.
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 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 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.
- Primary dysmenorrhea
- Pelvic inflammatory disease
- Uterine leiomyoma (fibroids)
- Uterine polyps
- Ovarian cyst with hemorrhage
- Ovarian torsion
- Obstructive Mullerian duct anomalies
- Cervical stenosis
- Intrauterine devices
- Asherman syndrome
- Pelvic congestion syndrome
Martha Hickey, BA Hon, MSc (Clinical Psychology), MBChB, FRCOG, FRANZCOG, MD
Professor and Deputy Head
Department of Obstetrics and Gynaecology
University of Melbourne
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
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
MC declares that she has no competing interests.
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.
MAL, SI, SMM and LCL declare that they have no competing interests.
Vani Dandolu, MD, MPH
Ob/Gyn and Urology
Division of Urogynecology
Associate Residency Program Director
Temple University Hospital
VD declares that he has no competing interests.
Mohamed Mitwally, MD, HCLD, FACOG
Reproductive Endocrinology & Infertility Department
Baptist Medical Center
Odessa Reproductive Medicine
MM declares that he has no competing interests.
Robert Shaw, MD
Professor and Chair
Department of Neurology
Wake Forest University School of Medicine
RS declares that he has no competing interests.
Peter Reid, BSc, MD, FRCOG, FRANZCOG
Peel Health Campus
PR declares that he has no competing interests.
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