Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 18-06: Pelvic Pain + Key Features Download Section PDF Listen +++ +++ 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) Anatomic abnormalities of other 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 Overall, 50% to 75% of women are affected at some time, and 5–6% have incapacitating pain + Clinical Findings Download Section PDF Listen +++ +++ 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, tubo-ovarian abscess, submucous myoma, 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 Download Section PDF Listen +++ +++ 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 help diagnose endometriosis or other pelvic abnormalities not visualized by imaging + Treatment Download Section PDF Listen +++ +++ 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 For women who do not wish to use hormonal contraception, other therapies that have shown at least some benefit include Local heat Thiamine, 100 mg/day orally Vitamin E, 200 units/day orally from 2 days prior to and for the first 3 days of menses High-frequency transcutaneous electrical nerve stimulation +++ OTHER CATEGORIES OF PELVIC PAIN ++ Combined estrogen and progestin and progestin-only hormonal contraceptives are first-line therapies for alleviating the symptom of dysmenorrhea Periodic use of analgesics, including the nonsteroidal anti-inflammatory drugs given for primary dysmenorrhea, may be beneficial Gonadotropin-releasing hormone agonists Effective in the treatment of endometriosis Long-term use may be limited by cost or side effects Levonorgestrel-releasing intrauterine system (LNG-IUS), uterine artery embolization, or hormonal approaches used to treat endometriosis are used to treat adenomyosis +++ Surgery ++ If disability is marked or prolonged, diagnostic laparoscopy is usually warranted Definitive surgery depends on the degree of disability and the findings at operation Uterine artery embolization can be done to remove or treat uterine fibroids Hysterectomy may be done if other treatments have not worked but is usually a last resort +++ Therapeutic Procedures ++ Other modalities that may be helpful in primary dysmenorrhea include local heat and high-frequency transcutaneous electrical nerve stimulation Cervical stenosis may result from induced abortion, creating crampy pain at the time of expected menses with no blood flow; this is easily cured by passing a sound into the uterine cavity after administering a paracervical block + Outcome Download Section PDF Listen +++ +++ When to Refer ++ Standard therapy fails to relieve pain Suspicion of pelvic pathology, such as endometriosis, leiomyomas, or adenomyosis + References Download Section PDF Listen +++ + +American College of Obstetrics and Gynecology. Committee Opinion No. 770: Dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018 Dec;132(6):e249–258. [PubMed: 30461694] + +Bishop LA. Management of chronic pelvic pain. Clin Obstet Gynecol. 2017 Sep;60(3):524–30. [PubMed: 28742584] + +Brown J et al. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev. 2018 May 22;5:CD001019. [PubMed: 29786828] + +Carey ET et al. Updates in the approach to chronic pelvic pain: what the treating gynecologist should know. Clin Obstet Gynecol. 2019 Dec;62(4):666–76. [PubMed: 31524660] + +Ferrero S et al. Current and emerging treatment options for endometriosis. Expert Opin Pharmacother. 2018 Jul;19(10):1109–25. [PubMed: 29975553] + +Matsushima T et al. Efficacy of hormonal therapies for decreasing uterine volume in patients with adenomyosis. Gynecol Minim Invasive Ther. 2018 Jul–Sep;7(3):119–23. [PubMed: 30254953] + +Oladosu FA et al. Nonsteroidal anti-inflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment. Am J Obstet Gynecol. 2018 Apr;218(4):390–400. [PubMed: 28888592] + +Smith SE et al. Interventional pain management and female pelvic pain: considerations for diagnosis and treatment. Semin Reprod Med. 2018 Mar;36(2):159–63. [PubMed: 30566982]