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Dysmenorrhea
is pelvic pain with menses. Primary dysmenorrhea begins during adolescence and
cannot be explained by structural gynecologic disorders. Usually,
secondary dysmenorrhea begins during adulthood and is due to underlying
pelvic abnormalities. Diagnosis is clinical and by exclusion of
structural disorders with pelvic ultrasonography and tests directed at
any other clinically suspected causes. Underlying disorders are
treated. Pain is treated with NSAIDs and sometimes with low-dose
estrogen-progestin contraceptives.
Primary dysmenorrhea is common. It usually starts during adolescence and tends to lessen with age and after pregnancy. Pain is thought to result from uterine contractions and ischemia, probably mediated by prostaglandins produced in secretory endometrium. Contributing factors may include passage of menstrual tissue through the cervix, a narrow cervical os, a malpositioned uterus, lack of exercise, and anxiety about menses.
Common causes of secondary dysmenorrhea include endometriosis, uterine adenomyosis, fibroids, and, in a few women, an extremely tight cervical os (secondary to conization, cryocautery, or thermocautery) that becomes painful when the uterus attempts to expel tissue. Pain occasionally results from a pedunculated submucosal fibroid or an endometrial polyp extruding through the cervix.
Symptoms,
Signs, and Diagnosis
Pelvic pain may occur with menses or precede menses by 1 to 3 days. Pain tends to peak 24 h after onset of menses and subside after 2 to 3 days. It is usually sharp but may be a dull, constant ache; it may radiate to the lower back or legs. Headache, nausea, constipation or diarrhea, and urinary frequency are common; vomiting occurs occasionally. Symptoms of premenstrual syndrome may occur during part or all of menses. Sometimes endometrial clots or casts are expelled.
Primary dysmenorrhea is suspected if symptoms begin soon after menarche or during adolescence. Secondary dysmenorrhea is suspected if symptoms begin after adolescence. Diagnosis requires a history of characteristic, recurrent symptoms. To differentiate primary and secondary dysmenorrhea, structural gynecologic disorders are excluded by clinical assessment, pelvic ultrasonography, and tests for other clinically suspected disorders.
Treatment
Underlying disorders are treated. Symptomatic treatment begins with adequate rest and sleep and regular exercise. Women with primary dysmenorrhea are reassured about the absence of structural gynecologic disorders. Persistent pain due to primary or secondary dysmenorrhea requires drug therapy; an NSAID is usually started 24 to 48 h before and continued until 1 or 2 days after menses begins. If these measures are ineffective, suppression of ovulation with a low-dose estrogen-progestin oral contraceptive is advisable. Hypnosis is occasionally useful. For intractable pain of unknown origin, interruption of uterine nerves by presacral neurectomy and division of the sacrouterine ligaments may help.
Last full review/revision November 2005
Content last modified November 2005
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