Dysmenorrhea Clinical Presentation

  • Author: Karim Anton Calis, PharmD, MPH, FASHP, FCCP; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Mar 8, 2011
 

History

  • History is critical in establishing the diagnosis of dysmenorrhea and should include an assessment of the onset, duration, type, and severity of pain. A thorough menstrual history is also essential and should include the age at menarche, cycle regularity, cycle length, last menstrual period, and duration and amount of menstrual flow.
  • Determine factors that exacerbate or ameliorate the symptoms and the degree of disruption to school, work, and social activities.
  • Consider gravidity and parity status, previous pelvic infections, dyspareunia, infertility, and pelvic surgeries, injuries, and procedures.
  • Also assess symptoms such as nausea, vomiting, bloating, diarrhea, and fatigue, which may be observed in patients with dysmenorrhea.
  • Consider sexual history, including the choice of contraceptive methods. If used, establish the effect of OCs on relieving or exacerbating the condition. Moreover, discuss the use of other agents that affect dysmenorrhea pain.
  • A family history may be helpful in differentiating endometriosis from primary dysmenorrhea.[32] The history should include questions pertaining to sexual abuse because this is reportedly associated with dysmenorrhea and chronic pelvic pain.[33]
  • In summary, a complete history should include the following:
    • Age at menarche
    • Menstrual frequency, length of period, estimate of the menstrual flow, and presence or absence of intermenstrual bleeding
    • Associated symptoms
    • Severity of pain and its relationship to the menstrual cycle
    • Impact on physical and social activity
    • Progression of symptom severity
    • Sexual history
  • Primary dysmenorrhea should be distinguished from secondary dysmenorrhea on the basis of clinical features.
    • Primary dysmenorrhea almost invariably occurs in ovulatory cycles and usually appears within a year after menarche. In classic primary dysmenorrhea, the pain begins with the onset of menstruation (or just shortly before) and persists throughout the first 1-2 days. The pain is described as spasmodic and superimposed over a background of constant lower abdominal pain, which radiates to the back or anterior and/or medial thigh.
    • Associated general symptoms, such as malaise, fatigue (85%), nausea and vomiting (89%), diarrhea (60%), lower backache (60%), and headache (45%), may be present with primary dysmenorrhea. Dizziness, nervousness, and even collapse are also associated with dysmenorrhea.
    • The clinical features of primary dysmenorrhea include the following:
      • Onset shortly after menarche
      • Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
      • Cramping or laborlike pain
      • Often unremarkable pelvic examination findings (including rectal)
    • A different pattern of pain is observed with secondary dysmenorrhea that is not limited to the onset of menses; this is usually associated with abdominal bloating, pelvic heaviness, and back pain. Typically, the pain progressively increases during the luteal phase until it peaks around the onset of menstruation.
    • The following may indicate secondary dysmenorrhea[19, 34] :
      • Dysmenorrhea occurring during the first or second cycles after menarche, which may indicate congenital outflow obstruction
      • Dysmenorrhea beginning after the age of 25 years
      • Pelvic abnormality with physical examination: Consider endometriosis, pelvic inflammatory disease, pelvic adhesions, and adenomyosis.
      • Little or no response to therapy with NSAIDs, OCs, or both
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Physical

  • A pelvic examination is indicated at the initial evaluation, which should be carefully performed in order to exclude uterine irregularities, cul-de-sac tenderness, or nodularity that may suggest endometriosis, pelvic inflammatory disease, or a pelvic mass.
  • Women with primary dysmenorrhea usually have normal findings on examination.
  • Pelvic pathology may be found during pelvic examination in women with secondary dysmenorrhea, although normal findings do not exclude the condition.
    • Women with endometriosis who present with secondary dysmenorrhea have physical findings approximately 40% of the time.[35, 36]
    • Patients presenting with secondary dysmenorrhea may have unique and specific findings on physical examination that correspond to their particular pathologies.
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Causes

  • Causes of secondary dysmenorrhea include the following:
    • Intrauterine contraceptive devices
    • Adenomyosis
    • Uterine myoma (fibroids)
    • Uterine polyps
    • Adhesions
    • Congenital malformation of the müllerian system
    • Cervical strictures or stenosis
    • Ovarian cysts
    • Pelvic congestion syndrome
    • Allen-Masters syndrome
    • Mittelschmerz (midcycle ovulation pain)
    • Psychogenic pain
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Contributor Information and Disclosures
Author

Karim Anton Calis, PharmD, MPH, FASHP, FCCP  Adjunct Clinical Investigator, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health; Clinical Professor, Medical College of Virginia, Virginia Commonwealth University School of Medicine; Clinical Professor, University of Maryland School of Medicine

Karim Anton Calis, PharmD, MPH, FASHP, FCCP is a member of the following medical societies: American College of Clinical Pharmacy, American Society of Health-System Pharmacists, and Endocrine Society

Disclosure: Nothing to disclose.

Coauthor(s)

Vaishali Popat, MD, MPH  Clinical Investigator, Intramural Research Program on Reproductive and Adult Endocrinology, National Institutes of Child Health and Human Development, National Institutes of Health

Vaishali Popat, MD, MPH is a member of the following medical societies: American College of Physicians and Endocrine Society

Disclosure: Nothing to disclose.

Devra K Dang, PharmD, BCPS, CDE  Associate Clinical Professor, University of Connecticut School of Pharmacy, Clinical Faculty, Burgdorf Health Center

Disclosure: Nothing to disclose.

Sophia N Kalantaridou, MD  Assistant Professor, Department of Obstetrics and Gynecology, University of Ioannina Medical School, Greece

Disclosure: Nothing to disclose.

Specialty Editor Board

Anthony Charles Sciscione, DO  Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal Medicine

Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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