eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Dysmenorrhea
Updated: Nov 13, 2006
Introduction
Background
Dysmenorrhea refers to the syndrome of painful menstruation. Primary dysmenorrhea occurs in the absence of pelvic pathology, whereas secondary dysmenorrhea results from identifiable organic diseases, most typically endometriosis, uterine fibroids, uterine adenomyosis, or chronic pelvic inflammatory disease. The prevalence of dysmenorrhea is estimated to be between 45 and 95% among reproductive-aged women. Although not life threatening, dysmenorrhea can be debilitating and psychologically taxing for many women and is one of the leading causes of absenteeism from work and school.
Pathophysiology
Historical attitudes toward menstrual pain were often dismissive. Pain was often attributed to women's emotional or psychological states, misconceptions about sex, and unhealthy maternal relations. Research has now established concrete physiologic explanations for dysmenorrhea, which discredit these prior theories.
Primary dysmenorrhea usually begins within the first 6-12 months after menarche once a regular ovulatory cycle has been established. During menstruation, sloughing endometrial cells release prostaglandins, which cause uterine ischemia through myometrial contraction and vasoconstriction. Elevated levels of prostaglandins have been measured in the menstrual fluid of women with severe dysmenorrhea. These levels are especially high during the first 2 days of menstruation. Vasopressin may also play a similar role.
Secondary dysmenorrhea may present at any time after menarche, but most commonly arises when a woman is in her 20s or 30s, after years of normal, relatively painless cycles. Elevated prostaglandins may also play a role in secondary dysmenorrhea, but, by definition, concomitant pelvic pathology must also be present. Common causes include endometriosis, leiomyomata (fibroids), adenomyosis, endometrial polyps, chronic pelvic inflammatory disease, and IUD use.
Frequency
United States
The prevalence of dysmenorrhea is estimated at 45-90%. This wide range can be explained by an assumed underreporting of symptoms. Many women self-medicate at home and never seek medical attention for their pain. As mentioned above, dysmenorrhea is responsible for significant absenteeism from work and school; 13-51% of women have been absent at least once, and 5-14% are repeatedly absent.
International
One longitudinal study from Sweden reported dysmenorrhea in 90% of women younger than 19 years and in 67% of women aged 24 years (French, 2005).
Mortality/Morbidity
Dysmenorrhea itself is not life threatening, but it can have a profoundly negative impact on a woman's day-to-day life. In addition to missing work or school, she may be unable to participate in sports or other activities, compounding the emotional distress brought on by the pain.
Race
No significant difference is apparent in the prevalence of dysmenorrhea among different populations.
Sex
Despite prevailing trends toward equality in the sexes, men are not yet known to experience dysmenorrhea.
Age
See Frequency above.
Clinical
History
Primary dysmenorrhea may be distinguished from secondary dysmenorrhea by means of a thorough history. Pertinent information includes age at menarche, abnormal vaginal bleeding or discharge, dyspareunia, and obstetric history.
- Primary dysmenorrhea
- Onset within 6-12 months after menarche
- Lower abdominal/pelvic pain begins with onset of menses and lasts 8-72 hours
- Low back pain
- Medial/anterior thigh pain
- Headache
- Diarrhea
- Nausea/vomiting
- Secondary dysmenorrhea
- Onset in 20s or 30s, after relatively painless menstrual cycles in the past
- Infertility
- Heavy menstrual flow or irregular bleeding
- Dyspareunia
- Vaginal discharge
- Lower abdominal or pelvic pain during times other than menses
- Pain unrelieved by nonsteroidal anti-inflammatory drugs (NSAIDs)
Physical
A complete physical examination should be performed. For younger adolescents who have never been sexually active, a careful abdominal examination is appropriate. In older adolescents or those known to be sexually active, a pelvic examination is crucial. Pelvic ultrasonography should be considered in women who are suspected to have secondary dysmenorrhea.
- Primary dysmenorrhea
- May have lower abdominal tenderness
- May have uterine tenderness or normal pelvic examination (Cervical stenosis may contribute to retrograde menstrual flow.)
- Secondary dysmenorrhea
- Palpable uterine mass or masses
- Cervical motion tenderness
- Adnexal tenderness or palpable mass or masses
- Vaginal or cervical discharge
- Visible vaginal pathology (mucosal tears, masses, prolapse)
- Normal abdominal and pelvic examinations do not rule out pathology. Ultrasonography or other imaging modalities may be warranted if suspicion of secondary dysmenorrhea is high.
Causes
Risk factors
- Primary dysmenorrhea
- Early age at menarche ( <12 y)
- Nulliparity
- Heavy or prolonged menstrual flow
- Smoking
- Positive family history
- Obesity
- Secondary dysmenorrhea
- Endometriosis
- Adenomyosis
- Leiomyomata (fibroids)
- Intrauterine device
- Pelvic inflammatory disease
- Endometrial carcinoma
- Ovarian cysts
- Congenital pelvic malformations
- Cervical stenosis
More on Dysmenorrhea |
 Overview: Dysmenorrhea |
| Differential Diagnoses & Workup: Dysmenorrhea |
| Treatment & Medication: Dysmenorrhea |
| Follow-up: Dysmenorrhea |
| References |
| Next Page » |
References
Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol. Nov 15 1982;144(6):655-60. [Medline].
Berkley KJ. A life of pelvic pain. Physiol Behav. Oct 15 2005;86(3):272-80. [Medline].
Durain D. Primary dysmenorrhea: assessment and management update. J Midwifery Womens Health. Nov-Dec 2004;49(6):520-8. [Medline].
French L. Dysmenorrhea. Am Fam Physician. Jan 15 2005;71(2):285-91. [Medline].
Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. Apr 1 2006;332(7544):749-55. [Medline].
Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. May 13 2006;332(7550):1134-8. [Medline].
Further Reading
Keywords
primary dysmenorrhea, secondary dysmenorrhea, dysmenorrhea, menstrual pain, painful menstruation, menorrhalgia, pelvic pain, cramps, cramping, endometriosis, uterine fibroids, uterine adenomyosis, chronic pelvic inflammatory disease, leiomyomata, fibroids, adenomyosis, endometrial polyps, IUD use, elevated prostaglandins
