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Dysmenorrhoea refers to pain on menstruation, typically felt as abdominal cramps. It is a common disorder, particularly in teenagers, with up to 60% of young women experiencing symptoms.

  • It is the most common cause of school absence in teenage girls

Typically it is benign and treated symptomatically – referred to as primary dysmenorrhoea, but it is important to assess for a more serious underlying cause.






  • Location
  • Character (constant, colicky, ache, burning, stabbing)
  • Duration

GI symptoms

  • Nausea
  • Vomiting
  • Diarrhoea
  • Constipation
  • Pain associated to bowel opening?

Urinary symptoms

  • Dysuria
  • Frequency

Menstrual history

  • Age of menarche
  • Typical cycle length and regularity
  • Normal period duration and associated symptoms
  • Use of tampons / pads
    • How many?
    • How often changed?
    • Use of both tampons and pads together?
    • ”Flooding” of tampons / pads
  • Effect on school and other activities


  • What have they tried? (E.g. NSAIDs)
  • Is it effective?

Medical History

  • Previous surgery?
  • Family history of gynaecological issues?
    • Particularly endometriosis

Sexual history

  • First intercourse
  • Male / female partners
  • Route of intercourse
  • Contraception use
  • History or symptoms of STI
  • Vaccination history – particularly HPV
  • Pain or bleeding during sex


Abdominal examination

  • Palpable masses
  • Location of tenderness
  • Auscultate for bowel sounds
  • Any previous scars to indicated previous abdominal surgery?

Pelvic examination (PV examination)

  • NOT appropriate in an adolescent whom has never been sexually active
  • Indicated only if:
    • Sexual active AND
    • Not responding to conventional treatment, OR
    • Organic pathology is suspected
  • If indicated:
    • Speculum examination
    • Bimanual examination
    • Consider STI testing if indicated

Primary Dysmenorrhoea

Primary dysmenorrhoea typically presents in the teenage years, and responds well to NSAIDs.

In the absence of concerning features, a diagnosis of primary dysmenorrhoea can typically be made without any further investigation on the first consultation. Concerning features might include:

  • Dyspareunia
  • Post-coital bleeding
  • Vaginal discharge
  • Menorrhagia
  • Unilateral pain

If symptoms do not respond to treatment, then consider an alternative cause. Typically, treatment should be tried for 3 months before assessing its effectiveness.

History and examination

As above.


  • Primary dysmenorrhoea is often a diagnosis of exclusion, and typically investigation is not required
  • Consider abdominal USS if:
    • Palpable abdominal mass
    • No responding to usual management
  • Consider blood tests to rule out other causes:


First line

  • NSAIDs
    • Typically naproxen, up to 750mg daily, OR
    • Mefanamic acid 500mg TDS
    • Tranexamic acid – useful if there is also heavy menstruales blood loss

Second line

  • Oral contraceptive pill
    • Typically COCP
    • No evidence that any particular preparation is more effective than any other
  • May be chosen first line – especially if contraception is desirable
  • Can be used continually for up to 12 months as a time to minimise withdrawal bleed symptoms
    • If there is any breakthrough bleeding, advise to cease for 3-7 days until bleeding stops before recommencing
    • Most women will have some breakthrough bleeding if the pill is used for >120 days continuously

Third line


  • Review at 3 months
  • If not responding to treatment, refer for pelvic / transvaginal USS, and consider alternatives – the most likely being endometriosis
  • In a small percentage of women, dysmenorrhoea develops into chronic pelvic pain


  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

Read more about our sources

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) FRACGP currently works as a GP and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University, and is studying for a Masters of Sports Medicine at the University of Queensland. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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