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Dysmenorrhoea

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ACOG dysmenorrhea management committee opinion primary dysmenorrhea

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https://www.acog.org/womens-health/faqs/dysmenorrhea-painful…

Dysmenorrhoea

Dysmenorrhoea means painful menstruation, usually felt as cramping lower-abdominal or pelvic pain just before or during the period. It can radiate to the back or thighs and may be accompanied by nausea, diarrhoea, headache, dizziness, or fatigue.

Types

  1. Primary dysmenorrhoea
    • Period pain without a pelvic disease.
    • Usually begins within 6-12 months after menarche, once ovulatory cycles begin.
    • Caused largely by increased endometrial prostaglandins, which cause strong uterine contractions and reduced uterine blood flow.
    • Pain commonly starts just before or with bleeding, peaks during the first 24-48 hours, and settles within 2-3 days.
  2. Secondary dysmenorrhoea
    • Painful periods due to an underlying condition.
    • Common causes include endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, ovarian cysts, and occasionally an intrauterine device.
    • It may begin later in life, progressively worsen, occur outside menstruation, or be associated with heavy/irregular bleeding or pain during sex.

Management of likely primary dysmenorrhoea

  • NSAIDs are first-line, for example ibuprofen or naproxen, if safe for the individual. They reduce prostaglandin production and are most effective when started at the first sign of pain or bleeding, or just before the expected period, then continued for the first 2-3 days. Harrison’s Principles of Internal Medicine, 22e, p. 894.
  • Hormonal contraception such as combined oral contraceptive pills or progestin-only options can be used if contraception is wanted or if NSAIDs alone are insufficient. They reduce endometrial growth and prostaglandin production. AAFP review
  • Heat pads, regular exercise, adequate sleep, and stress-management strategies may help symptoms. Evidence for supplements, acupuncture, and dietary interventions is less certain. Harrison’s Principles of Internal Medicine, 22e, p. 894.
Avoid NSAIDs without medical advice if you have a past stomach ulcer or GI bleeding, kidney disease, certain asthma or aspirin reactions, a bleeding disorder, take anticoagulants, or may be pregnant. The ACOG patient guidance also advises caution with these conditions.

Seek medical assessment if you have

  • New or worsening severe pain, especially after years of previously tolerable periods
  • Heavy bleeding, bleeding between periods, or irregular cycles
  • Pain during sex, persistent pain between periods, infertility, fever, or abnormal vaginal discharge
  • Severe pain from the first period, or no response after about 3-6 months of appropriate NSAID/hormonal treatment
  • Possible pregnancy with pelvic pain or bleeding, which needs urgent assessment
A clinician may take a menstrual and sexual history, do a pregnancy test when relevant, examine the pelvis, and arrange pelvic ultrasound if secondary dysmenorrhoea is suspected. Endometriosis is a frequent underlying cause.

Dd

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dysmenorrhea differential diagnosis secondary causes AAFP

DD = differential diagnosis of dysmenorrhoea, especially secondary dysmenorrhoea:
  • Endometriosis - most common cause; progressive pain, pain during sex, infertility, bowel/bladder symptoms with periods.
  • Adenomyosis - heavy painful periods, enlarged tender uterus, commonly later reproductive age.
  • Uterine fibroids (leiomyomas) - heavy/prolonged bleeding, pelvic pressure or enlarged irregular uterus.
  • Pelvic inflammatory disease / chronic endometritis - pelvic pain with discharge, fever, cervical-motion tenderness, STI risk.
  • Ovarian cyst or pelvic mass
  • Müllerian anomalies / outflow obstruction - often severe pain from menarche, especially in adolescents.
  • Copper IUD-related pain
  • Cervical stenosis or polyps
  • Non-gynaecological mimics: irritable bowel syndrome, inflammatory bowel disease, urinary tract disorders, pelvic-floor or musculoskeletal pain.
Features favoring secondary rather than primary dysmenorrhoea: later onset, pain worsening over time, abnormal/heavy bleeding, pain between periods, dyspareunia, discharge, infertility, or poor response to NSAIDs/hormonal treatment. Pelvic examination and pelvic ultrasound are usually appropriate when these are present. Berek & Novak’s Gynecology describes secondary dysmenorrhoea as cyclic pain due to pelvic pathology, including endometriosis, adenomyosis, PID, IUDs, ovarian cysts, and congenital anomalies. AAFP differential review

Dysmenorrhoea and related terms

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ACOG menstrual terminology dysmenorrhea amenorrhea menorrhagia oligomenorrhea definitions

Dysmenorrhoea and related menstrual terms

TermMeaning
DysmenorrhoeaPainful menstruation, usually lower abdominal cramps during or just before periods.
Primary dysmenorrhoeaPainful periods without pelvic pathology. Usually begins within 1-2 years after menarche and is related to prostaglandin-mediated uterine contractions.
Secondary dysmenorrhoeaPainful periods caused by pathology, such as endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, or a pelvic mass.
MenorrhagiaTraditional term for abnormally heavy menstrual bleeding occurring at regular intervals. The preferred modern term is heavy menstrual bleeding.
HypomenorrhoeaUnusually scanty menstrual flow.
OligomenorrhoeaInfrequent menstrual periods, generally cycles more than 35-38 days apart.
PolymenorrhoeaFrequent menstrual periods, traditionally cycles less than 21 days apart.
AmenorrhoeaAbsence of menstruation. Primary: no first period by age 15. Secondary: periods stop for at least 3 months in someone with previously regular cycles.
MetrorrhagiaBleeding between expected menstrual periods. Now generally described as intermenstrual bleeding.
MenometrorrhagiaHeavy and irregular bleeding, both during and between periods. This older term is now usually replaced by a description of the bleeding pattern.
Abnormal uterine bleeding (AUB)Umbrella term for bleeding that is abnormal in regularity, frequency, duration, or volume in a nonpregnant person.
Menstrual irregularityUnpredictable timing of periods or marked cycle-to-cycle variation.
MittelschmerzMid-cycle lower abdominal pain associated with ovulation.
Premenstrual syndrome (PMS)Recurrent physical and emotional symptoms in the luteal phase that improve shortly after menstruation begins.
Premenstrual dysphoric disorder (PMDD)Severe PMS with prominent mood symptoms that impair daily functioning.
DyspareuniaPain during sexual intercourse. It can coexist with endometriosis or pelvic inflammatory disease.
Chronic pelvic painPelvic pain lasting at least 6 months, which may or may not be related to menstruation.

Quick distinction

  • Dysmenorrhoea = pain
  • Menorrhagia/heavy menstrual bleeding = excessive amount of blood loss
  • Oligomenorrhoea = too few periods
  • Polymenorrhoea = too frequent periods
  • Amenorrhoea = no periods
  • Metrorrhagia/intermenstrual bleeding = bleeding between periods
Dysmenorrhoea is defined as painful menstruation. Ganong’s Review of Medical Physiology, 26e, p. 953. Current terminology prefers heavy menstrual bleeding rather than menorrhagia, as noted in the ACOG terminology guidance.
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