Introduction

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.

 

Differentials

 

History

Pain

  • 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

Treatments

  • 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

Examination

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.

Investigation

  • 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:
    • FBC
    • Ferritin and iron studies
    • ESR
    • CRP

Management

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

  • Mirena IUD
  • Implanon

Follow-up

  • 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

References

  • 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

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