Dysmenorrhea is one of the most common gynecological symptoms affecting the quality of life of menstruating women. 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. The reported prevalence of dysmenorrhea varies substantially. 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%. A greater prevalence is generally observed in young women, with estimates ranging from 67% to 90% for those aged 17-24 years. An Australian study found that a higher proportion, 93%, of teenagers reported menstrual pain. Studies in adult women are less consistent, with rates varying from 15% to 75%. 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.
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, with a mean prevalence of 64% in 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
Use of this content is subject to our disclaimer