Dysmenorrhea

Dysmenorrhea is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Pelvic pain occurring at/around time of menses; a leading cause of absenteeism for women <30 years old
  • Primary dysmenorrhea: pelvic pain without pathologic physical findings
  • Secondary dysmenorrhea: often more severe, results from specific pelvic pathology; severity based on activity impairment
    • Mild: painful, rarely limits daily function, or requires analgesics
    • Moderate: daily activity affected, rare absenteeism, requires analgesics
    • Severe: daily activity affected, likelihood of absenteeism increased, limited benefit from analgesics
  • System affected: reproductive
  • Synonym(s): menstrual cramps

Epidemiology

  • Predominant age
    • Primary: onset 6 to 12 months after the start of menarche, teens to early 20s
    • Secondary: 20s to 30s
  • Predominant sex: women only

Prevalence
  • Up to 90% of menstruating females have experienced primary dysmenorrhea (1).
  • Up to 42% lose days of school/work monthly due to dysmenorrhea.
  • Up to 20% reported impairment in daily activities and/or sleep.

Etiology and Pathophysiology

  • Primary: Elevated prostaglandin (PGF2α) production through indirect hormonal control (decrease in progesterone at start of menses leads to increase in prostaglandins) causes nonrhythmic hypercontractility and increased uterine muscle tone with vasoconstriction and resultant uterine ischemia. Ischemia results in hypersensitization of type C pain nerve fibers; intensity of cramps directly proportional to amount of PGF2α released (1)
  • Secondary
    • Endometriosis (most common cause)
    • Adenomyosis
    • Congenital abnormalities of uterine/vaginal anatomy
    • Cervical stenosis
    • Pelvic inflammatory disease
    • Ovarian cysts
    • Pelvic tumors, especially leiomyomata (fibroids) and uterine polyps

Genetics
Not well studied

Risk Factors

  • Primary (1,2)
    • Cigarette smoking
    • Alcohol use
    • Early menarche (age <12 years)
    • Age <30 years
    • Family history of dysmenorrhea
    • Irregular/heavy menstrual flow
    • Nonuse of oral contraceptives
    • Sexual abuse/history of sexual assault
    • Psychological symptoms (depression, anxiety, increased stress, etc.)
    • Nulliparity
  • Secondary
    • Pelvic infection
    • Use of intrauterine device (IUD) in the few months following insertion
    • Structural pelvic malformations
    • Family history of endometriosis in first-degree relative

General Prevention

  • Primary: regular exercise; early childbirth
  • Secondary: Reduce risk of sexually transmitted infections (STIs).

Pediatric Considerations
Onset with first menses raises probability of genital tract anatomic abnormality (i.e., transverse vaginal septum, imperforate or minimally perforated hymen, uterine anomalies).

Commonly Associated Conditions

  • Irregular/heavy menstrual periods
  • Longer menstrual cycle length/duration of bleeding
  • Anxiety/depression
  • Decreased quality of life

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