Dysmenorrhea Workup

Updated: Oct 27, 2016
  • Author: Karim Anton Calis, PharmD, MPH; Chief Editor: Michel E Rivlin, MD  more...
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Workup

Approach Considerations

No tests are specific to the diagnosis of primary dysmenorrhea. The diagnosis is made on the basis of clinical findings.

Laboratory studies may be indicated to elucidate the cause of secondary dysmenorrhea. Noninvasive studies may include abdominal and transvaginal ultrasonography. Other more invasive studies, including hysterosalpingography, may be required. Further investigation might include hysteroscopy or laparoscopy; the latter is usually indicated when initial interventions fail to relieve symptoms.

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Laboratory Studies

The following laboratory studies may be performed to identify or exclude organic causes of secondary dysmenorrhea:

  • Complete blood count (CBC) with differential to search for evidence of infection or a neoplastic process
  • Gonococcal and chlamydial cultures, enzyme immunoassay (EIA), and DNA probe testing to exclude sexually transmitted infections (STIs) and pelvic inflammatory disease (PID)
  • Quantitative human chorionic gonadotropin level to exclude ectopic pregnancy
  • Erythrocyte sedimentation rate (ESR) for subacute salpingitis
  • Urinalysis to exclude urinary tract infection
  • Stool guaiac to rule out GI bleeding
  • Cancer antigen 125 (CA-125) assay – This test has relatively low negative predictive value and thus is of limited clinical utility for evaluating dysmenorrheal women

Although these tests can be useful adjuncts in the workup of dysmenorrhea, they also may be misleading at times. For instance, the CBC may show a normal white blood cell (WBC) count in as many as 56% of patients with PID. On the other hand, the WBC count can be elevated as a consequence of physiologic stress.

In a patient with associated vaginal bleeding, the hematocrit may be normal even when the patient has obvious hypovolemia on examination (eg, positive orthostasis or tachycardia), especially if hemorrhage started within minutes to hours of presentation. [27] Moreover, the EIA and DNA probe tests for gonorrhea and chlamydia have varying sensitivities, ranging from 86% to 93%. [27]

Accordingly, for diagnosing dysmenorrhea and its underlying cause, laboratory testing should be understood to play an ancillary rather than a primary role and should not be allowed to replace a sound clinical basis for the diagnosis.

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Ultrasonography and Other Imaging Studies

In cases of well-established primary dysmenorrhea, imaging studies are of little value. However, if pelvic pathology is suspected, abdominal and transvaginal ultrasonography are inexpensive and effective modalities.

Ultrasonography is relatively noninvasive, can easily be performed in the emergency department (ED), and reveals most relevant pelvic pathology. For instance, endometriosis may appear as a complex mass with a speckled appearance. [27] Pelvic ultrasonography is indicated for evaluating situations such as ectopic pregnancy, ovarian cysts, fibroids, and intrauterine contraceptive devices (IUCDs). It is highly sensitive for detecting pelvic masses.

Hysterosalpingography is used to exclude endometrial polyps, leiomyomas, and congenital abnormalities of the uterus. Intravenous pyelography is indicated if uterine malformation is confirmed as a cause or contributing factor for the dysmenorrhea.

Although computed tomography (CT) is not routinely ordered in the ED for patients with dysmenorrhea, it does have some utility, particularly in identifying ovarian torsion. [27, 29, 28] Magnetic resonance imaging (MRI) also is not routinely ordered in the ED but has some ability to detect adenomyosis and submucous myomas that might otherwise be missed by other imaging modalities. [27]

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Laparoscopy, Hysteroscopy, D&C, and Biopsy

On occasion, other more invasive studies, including laparoscopy, hysteroscopy, and dilatation and curettage (D&C), may be required.

Laparoscopic examination is the single most useful procedure. It involves a complete diagnostic survey of the pelvis and reproductive organs to ascertain the presence of any pathology that may account for the clinical symptoms. Hysteroscopy and D&C may be indicated to evaluate intrauterine pathology found on imaging. An endometrial biopsy may be indicated if endometritis is considered likely.

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