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Key Features

Essentials of Diagnosis

  • Primary dysmenorrhea is menstrual pain associated with menstrual cycles in the absence of pathologic findings

  • Other causes of pelvic pain may present during the menstrual cycle or be more chronic, including

    • Endometriosis

    • Fibroids

    • Pelvic inflammatory disease (PID)

    • Other anatomic abnormalities of the pelvic organs, including the bowels or bladder

General Considerations

PRIMARY DYSMENORRHEA

  • The pain usually begins within 1–2 years after the menarche and may become progressively more severe

  • The pain is produced by uterine vasoconstriction, anoxia, and sustained contractions mediated by prostaglandins

Demographics

PRIMARY DYSMENORRHEA

  • The frequency of cases increases up to age 20 and then decreases with both increasing age and parity

  • Fifty to 75% of women are affected at some time, and 5–6% have incapacitating pain

Clinical Findings

Symptoms and Signs

PRIMARY DYSMENORRHEA

  • Pain is low, midline, wave-like, cramping pelvic pain often radiating to the back or inner thighs

  • Cramps may last for 1 or more days and may be associated with nausea, diarrhea, headache, and flushing

  • Pelvic examination reveals no pathologic findings

OTHER CATEGORIES OF PELVIC PAIN

  • The history and physical examination commonly suggest endometriosis, adenomyosis, or fibroids

  • Other causes may be pelvic inflammatory disease, submucous myoma, intrauterine device (IUD) use, cervical stenosis with obstruction, or blind uterine horn (rare)

Differential Diagnosis

  • Endometriosis

  • Adenomyosis

  • Pelvic inflammatory disease

  • Uterine leiomyomas (fibroids)

  • IUD

  • Pelvic pain syndrome

  • Endometrial polyp

  • Cervicitis

  • Cervical stenosis

  • Cystitis

  • Interstitial cystitis

Diagnosis

Imaging Studies

  • Pelvic imaging is useful in detecting uterine fibroids or other anomalies

  • Ultrasound or, preferably, MRI is useful in identifying adenomyosis

Diagnostic Procedures

OTHER CATEGORIES OF PELVIC PAIN

  • Laparoscopy may be used to diagnose endometriosis or other pelvic abnormalities not visualized by imaging

Treatment

Medications

PRIMARY DYSMENORRHEA

  • Nonsteroidal anti-inflammatory drugs (ibuprofen, ketoprofen, mefenamic acid, naproxen) and the COX-2 inhibitor celecoxib are generally helpful

  • Drugs should be started 1–2 days before expected menses

  • Symptoms can be suppressed by

    • Combined oral contraceptives

    • Depot-medroxyprogesterone acetate

    • Etonogestrel subdermal (Nexplanon)

    • Levonorgestrel-containing IUD

  • Oral contraceptives can be administered continuously to suppress menstruation completely and prevent dysmenorrhea

  • Cervical stenosis is easily cured by passing a sound into the uterine cavity after administering a paracervical block

OTHER CATEGORIES OF PELVIC PAIN

  • Periodic use of analgesics, including the nonsteroidal anti-inflammatory drugs given for primary dysmenorrhea, may be beneficial

  • Combined oral contraceptives alleviate the symptoms of dysmenorrhea

  • Oral contraceptives may be particularly effective in endometriosis

  • Gonadotropin-releasing hormone agonists are effective in ...

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