痛经是影响月经期女性生活质量的最常见妇科症状之一。[1]Fernández-Martínez E, Onieva-Zafra MD, Parra-Fernández ML. The impact of dysmenorrhea on quality of life among Spanish female university students. Int J Environ Res Public Health. 2019 Feb 27;16(5):713.
https://www.doi.org/10.3390/ijerph16050713
http://www.ncbi.nlm.nih.gov/pubmed/30818861?tool=bestpractice.com
[2]Iacovides S, Avidon I, Bentley A, et al. Reduced quality of life when experiencing menstrual pain in women with primary dysmenorrhea. Acta Obstet Gynecol Scand. 2014 Feb;93(2):213-7.
https://www.doi.org/10.1111/aogs.12287
http://www.ncbi.nlm.nih.gov/pubmed/24266425?tool=bestpractice.com
[3]Al-Jefout M, Seham AF, Jameel H, et al. Dysmenorrhea: prevalence and impact on quality of life among young adult Jordanian females. J Pediatr Adolesc Gynecol. 2015 Jun;28(3):173-85.
https://www.doi.org/10.1016/j.jpag.2014.07.005
http://www.ncbi.nlm.nih.gov/pubmed/26046607?tool=bestpractice.com
[4]Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21:762-78.
http://www.ncbi.nlm.nih.gov/pubmed/26346058?tool=bestpractice.com
它意指“疼痛性月经”，来源于希腊词汇（dys 意指疼痛的；meno 指每月的；rhoe 指流出）。其表现为下腹痛或子宫痛性痉挛，发生在月经来潮前数日和/或经期，通常在月经结束时消退。
痛经可分为原发性和继发性，但是单纯依据病史和检查，并不总能轻易地区分这两种亚型：
在不存在盆腔疾病的情况下，为原发性痛经。
在存在盆腔疾病的情况下，为继发性痛经。
因为痛经的定义和诊断标准不同，所以难以估计发生率，并且经常低估和治疗不足。[5]Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332:1134-1138.
http://www.ncbi.nlm.nih.gov/pubmed/16690671?tool=bestpractice.com
[6]Burnett M, Lemyre M. No. 345-Primary Dysmenorrhea Consensus Guideline. J Obstet Gynaecol Can. 2017 Jul;39(7):585-95.
https://www.doi.org/10.1016/j.jogc.2016.12.023
http://www.ncbi.nlm.nih.gov/pubmed/28625286?tool=bestpractice.com
一项关于慢性盆腔痛和痛经的系统评价显示发生率为 47%-97%。[7]Zondervan KT, Yudkin PL, Vessey MP, et al. The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review. Br J Obstet Gynaecol. 1998;105:93-99.
http://www.ncbi.nlm.nih.gov/pubmed/9442169?tool=bestpractice.com
一项横断面研究报道，19岁的年轻女性中72%存在痛经，这其中有15%的女性痛经严重，影响日常活动。[8]Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol. 1982;144:655-660.
http://www.ncbi.nlm.nih.gov/pubmed/7137249?tool=bestpractice.com
它可能会导致误工误学，多达 50％ 的女性报告至少缺勤一次，5％-14％ 的女性报告经常缺勤。[9]Burnett MA, Antao V, Black A, et al. Prevalence of primary dysmenorrhea in Canada. J Obstet Gynaecol Can. 2005;27:765-770.
http://www.ncbi.nlm.nih.gov/pubmed/16287008?tool=bestpractice.com
与痛经呈正相关的因素包括吸烟、月经初潮过早、无生育史以及家族史。[10]Harlow SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol. 1996;103:1134-42.
http://www.ncbi.nlm.nih.gov/pubmed/8917003?tool=bestpractice.com
[11]Sundell G, Milsom I, Andersch B. Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol. 1990;97:588-594.
http://www.ncbi.nlm.nih.gov/pubmed/2390501?tool=bestpractice.com
痛经与月经周期的长短无关，但通常与月经量过多共存。许多女性存在诊断和治疗的延误。[12]Chen CX, Draucker CB, Carpenter JS. What women say about their dysmenorrhea: a qualitative thematic analysis. BMC Womens Health. 2018 Mar 2;18(1):47.
https://www.doi.org/10.1186/s12905-018-0538-8
http://www.ncbi.nlm.nih.gov/pubmed/29499683?tool=bestpractice.com
由患者报告结局组成的经验证问卷可能有助于对痛经的初步评估和疗效评估。[13]Gray TG, Moores KL, James E, et al. Development and initial validation of an electronic personal assessment questionnaire for menstrual, pelvic pain and gynaecological hormonal disorders (ePAQ-MPH). Eur J Obstet Gynecol Reprod Biol. 2019 Jul;238:148-156.
https://www.doi.org/10.1016/j.ejogrb.2019.05.024
http://www.ncbi.nlm.nih.gov/pubmed/31132692?tool=bestpractice.com
原发性痛经
一旦建立排卵周期，原发性痛经通常发生在初潮后的 6-12 个月。[14]ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018 Dec;132(6):1517-8.
https://journals.lww.com/greenjournal/Fulltext/2018/12000/ACOG_Committee_Opinion_No__760_Summary_.45.aspx
http://www.ncbi.nlm.nih.gov/pubmed/30461690?tool=bestpractice.com
这更常见于青少年和 30 岁以下女性，但仍可能存在基础病变。子宫内膜异位症常见于青少年，经腹腔镜检查发现 70％ 的痛经女童患该病。[15]Janssen EB, Rijkers AC, Hoppenbrouwers K, et al. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update. 2013 Sep-Oct;19(5):570-82.
https://www.doi.org/10.1093/humupd/dmt016
http://www.ncbi.nlm.nih.gov/pubmed/23727940?tool=bestpractice.com
原发性痛经引起的疼痛通常是下腹部痉挛性疼痛，可能放射至背部和大腿内侧。通常发生在月经来潮时，或者在月经来潮前仅数小时，通常持续 8-72 小时。疼痛还可伴随其他全身性症状，如呕吐、恶心、腹泻、乏力及头痛。还可能存在对疼痛的敏感性增加。[4]Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21:762-78.
http://www.ncbi.nlm.nih.gov/pubmed/26346058?tool=bestpractice.com
可根据临床表现诊断。检查未发现潜在的盆腔病变。
继发性痛经
相比之下，继发性痛经常发生在初潮后数年。或者在女性 30 多岁或 40 多岁确诊盆腔疾病时的新发症状。这种疼痛并不总是仅与月经期相关，甚至可贯穿整个黄体期。它可能随着月经进展加重，而非仅发生在月经来潮的最初 24-48 小时。一些伴随症状（例如，不规则出血、经量过多、阴道分泌物和性交痛）可能提示某种潜在的盆腔病变。[16]Dawood MY. Dysmenorrhea. Clin Obstet Gynecol. 1990;33:168-178.
http://www.ncbi.nlm.nih.gov/pubmed/2178834?tool=bestpractice.com
继发性痛经的常见病因有子宫内膜异位症、慢性盆腔炎性疾病、子宫腺肌病、子宫内膜息肉、子宫腺肌病、子宫内膜息肉以及纤维瘤。存在宫内节育器（intrauterine contraceptive device, IUCD）是一种潜在的医源性原因。较罕见的原因包括先天性子宫畸形、宫颈狭窄和卵巢病变。
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