Contents
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
- Primary dysmenorrhoea
- The most common cause, and is discussed below
- Secondary dysmenorrhoea
- Endometriosis
- Adenomyosis
- Ovarian cyst
- Fibroids
- Adenomyosis
- Ectopic pregnancy
- Pelvic inflammatory disease
- Constipation
- Colitis
- UTI
- STI
- Irritable bowel syndrome
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
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