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COMMONLYASSOCIATED CONDITIONS

Irregular/heavy menstrual periods

Longer menstrual cycle length/duration of bleeding Endometriosis

DIAGNOSIS

Based on characteristic history of suprapubic/low back cramping/pain occurring at or near menstrual flow onset lasting for 8 to 72 hours (2)

HISTORY

Primary: Onset once ovulatory cycles are established in adolescents; 6 to 12 months after menarche on average

Patients may have associated nausea, vomiting, diarrhea, headache, fatigue, or pain radiating into the inner thighs.

Recurrence at or just before the onset of the menstrual flow

–Pelvic pain occurring between menstrual periods is not likely to be dysmenorrhea.

–Present with most menstrual periods (cyclic)

Relief associated with the following:

–Continued bleeding for the usual duration

–Use of analgesics, especially NSAIDs

–Orgasm

–Local heat application

Response to NSAIDs helps confirm diagnosis.

Secondary: associated with chronic pelvic pain, midcycle pain, dyspareunia, and abnormal uterine bleeding

PHYSICALEXAM

Primary: Physical exam typically is normal. Examine to rule out secondary dysmenorrhea. Pelvic exam is recommended if sexually active to rule out infection.

Secondary: Evaluate for cervical discharge, uterine enlargement, tenderness, irregularity, or fixation.

DIFFERENTIALDIAGNOSIS

Primary: History is characteristic.

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Secondary

–Pelvic/genital infection

–Complication of pregnancy

–Missed/incomplete abortion

–Ectopic pregnancy

–Uterine/ovarian neoplasm

–Endometriosis

–UTI

–Complication with IUD use

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Pregnancy test

Urine testing for infection

Gonorrhea/chlamydia cervical testing, especially in women age <25 years and in high-prevalence areas

Primary: Consider pelvic ultrasound to rule out secondary abnormalities if history is not characteristic or suspected abnormality on exam.

Secondary: Ultrasound/laparoscopy to define anatomy for severe/refractory cases. MRI may be useful as second-line noninvasive imaging if ultrasound is nondiagnostic and torsion, deep endometriosis, or adenomyosis suspected.

Follow-Up Tests & Special Considerations

Counsel regarding appropriate preventive measures for STI and pregnancy.

Diagnostic Procedures/Other

Laparoscopy is rarely needed.

Test Interpretation

Primary: none

Secondary: Specific anatomic abnormalities may be noted (see “Differential Diagnosis”).

Pregnancy Considerations

Consider ectopic pregnancy when pelvic pain occurs with vaginal bleeding.

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TREATMENT

Reassure the patient that treatment success is very likely with adherence to recommendations.

Relief may require the use of several treatment modalities at the same time.

GENERALMEASURES

Exercise and local heat are noninvasive general measures to relieve pain.

High-frequency transcutaneous electrical nerve stimulation (TENS) has been found to be beneficial. There is conflicting evidence for low-frequency TENS.

Secondary dysmenorrhea: treatment of infections; suppression of endometrium if endometriosis suspected; remove IUD if contributing factor.

MEDICATION

First Line

NSAIDs: No NSAID has been found to be superior to others. Medication should be taken on scheduled dosing 1 to 2 days prior to onset of menses and continued for 2 to 3 days (2,3)[A]. If one NSAID preparation does not work, another NSAID preparation should be tried.

–Ibuprofen 400 mg q8h

–Naproxen sodium 500 mg BID

–Celecoxib 400 mg × 1 and then 200 mg q12h

–Mefenamic acid 500 mg × 1 and then 250 mg q6h

Hormonal contraceptives: recommended for primary dysmenorrhea in women desiring contraception (2)[B]. Directly limits endometrial growth resulting in reduced prostaglandin production and intrauterine pressure. Continuous rather than cyclic dosing may initially be more effective at reducing pain, however, may have similar benefit after 6 months (4)[B]. Estrogen-containing contraceptives are recommended first-line for secondary dysmenorrhea due to endometriosis, although progestin-only methods have also been shown to be beneficial (2)[B].

Levonorgestrel IUDs can decrease primary dysmenorrhea (5)[B]. Potential contraindications to NSAIDs and combined oral contraceptives (COCs)

–Platelet disorders

–Gastric ulceration or gastritis

–Thromboembolic disorders

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–Vascular disease

–Migraine with aura

Precautions

–GI irritation

–Lactation

–Coagulation disorders

–Impaired renal function

–Heart failure

–Liver dysfunction

Significant possible interactions

–Coumadin-type anticoagulants

–Aspirin with other NSAIDs

Second Line

Local heat can help relieve pain and may be as effective as NSAIDs (2)[B].

Exercise may have beneficial effects in relieving pain (6)[B].

β2-Adrenoceptor agonists have not definitively been shown to relieve pain in

dysmenorrhea (7)[B].

Behavioral interventions, such as relaxation exercises, may help alleviate pain in primary dysmenorrhea.

SURGERY/OTHER PROCEDURES

Laparoscopic uterosacral nerve ablation has been shown to relieve pain at >12 months postoperatively.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Spinal manipulation has not been shown to be effective in treating pain.

Chinese herbal medicine shows promising evidence of decreasing pain, but more evidence is needed.

Acupuncture treatments have been shown to decrease pain in dysmenorrhea, but further randomized, well-designed studies are needed.

Acupoint stimulation, particularly noninvasive stimulation (acupressure), can relieve pain.

Aromatherapy abdominal massage performed daily for 10 minutes, 7 days prior to onset of menses can decrease primary dysmenorrhea.

Further research needed to determine benefit and safety for use of oral fennel, extracorporeal magnetic innervation, vitamin K1 injection into the spleen-6

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acupuncture point, use of high-frequency vibratory stimulation tampon, and vaginal sildenafil

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Both primary and secondary dysmenorrhea are usually managed in the outpatient setting.

Primary: outpatient care Secondary: usually outpatient care

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Normal

DIET

Vitamin B1 100 mg daily, ω-3 fatty acid, and fish oil supplementation may be

beneficial.

Magnesium has been shown to be useful, but the correct dosage has not been determined.

Insufficient evidence to show usefulness of zinc and vitamin E at this time

Low-fat vegetarian diet can be helpful in some patients.

PATIENT EDUCATION

Reassure the patient that primary dysmenorrhea is treatable with the use of NSAIDs, COCs, IUD, or local heat, and that it will usually abate with age and parity.

PROGNOSIS

Primary: reduced with age and parity

Secondary: likely to require therapy based on underlying cause

COMPLICATIONS

Primary: anxiety and/or depression

Secondary: infertility from underlying pathology

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REFERENCES

1.Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36:104–113.

2.Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014;89(5):341–346.

3.Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013; (1):CD000400.

4.Dmitrovic R, Kunselman AR, Legro RS. Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial. Obstet Gynecol. 2012;119(6):1143–1150.

5.Lindh I, Milsom I. The influence of intrauterine contraception on the prevalence and severity of dysmenorrhea: a longitudinal population study. Hum Reprod. 2013;28(7):1953–1960.

6.Brown J, Brown S. Exercise for dysmenorrhoea. Cochrane Database Syst Rev. 2010;(2):CD004142.

7.Fedorowicz Z, Nasser M, Jagannath VA, et al. Beta2-adrenoceptor agonists for dysmenorrhoea. Cochrane Database Syst Rev. 2012;(5):CD008585.

ADDITIONALREADING

Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol. 2001;97(3):343–349.

Allen LM, Lam AC. Premenstrual syndrome and dysmenorrhea in adolescents. Adolesc Med State Art Rev. 2012;23(1):139–163.

Altunyurt S, Göl M, Altunyurt S, et al. Primary dysmenorrhea and uterine blood flow: a color Doppler study. J Reprod Med. 2005;50(4):251–255.

Bayer LL, Hillard PJ. Use of levonorgestrel intrauterine system for medical indications in adolescents. J Adolesc Health. 2013;52(Suppl 4):S54–S58.

Chen MN, Chien LW, Liu CF. Acupuncture or acupressure at the Sanyinjiao (SP6) acupoint for the treatment of primary dysmenorrhea: a meta-analysis.

Evid Based Complement Alternat Med. 2013;2013:493038.

Cho SH, Hwang EW. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG. 2010;117(5):509–521.

Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428–441.

Eby GA. Zinc treatment prevents dysmenorrhea. Med Hypotheses. 2007;69(2):297–301.

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Hansen SO, Knudsen UB. Endometriosis, dysmenorrhoea and diet. Eur J

Obstet Gynecol Reprod Biol. 2013;169(2):162–171.

Kannan P, Claydon LS. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review. J Physiother. 2014;60(1):13–21.

Kannan P, Claydon LS, Miller D, et al. Vigorous exercises in the management of primary dysmenorrhea: a feasibility study. Disabil Rehabil. 2015;37(15):1334–1339.

Khan KS, Champaneria R, Latthe PM. How effective are non-drug, nonsurgical treatments for primary dysmenorrhoea? BMJ. 2012;344:e3011.

Latthe P, Mignini L, Gray R, et al. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749–755.

Marzouk TM, El-Nemer AM, Baraka HN. The effect of aromatherapy abdominal massage on alleviating menstrual pain in nursing students: a prospective randomized cross-over study. Evid Based Complement Alternat Med. 2013;2013:742421.

Polat A, Celik H, Gurates B, et al. Prevalence of primary dysmenorrhea in young adult female university students. Arch Gynecol Obstet. 2009;279(4):527–532.

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134–1138.

Reyes-Campos MD, Díaz-Toral LG, Verdín-Terán SL, et al. Acupuncture as an adjunct treatment for primary dysmenorrhea: a comparative study. Med Acupunct. 2013;25(4):291–294.

Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: a review. Contraception. 2010;81(3):185–196.

Zannoni L, Giorgi M, Spagnolo E, et al. Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol. 2014;27(5):258–265.

Zhu X, Proctor M, Bensoussan A, et al. Chinese herbal medicine for primary dysmenorrhoea. Cochrane Database Syst Rev. 2008;(2):CD005288.

SEE ALSO

Dyspareunia; Endometriosis; Menorrhagia (Heavy Menstrual Bleeding); Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

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Algorithm: Pelvic Pain

CODES

ICD10

N94.6 Dysmenorrhea, unspecified

N94.4 Primary dysmenorrhea

N94.5 Secondary dysmenorrhea

CLINICALPEARLS

Dysmenorrhea is a leading cause of absenteeism for women age <30 years.

In women who desire contraception, hormonal contraceptives are the preferred treatment.

All NSAIDs studied have been found to be equally effective in the relief of dysmenorrhea and should be initiated 1 to 2 days prior to onset of menses with scheduled dosing.

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DYSPAREUNIA

Scott T. Henderson, MD

BASICS

DESCRIPTION

Recurrent and persistent genital pain is associated with sexual activity, which is not exclusively due to lack of lubrication or vaginismus, and is associated with distress or interpersonal difficulty.

May be the result of organic, emotional, or psychogenic causes

–Primary: present throughout one’s sexual history

–Secondary: arising from some specific event or condition (e.g., menopause, drugs)

–Superficial: pain at, or near, the introitus or vaginal barrel associated with penetration

–Deep: pain after penetration located at the cervix or lower abdominal area

–Complete: present under all circumstances

–Situational: occurring selectively with specific situations

System(s) affected: reproductive

EPIDEMIOLOGY

Predominant age: all ages

Predominant sex: female > male

Incidence

>50% of all sexually active women will report dyspareunia at some time.

Geriatric Considerations

Incidence increases dramatically in postmenopausal women primarily because of vaginal atrophy.

Prevalence

Most sexually active women will experience dyspareunia at some time in their lives.

~15% (4–40%) of adult women will have dyspareunia on a few occasions during a year.

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~1–2% of women will have painful intercourse on a more-than-occasional basis.

Male prevalence is ~1%.

ETIOLOGYAND PATHOPHYSIOLOGY

Disorders of vaginal outlet

–Adhesions

–Condyloma

–Clitoral irritation

–Episiotomy scars

–Fissures

–Hymenal ring abnormalities

–Inadequate lubrication

–Infections

–Lichen planus

–Lichen sclerosus

–Postmenopausal atrophy

–Psoriasis

–Trauma

–Vulvar papillomatosis

–Vulvar vestibulitis/vulvodynia

Disorders of vagina

–Abnormality of vault owing to surgery or radiation

–Congenital malformations

–Inadequate lubrication

–Infections

–Inflammatory or allergic response to foreign substance

–Masses or tumors

–Pelvic relaxation resulting in rectocele, uterine prolapse, or cystocele

Disorders of pelvic structures

–Endometriosis

–Levator ani myalgia/spasm

–Malignant or benign tumors of the uterus

–Ovarian pathology

–Pelvic adhesions

–Pelvic inflammatory disease (PID)

–Pelvic venous congestion

–Prior pelvic fracture

–Uterine fibroids

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