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.
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
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，通常在月经结束时缓解。
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.
http://www.ncbi.nlm.nih.gov/pubmed/28625286?tool=bestpractice.com
有关痛经患病率的报道差异很大。[7]Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-13.
https://www.doi.org/10.1093/epirev/mxt009
http://www.ncbi.nlm.nih.gov/pubmed/24284871?tool=bestpractice.com
根据 2006 年世界卫生组织的一项系统评价，月经期女性的痛经患病率为 16.8%-81%。[8]Latthe P, Latthe M, Say L, et al. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006 Jul 6;6:177.
https://www.doi.org/10.1186/1471-2458-6-177
http://www.ncbi.nlm.nih.gov/pubmed/16824213?tool=bestpractice.com
年轻女性的患病率通常更高，17-24 岁女性的患病率估计为 67%-90%。[7]Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-13.
https://www.doi.org/10.1093/epirev/mxt009
http://www.ncbi.nlm.nih.gov/pubmed/24284871?tool=bestpractice.com
[9]Harlow SD, Ephross SA. Epidemiology of menstruation and its relevance to women's health. Epidemiol Rev. 1995;17(2):265-86.
http://www.ncbi.nlm.nih.gov/pubmed/8654511?tool=bestpractice.com
[10]Kennedy S. Primary dysmenorrhoea. Lancet. 1997 Apr 19;349(9059):1116.
http://www.ncbi.nlm.nih.gov/pubmed/9113008?tool=bestpractice.com
澳大利亚一项研究发现，青少年女性中报道的痛经比例更高，达 93%。[11]Parker MA, Sneddon AE, Arbon P. The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large population-based study of Australian teenagers. BJOG. 2010 Jan;117(2):185-92.
https://www.doi.org/10.1111/j.1471-0528.2009.02407.x
http://www.ncbi.nlm.nih.gov/pubmed/19874294?tool=bestpractice.com
成年女性相关研究结果不太一致，患病率从 15% 到 75% 不等。[7]Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104-13.
https://www.doi.org/10.1093/epirev/mxt009
http://www.ncbi.nlm.nih.gov/pubmed/24284871?tool=bestpractice.com
[9]Harlow SD, Ephross SA. Epidemiology of menstruation and its relevance to women's health. Epidemiol Rev. 1995;17(2):265-86.
http://www.ncbi.nlm.nih.gov/pubmed/8654511?tool=bestpractice.com
痛经可导致误工误学。据报道，多达 50% 的痛经女性至少缺勤一次，5%-14% 的痛经女性经常缺勤。[12]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。[13]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
[14]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。[15]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。[16]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.
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。[17]ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018 Dec (Re-affirmed 2021);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
这一痛经在青少年及 30 岁以下女性中更常见，但她们仍可能存在基础疾病。子宫内膜异位症在青少年中常见。痛经少女中，经腹腔镜检查发现，子宫内膜异位症的平均患病率为 64%。[18]Hirsch M, Dhillon-Smith R, Cutner AS, et al. The prevalence of endometriosis in adolescents with pelvic pain: a systematic review. J Pediatr Adolesc Gynecol. 2020 Dec;33(6):623-30.
https://www.doi.org/10.1016/j.jpag.2020.07.011
http://www.ncbi.nlm.nih.gov/pubmed/32736134?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。[19]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。
登录或订阅即可浏览 BMJ Best Practice 临床实践完整内容