Dysmenorrhea Clinical Presentation

Updated: Nov 02, 2017
  • Author: Karim Anton Calis, PharmD, MPH, FASHP, FCCP; Chief Editor: Michel E Rivlin, MD  more...
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Presentation

History

The 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 assess the degree of disruption to school, work, and social activities.

Consider gravidity and parity status, previous pelvic infections, dyspareunia, infertility, and pelvic injuries or surgical or other procedures.

In addition, assess symptoms such as nausea, vomiting, bloating, diarrhea, and fatigue, which may be observed in patients with dysmenorrhea.

Consider the patient’s sexual history, including the choice of contraceptive methods. If oral contraceptives (OCs) have been used, establish their effect (if any) on relieving or exacerbating the condition. Moreover, discuss the use of other agents that affect dysmenorrhea pain.

A family history should be sought for bleeding diatheses or sickle cell disease. Such a history may be helpful in differentiating endometriosis from primary dysmenorrhea. [52]

The history should include questions pertaining to sexual abuse because this is reportedly associated with dysmenorrhea and chronic pelvic pain. [53]

In summary, a complete history should include the following [28] :

  • Age at menarche
  • Menstrual frequency, length of period, estimated menstrual flow, and presence or absence of intermenstrual bleeding
  • Associated symptoms
  • Onset, duration, type, and severity of pain, as well as its relation to the menstrual cycle
  • External factors affecting the pain
  • Impact of dysmenorrhea on physical and social activity
  • Progression of symptom severity
  • Sexual and obstetric history

Primary dysmenorrhea should be distinguished from secondary dysmenorrhea on the basis of clinical features. Clinical features of primary dysmenorrhea include the following:

  • Onset shortly after menarche (typically within 6 months)
  • Usual duration of 48-72 hours (often starting several hours before or just after the menstrual flow)
  • Cramping or laborlike pain
  • Background of constant lower abdominal pain, radiating to the back or the anterior or medial thigh
  • Often unremarkable pelvic examination findings (including rectal)

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.

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 [1, 2] :

  • Dysmenorrhea beginning in the 20s or 30s, after relatively painless menstrual cycles in the past
  • Heavy menstrual flow or irregular bleeding
  • Dysmenorrhea occurring during the first or second cycles after menarche, which may indicate congenital outflow obstruction
  • Pelvic abnormality with physical examination (consider endometriosis, pelvic inflammatory disease [PID], pelvic adhesions, and adenomyosis)
  • Little or no response to nonsteroidal anti-inflammatory drugs (NSAIDs) or OCs
  • Infertility
  • Dyspareunia
  • Vaginal discharge
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Physical Examination

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 for excluding uterine irregularities, cul-de-sac tenderness, or suggestive nodularities. This examination includes the following [28] :

  • Inspection of the external genitalia for rashes, swelling, or discoloration
  • Inspection of the vaginal vault for discharge, blood, or foreign bodies
  • Inspection of the cervix for the above, plus any masses or signs of infection
  • Bimanual examination to assess cervical motion tenderness, uterine or adnexal tenderness, or any masses in the pelvis

Women with primary dysmenorrhea usually have normal findings on pelvic examination. Lower abdominal or uterine tenderness may be present. Cervical stenosis may contribute to retrograde flow.

Women with secondary dysmenorrhea may have pelvic pathology, though normal findings do not exclude the condition. Women with endometriosis who present with secondary dysmenorrhea have physical findings about 40% of the time. [54, 55] A palpable uterine mass may be present. Cervical motion tenderness may be noted. There may be adnexal tenderness or a palpable mass. Vaginal or cervical discharge may be seen. Visible vaginal pathology (eg, mucosal tears, masses, or prolapse) may be visible.

Pelvic ultrasonography should be considered in women who are suspected of having secondary dysmenorrhea. Attention should also be paid to the abdominal examination and back-flank examinations to rule out pelvic pain as a presentation of gastrointestinal (GI) pathology and upper genitourinary (GU) pathology, respectively.

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