Dysmenorrhea
Cheryl A. Glass and Rhonda Arthur
Definition
Dysmenorrhea is painful uterine cramping felt primarily in the lower abdomen but also in the lower back and upper thighs:
A.Primary dysmenorrhea: Not associated with pelvic pathology; usually associated with ovulatory cycles. Occurs first day or two of the menstrual period. Usually worse the first day. Affects teens and women in their 20s. Often associated with prostaglandin-induced symptoms of diarrhea, nausea, vomiting, and/or headache.
B.Secondary dysmenorrhea: Painful uterine contractions due to a pathologic etiology such as endometriosis or pelvic inflammatory disease (PID). Occurs in women primarily after menstruation has been established for several years, occurring in their 20s, 30s, and 40s. This type of pain is usually a progressive pain that intensifies over time.
Incidence
A.Primary dysmenorrhea is very common, affecting virtually 100% of young women to some extent at some time. It is the leading cause of absenteeism from work or school in women younger than 30. A smaller but significant group, perhaps 10%, miss days of school or work each month because of the incapacitating pain. The incidence of endometriosis is 8% to 30% of women of reproductive age.
Pathogenesis
A.Primary dysmenorrhea is due to myometrial contractions that are caused by prostaglandins in the secretory endometrium. The prostaglandins cause uterine ischemia through platelet aggregation, vasoconstriction, and dysrhythmic contractions.
B.Secondary dysmenorrhea is associated with pathologic conditions such as endometriosis, cervical stenosis, tumors, adhesions, adenomyosis, myomas, polyps, infection (PID), intrauterine device (IUD) malposition, retained products of conception, or nongynecologic causes. The pain of secondary dysmenorrhea may also be unrelated to menses.
C.In endometriosis, there are islands of endometrium found on peritoneal surfaces of the bladder, broad ligaments, fallopian tubes, ovaries, bowel, and cul-de-sac, as well as distant sites on the abdominal wall, vagina, lung, or other sites.
Predisposing Factors
A.Female.
B.Reproductive age.
C.Ovulatory menstrual cycles.
D.Cervical stenosis, possibly.
Common Complaints
A.I have painful periods.
B.My menstrual cramps are terrible, particularly the first day of my cycle.
C.My cramps are so bad I feel sick to my stomach and have diarrhea.
Other Signs and Symptoms
A.History of menstrual cramps just prior to the onset of the menstrual period and for the first 24 to 48 hours.
B.Pain beginning earlier; associated with intercourse, defecation, and urination; and lasting throughout the menstrual period is usually associated with endometriosis or adenomyosis.
C.Acute pain may be associated with infection (PID) or ectopic pregnancy.
Subjective Data
A.Obtain a complete menstrual history: age at menarche; frequency, duration, and regularity of periods; amount of flow, measured in the number of perineal pads or tampons used.
B.Ask the patient about the location of the pain; note radiation and associated symptoms such as nausea, vomiting, or diarrhea.
C.Is pain rhythmic or spasmodic?
D.How old was the patient when the pain began? Primary dysmenorrhea usually begins 2 to 3 years after menarche, with the onset of ovulatory cycles.
E.Inquire about the type of contraception used.
F.Obtain obstetric history and last menstrual period (LMP).
G.Is the pain related to the menstrual period, or does it occur prior to or independent of the menstrual period?
H.Does the patient have dyspareunia?
I.Does she have urinary tract infection (UTI) symptoms?
J.What treatments have been tried, and which were effective?
Physical Examination
A.Check height and weight to calculate body mass index (BMI), temperature (if indicated), blood pressure (BP), and pulse.
B.Inspect:
1.Examine the general body habitus for female adipose distribution on the buttocks and thighs.
2.Note breast development.
3.Observe the abdomen for distension.
4.Inspect the external genitalia for pubic hair pattern, lesions, discharge, and odor.
C.Palpate and percuss: Examine the abdomen for masses or tenderness.
D.Auscultate: Auscultate the heart, lungs, and abdomen for bowel sounds.
E.Pelvic examination: Palpate the external genitalia for masses or areas of tenderness.
F.Speculum examination: Inspect the cervix and vagina for discharge, lesions, ectropion, cervical erosion, and IUD string.
G.Bimanual examination:
1.Palpate the vagina and cul-de-sac areas for tenderness or masses.
2.Check:
a.Cervical position, mobility, and pain with mobility.
b.Uterine size, mobility, shape, regularity, masses, position, and tenderness.
c.Adnexa for masses (cystic or solid) and tenderness.
3.A normal pelvic examination is a significant finding in primary dysmenorrhea and often in endometriosis.
Diagnostic Tests
A.Perform stat quantitative serum pregnancy test if suggested by history/physical exam.
B.Consider pelvic ultrasonography to rule out pelvic pathology.
C.Laboratory studies: Urinalysis, hemoglobin, hematocrit, and white blood cell (WBC).
D.Consider vaginal and cervical cultures for Chlamydia trachomatis (CT) and gonorrhea (GC), if infection is suspected.
Differential Diagnoses
A.Dysmenorrhea: The patient’s history and a normal pelvic examination are used to diagnose primary dysmenorrhea.
B.Complication of pregnancy: missed or incomplete abortion or ectopic pregnancy.
C.Endometriosis or adenomyosis.
D.Ruptured/ovarian cyst.
E.Infection: endometritis, salpingitis, PID, or pelvic adhesions.
F.Fibroid tumors.
G.Adhesions.
H.UTI.
I.Bowel disease: irritable bowel disease, inflammatory or diverticular bowel disease.
Plan
A.General interventions: Support patient concerns and identify reality of discomfort. Identify primary source of pain if other diagnoses exist.
B.
See Section III: Patient Teaching Guide Dysmenorrhea (Painful Menstrual Cramps or Periods)
and Contraception: How to Take Birth Control Pills (for a 28-Day Cycle)
:
1.Educate the patient about the physiology of menstruation.
2.Teach the patient that endometriosis is one of the leading causes of infertility. Discuss the consequences that may occur with chronic pelvic pain/endometriosis, which includes compromised fertility issues.
3.Encourage activity and exercise, such as walking or swimming.
4.Advise warm baths or heating pads to help relieve some pain.
C.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs):
a.They inhibit prostaglandin synthesis in the endometrium, thus decreasing uterine cramping while providing an analgesic effect.
b.The drugs should be started as the menstrual period begins. It is no longer considered the standard of care to begin the drugs a few days prior to onset of the menstrual period.
c.Prostaglandin inhibitors relieve dysmenorrhea in 80% of women.
d.Take NSAIDs with food to avoid gastrointestinal (GI) upset and irritation.
2.Medications of choice for dysmenorrhea:
a.NSAIDs available over-the-counter (OTC):
i.Arylacetic acid derivatives: naproxen sodium (Aleve) 200 mg every 8 to 10 hours; naproxen sodium (Anaprox) 275 mg every 6 to 8 hours, or 550 mg every 12 hours; or naproxen sodium (Naprelan) 1 to 1.5 g once daily.
ii.Propionic acid derivatives: ibuprofen (Advil, Motrin, Nuprin) 200 to 800 mg every 4 to 6 hours; ketoprofen (Orudis) 12.5 to 25 mg every 4 to 6 hours.
3.Medications of choice for endometriosis (Refer to the Endometriosis
section of Chapter 17 for a detailed review):
a.NSAIDs.
b.Combined hormonal contraception.
c.With physician consultation or referral, danazol (Danocrine).
d.With physician consultation or referral, gonadotropin-releasing hormone (Gn-RH) agonists such as nafarelin (Synarel), leuprolide acetate (Lupron, Lupron Depot), goserelin acetate (Zoladex), and elagolix (Orilissa).
e.Levonorgestrel intrauterine system (LNG-IUS; Mirena, Skylar, Kyleena, and Liletta): Note: Only trained healthcare providers who carefully review the selected device’s manufacturer’s package insert for indications and use as well as specific insertion instructions should place IUDs.
4.Antibiotics as indicated for sexually transmitted infection (STI) and/or PID:
a.Refer to Chapter 18 (Sexually Transmitted Infections).
b.Refer to Pelvic Inflammatory Disease
section of Chapter 17.
Follow-Up
A.Have the patient return in 3 months. Encourage the patient to give the treatment 3 months to determine effectiveness.
Consultation/Referral
A.Consult with a physician if dysmenorrhea does not respond to NSAIDs or oral contraceptives for further workup to determine the source of the pain.
B.Consider consultation with OB/GYN for laparoscopy or hysteroscopy to diagnose endometriosis; however, empirical treatment is recommended.
Individual Considerations
A.Pregnancy: Uterine contractions in pregnancy could be preterm labor.
B.Adolescents: Remember that endometriosis can occur in this age group. It is not an extremely rare finding.
C.Adults: Endometriosis can be a disabling condition interfering with work and sexual relationships. It may continue into the perimenopausal period.