Dysmenorrhea

Dysmenorrhea: Excerpt from In a Page: Signs and Symptoms

Dysmenorrhea, or painful menstruation, is one of the most common gynecologic complaints. It is divided into two broad categories: Primary dysmenorrhea refers to severe uterine cramping during ovulatory menses and in the absence of demonstrable pelvic disease; secondary dysmenorrhea is painful menstruation in the presence of underlying pelvic disease (e.g., endometriosis).

Differential Diagnosis

• Primary dysmenorrhea
  –Symptoms develop before age 25
  –Pain occurs with onset of bleeding, then gradually diminishes

• Secondary dysmenorrhea
  –Endometriosis (uterosacral ligament nodules, severe dysmenorrhea)
  –Adenomyosis (enlarged uterus, menorrhagia, age 40–50, parous)
  –Acute PID (acute adnexal and cervical motion tenderness, fever, discharge, and/or new-onset dysmenorrhea)
  –Chronic PID (due to scarring)
  –Uterine leiomyoma/fibroids (enlarged, mobile uterus, menorrhagia)
  –Ovarian cysts (new dysmenorrhea, unilateral fullness)

• Mental health issues
  –Somatization
  –Substance abuse
  –Depression
  –Sexual abuse
• Extrapelvic disorders
  –Irritable bowel syndrome
  –Appendicitis
  –Urinary tract infection
  –Inflammatory bowel disease
  –Diverticulitis
  –Cholecystitis
• Fibromyalgia
• Malformations of the müllerian ducts
• Interstitial cystitis
• Intestinal or uteropelvic junction obstruction
• Malignancy (e.g., uterine, ovarian)
• Ectopic pregnancy

Workup and Diagnosis

• History, physical, pelvic, and rectal examination will often identify the diagnosis
• Patients unresponsive to an initial trial of NSAIDs and oral contraceptives may have pelvic pathology (secondary dysmenorrhea)
• Initial labs include CBC, urinalysis, β-hCG, wet mount, KOH prep, and gonorrhea and Chlamydia cultures, which may uncover pathology associated with secondary dysmenorrhea
• Abdominal and/or vaginal (with vaginal probe) ultrasound may be used to detect pelvic masses (e.g., ovarian cysts, uterine leiomyoma)
• Hysterosonogram if intrauterine pathology is suspected
• Hysteroscopy should follow abnormal hysterosonogram
• Abdominal and/or pelvic CT scan will evaluate gynecologic and abdominal pathology
• Laparoscopy may be both diagnostic and therapeutic
• Culdocentesis may be indicated if ruptured ectopic pregnancy is suspected; however, rarely used today, because of the advent of ultrasound

Treatment

• Primary dysmenorrhea is initially treated with NSAIDs
  –High-dose ibuprofen may be administered beginning the day before the onset of menses
  –Oral contraceptives with or without NSAIDs may be effective when NSAIDs alone are inadequate
  –Low-fat vegetarian diet, a fish oil supplement, and vitamin E may reduce pain severity
• Patients unresponsive to NSAIDs and oral contraceptives should be evaluated for pelvic pathology (secondary dysmenorrhea)
  –Endometriosis: GnRH analogs, danazol; laparoscopy in severe cases; treat infertility if necessary
  –Adenomyosis: Hysterectomy is treatment of choice
  –Leiomyoma: Removal, embolization, hysterectomy
  –Pelvic inflammatory disease: Antibiotics, oral contraceptives (to prevent ectopic pregnancy), treat infertility if necessary
  –Treat depression and/or anxiety as necessary

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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