Dysmenorrhea
Dysmenorrhea: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Albert A. Meyer
Approach
Dysmenorrhea can be defined as a complaint of pain experienced during or immediately before menstruation. Up to 90% of women experience this symptom for some part in their lives (1). Risk factors include the concomitant presence of prolonged, heavy, and irregular periods. Pregnancy history and dietary factors do not seem to correlate with this symptom.
History (2)
A. It is extremely important to distinguish primary from secondary dysmenorrhea.
B. Primary dysmenorrhea starts at the onset of menarche, and is thought to be the result of prostaglandin-2α, which produces uterine ischemia. It can be treated with antiprostaglandins and oral contraceptives.
C. Secondary dysmenorrhea starts later in a woman’s ovulatory life and may be caused by endometriosis or pelvic pathology.
D. If abnormal bleeding is associated with either type of dysmenorrhea, it is important to elicit symptoms of pregnancy, such as missed or late menses, breast tenderness, nausea, or urinary frequency (Chapter 11.5).
E. If severe pain develops during the first part of the menstrual cycle, ascertain the history of a new sexual partner, abnormal vaginal discharge, or dyspareunia. These symptoms could point toward pelvic inflammatory disease (PID) (Chapter 11.3).
F. Pain that develops during menses, but not related to pregnancy or infection, can also be caused by tumor. In younger women, secondary dysmenorrhea sufficiently severe to affect daily functioning or relationships suggests endometriosis. This condition can affect as many as 10% of women. Deep dyspareunia and sacral backache with menses are common symptoms. Premenstrual tenesmus or diarrhea correlates with endometriosis of the rectosigmoid area, whereas cyclic hematuria or dysuria may indicate bladder endometriosis.
G. Infertility is often a consequence of endometriosis.
Physical examination
As with all menstrual complaints, a thorough physical examination is an essential part of making a diagnosis.
A. The general condition of the patient needs to be assessed. Are the vital signs stable or is the patient showing signs of systemic illness such as fever, which can indicate pelvic infection. Hypotension and pallor can indicate a ruptured ectopic pregnancy.
B. A general physical assessment with attention to the back, sacrum, spine abdomen, and bladder is important.
C. A thorough pelvic examination is key. The external genitalia may show signs of cyanosis, as is seen with pregnancy, or abnormal discharge, as is seen with infection. Palpate the vaginal area for nodules which may present on the anterior cul-de-sac or on the posterior vaginal fornix on bimanual examination; they could indicate endometriosis. Cervical motion tenderness and cervical leukorrhea may be present in PID. Uterine tenderness is often present and uterine displacement and fixation may be noted. Ovarian enlargement or adnexa fixation, which correlates with endometriosis or adnexal mass from neoplastic or infectious cause, may be found. Nodules may also be palpated along the uterosacral ligaments on rectovaginal examination.
Laboratory testing (3)
A. A complete blood count looking for anemia or leucocytosis is helpful.
B. If abnormal bleeding is associated with the dysmenorrhea, thyroid testing and a qualitative serum pregnancy test are indicated.
C. Urine analysis looking for hematuria should be obtained. With any indication of infection, a urine culture is often helpful.
D. A pelvic ultrasound may be helpful if any masses seem apparent on pelvic examination.
E. The definitive diagnosis of endometriosis can only be positively diagnosed with laporoscopy.
Diagnostic assessment (1)
Difficult menstrual periods occur at some point for most women during their reproductive years. If it is recurrent and significantly interferes with daily activity or relationships, it warrants treatment. Primary dysmenorrhea not associated with abnormal bleeding can often be treated successfully with nonsteroidal agents or oral contraceptives. If it does not respond to these agents or if it is associated with abnormal bleeding, further diagnostic testing is indicated. Secondary dysmenorrhea, either with or without abnormal bleeding, may point to a pelvic tumor, infection, or pregnancy. Further testing is essential in this setting.
References
1. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain and irritable bowel syndrome in primary care practices. Obstet Gynecol 1996;87:
55–58.
2. Apgar BS. Dysmenorrhea and dysfunctional uterine bleeding. Prim Care 1997;
24(1):161–179.
3. Chan PD, Winkle CR. Gynecology and obstetrics 1999–2000. Laguna Hills, CA: Current Clinical Strategies Publishers, 1999:25–26.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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