creation date: 2026-01-19 17:43
tags: Workups
Dysmenorrhea
Background
Dysmenorrhea refers to painful menstruation. It has a major impact on daily life including school attendance and work productivity.
Dysmenorrhea is described as recurrent, crampy, lower abdominal pain and typically associated with younger age, smoking, and stress.
Primary dysmenorrhea refers to dysmenorrhea in the absence of a demonstrable disease that could cause the symptoms and is a diagnosis of exclusion typically made in adolescents and young females.
Secondary dysmenorrhea refers to dysmenorrhea caused by a clinically identifiable disorder
Pathophysiology
Endometrial sloughing at the beginning of menses release prostaglandins which induce uterine contractions. They are high frequency, nonrhythmic, and results in elevated intrauterine pressures.
When intrauterine pressures exceed arterial pressure, uterine ischemia develops which stimulate type C pain neurons and thus dysmenorrhea.
Differential Diagnosis
Primary dysmenorrhea: dysmenorrhea in absence of demonstrable disease; diagnosis of exclusion typically made in adolescents and young females
Secondary dysmenorrhea
Urgent causes (requiring prompt evaluation and treatment):
- Pelvic inflammatory disease
- Tubo-ovarian abscess
- Anomalies of the reproductive tract
Non-urgent causes include:
- Endometriosis
- Adenomyosis
- Leiomyoma
- Hematometra (build up of fluid)
Alternative causes of pain include those unrelated to menstruation:
- Obstetric causes (pregnancy loss, ectopic pregnancy)
- Chronic pelvic pain syndromes
- Urologic causes (eg. simple cystitis, bladder pain syndrome, nephrolithiasis)
- Gastrointestinal causes (appendicitis, inflammatory bowel disease, diverticulitis, infectious colitis)
Initial Evaluation
History
HPI should include:
- Onset of pain 1-2 days before to with the onset of menstrual bleeding
- Quality of pain characteristic of dysmenorrhea (crampy, intermittently intense, continuously dull ache)
- Gradual diminishing of pain over 12-72 hours (although in some cases may persist as long as menstrual flow continues)
- Associated symptoms (eg. nausea, diarrhea, fatigue, headache, malaise)
Primary dysmenorrhea tends to begin early in life and improve with advancing age and childbirth while secondary dysmenorrhea tends to worsen over time and begin later in life.
A general menstrual history should be taken as well as past medical history and prior attempts at treatment.
Physical Exam
Physical exam is typically performed in adult patients and deferred in non-sexually active adolescents if history suggests primary dysmenorrhea.
Investigations
First line study consist of transvaginal ultrasound. Further workup depends on findings if any.