Primary dysmenorrhea in adolescents

INTRODUCTION — Primary dysmenorrhea refers to recurrent, crampy lower abdominal pain that occurs prior to and during menstruation in the absence of pelvic pathology. It is the most common gynecologic complaint among adolescent females. Management is directed toward excluding pelvic pathology (secondary dysmenorrhea) and selecting medication appropriate for the patient's individual characteristics and symptom severity.

The diagnosis and treatment of primary dysmenorrhea in adolescents will be discussed in this topic review. Evaluation and treatment of primary dysmenorrhea in adults are reviewed separately. (See "Dysmenorrhea in adult females: Clinical features and diagnosis" and "Dysmenorrhea in adult females: Treatment".)

DEFINITIONS — For clinical purposes, dysmenorrhea is divided into two broad categories:

●Primary dysmenorrhea – This refers to the presence of recurrent, crampy lower abdominal pain that occurs prior to and during menses in the absence of demonstrable disease that could account for these symptoms.

●Secondary dysmenorrhea – This has the same clinical features but occurs in individuals with a disorder that could account for their symptoms such as endometriosis (table 1 and table 2). Secondary dysmenorrhea is more common among adults in the fourth and fifth decades of life but occasionally occurs in adolescents.

EPIDEMIOLOGY — The prevalence of dysmenorrhea among adolescent females ranges from 60 to 93 percent [1-4]. Many adolescents report that the dysmenorrhea interferes with daily activities, such as school, athletics, and other social activities [2-5]. However, only 15 percent of females seek medical advice for menstrual pain, suggesting that some cases are mild or effectively self-medicated but also signifying the importance of screening all adolescent females for dysmenorrhea [3].

Dysmenorrhea generally worsens once ovulatory menstrual cycles are established, which occurs from months to several years after menarche, depending on the individual rate of maturation of the hypothalamic-pituitary-gonadal axis. Approximately 18 to 45 percent of teens have ovulatory cycles two years postmenarche, 45 to 70 percent by two to four years, and 80 percent by four to five years [6]. Dysmenorrhea occasionally accompanies anovulatory cycles, especially if heavy bleeding and clots are present. (See "Normal menstrual cycle".)

MECHANISMS — Dysmenorrhea appears to be caused by excess production of endometrial prostaglandin F2 alpha (PGF2 alpha) or an elevated PGF2 alpha:prostaglandin E2 (PGE2) ratio. Excessive levels of endometrial, but not plasma, PGE2 and PGF2 alpha have been detected in individuals with primary dysmenorrhea [7]. These compounds can cause dysrhythmic uterine contractions, hypercontractility, and increased uterine muscle tone leading to uterine ischemia. They also can account for nausea, vomiting, and diarrhea via stimulation of the gastrointestinal tract. The role of prostaglandins in the pathogenesis of primary dysmenorrhea is supported by the observation that nonsteroidal anti-inflammatory drugs (NSAIDs), which are prostaglandin synthetase inhibitors, often alleviate the symptoms of primary dysmenorrhea [8-12]. (See 'Treatment' below.)

CLINICAL MANIFESTATIONS — The primary symptom of dysmenorrhea is crampy lower abdominal pain or back pain. In severe cases, the pain is not substantially relieved by analgesics and may be accompanied by nausea, vomiting, diarrhea, headache, fatigue, and/or dizziness (table 3). The pain and associated symptoms typically begin several hours prior to the onset of menstruation and continue for one to three days.

EVALUATION — The evaluation of an adolescent presenting with menstrual cramps begins with a complete medical and menstrual history to assess the severity of the symptoms and exclude secondary causes of dysmenorrhea (table 2).

History — A complete history should include the following information (table 1):

●Menstrual history:

•Age at menarche

•Duration of menstrual bleeding

•Menstrual flow assessment

•Interval between menstrual periods (from first day of one period to the first day of the following period)

•First day of last two menstrual periods

●Symptom history:

•Initial onset of symptoms and progression over time.

•Relation of symptoms to menstrual bleeding.

•Presence or absence of nausea, vomiting, diarrhea, back pain, dizziness, fatigue, and headache during menstruation.

•Impact of symptoms on daily activities, such as school attendance, sports participation, and other activities.

•Medication use, including type, dose, and timing in relation to the onset of cramps and perceived effectiveness in terms of pain relief and ability to engage in all daily activities.

•The severity of the disorder can be categorized by a grading system based on the degree of menstrual pain, presence of systemic symptoms, and impact on daily activities. One system for grading severity is outlined in the table (table 3) [13].

●Sexual history:

•Ever sexually active

•Current sexual activity and type of contraception used

•History of sexually transmitted infections and history of pelvic inflammatory disease

Physical examination

●Abdomen – In a patient with primary dysmenorrhea, the abdominal examination is unremarkable when the patient is not menstruating and may include generalized lower abdominal tenderness during menses. A finding of localized tenderness, with or without a mass, suggests a diagnosis other than primary dysmenorrhea.

●Pelvic examination – A pelvic examination should be performed in all sexually active adolescents with severe symptoms (eg, grade 3 dysmenorrhea (table 3)) to exclude causes of secondary dysmenorrhea. If the symptoms are not attributed to a sexually transmitted infection or musculoskeletal causes, a pelvic ultrasound should be performed to assess for other causes of secondary dysmenorrhea.

A pelvic examination may be deferred if symptoms are mild to moderate and the history is typical for primary dysmenorrhea. In nonsexually active adolescents, a pelvic examination is not indicated unless symptoms persist despite treatment [14].

DIAGNOSIS — A clinical diagnosis of primary dysmenorrhea can be made if the characteristic clinical symptoms develop in an ovulatory adolescent and secondary dysmenorrhea (ie, painful menstruation in the presence of pelvic pathology) has been excluded. The extent of the evaluation to exclude secondary causes varies depending on whether the history is typical or atypical for primary dysmenorrhea and the severity of the symptoms. The evaluation should include a pelvic examination for patients who are sexually active (but may be deferred if the pain is mild and typical for primary dysmenorrhea) and either a pelvic examination or ultrasound for all patients with severe symptoms.

DIFFERENTIAL DIAGNOSIS — A focused history and physical examination usually are sufficient to distinguish primary dysmenorrhea from secondary dysmenorrhea (table 1 and table 2) and from other disorders. As examples:

●Anatomic abnormalities – A history of painful menses commencing at menarche is unlikely to be primary dysmenorrhea because most menstrual cycles are anovulatory for several months to several years after menarche. Possible causes for this pattern of pain include incomplete fenestration of the hymen or other developmental anomalies of the müllerian duct. To easily exclude a hymenal abnormality, vaginal introitus should be visualized, and a cotton swab may be inserted into the vagina.

●Psychogenic contributors – A complete psychosocial history may suggest other causes for abdominal pain such as depression, substance abuse, or stress secondary to abuse or other trauma.

●Endometriosis – Menstrual pain that has become progressively worse over time is characteristic of endometriosis, which may present as cyclic or noncyclic pain. Endometriosis is a common cause of secondary dysmenorrhea. A pelvic examination may reveal a tender cul-de-sac or uterosacral ligament nodularity. (See "Endometriosis in adolescents: Diagnosis and treatment".)

●Pelvic inflammatory disease – Adolescents who have had pelvic infections (eg, gonorrhea, chlamydia) may develop adhesions that result in pelvic pain, especially during menstruation. On examination, patients with acute pelvic infections typically have lower abdominal tenderness on external palpation and cervical motion and adnexal tenderness on bimanual examination. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

The presence of pelvic pain between menses, or that is unrelated to menses, also suggests secondary dysmenorrhea. Gynecologic causes of acute pelvic pain are outlined in the table; these and other causes of pelvic pain are discussed in a separate topic review (table 4). (See "Evaluation of acute pelvic pain in female children and adolescents", section on 'Differential diagnosis'.)

TREATMENT

Overview of treatment — The goal of treatment is to relieve pain and discomfort enough so that patients are able to carry out all of their daily activities (eg, attend school, work, participate in hobbies). We recommend to patients that they start with baseline interventions if they have not already done so. (See 'Baseline interventions' below.)

The severity of menstrual pain and limitation of daily activities will help guide treatment decisions (table 3 and algorithm 1).

Mild to moderate pain — In addition to baseline interventions, for patients with mild to moderate dysmenorrhea symptoms, we suggest nonsteroidal anti-inflammatory drugs (NSAIDs) and/or hormonal therapy, rather than other analgesics (eg, acetaminophen). Both NSAIDs and hormonal methods have been shown to be effective in randomized trials. However, they have not been evaluated in head-to-head trials.

●Randomized trials of hormonal methods in adults and adolescents demonstrate moderate efficacy in pain relief [15].

●In randomized trials of NSAIDs, approximately 70 to 90 percent of adults and adolescents have effective pain relief, a value that is greater than with placebo [8-12,16,17].

Consequently, we select initial treatment based on patient preferences, including the desire for hormonal contraception. For patients who prefer to start hormonal contraceptive methods, we encourage the use of NSAIDs if needed for additional pain relief.

Severe pain — If the patient's pain is so severe as to interfere with daily function (eg, school, work, sports, social activities), we discuss starting treatment with both a hormonal method and an NSAID. When pain is no longer limiting daily activities, and if desired by the patient, a trial period with elimination of one of the methods is reasonable.

Baseline interventions — General measures for therapy include education about self-care such as exercise and heat therapy. Both have demonstrated efficacy for pain relief in adults. (See "Dysmenorrhea in adult females: Treatment", section on 'Baseline interventions'.)

Patients who do not desire contraception — For patients who do not need or desire contraception, NSAIDs are considered first-line therapy (algorithm 1) [14,18-20]. NSAIDs are generally more effective than acetaminophen for treatment of dysmenorrhea.

Choice of NSAID — We start with ibuprofen or naproxen (from the propionic acid group of NSAIDs), which block prostaglandin synthetase. If this group of NSAIDs is not effective, we use mefenamic acid (from the fenamate class), which both inhibits prostaglandin synthetase and blocks the action of prostaglandins that are already formed [21]. (See 'Mechanisms' above and "Dysmenorrhea in adult females: Treatment", section on 'Nonsteroidal anti-inflammatory drugs'.)

How to take NSAIDs

●Timing of first dose – NSAIDs should be started one or two days prior to the expected onset of menstrual pain and continued for the first one to two days of the menstrual cycle or for the usual duration of crampy pain. They are most effective when begun early in the course of symptoms because of their inhibitory effect on the enzymes that cause dysmenorrhea.

●Take with food – NSAIDs should be taken with food to minimize side effects such as gastrointestinal irritation or bleeding. Because selective cyclooxygenase 2 (COX-2) inhibitors are associated with some serious adverse events, we generally use NSAIDs that are nonselective COX inhibitors, as described above. (See "Nonselective NSAIDs: Overview of adverse effects".)

Inadequate response to NSAIDs — Hormonal therapies are appropriate for any patient, including those never sexually active and those for whom NSAID therapy is not effective or not tolerated [22]. If NSAID therapy is tolerated but not effective after two to three menstrual cycles, we suggest addition of a hormonal therapy. (See 'Choice of hormonal method' below.)

Patients who desire contraception

Choice of hormonal method — All hormonal contraceptives reduce dysmenorrhea symptoms, although this indication is off label. Options include combined hormonal contraceptives (pills, transdermal patches, vaginal ring); progestin-only contraceptive pills; and injectable, implant, and hormonal intrauterine devices. However, adolescents with contraindications to estrogen (eg, migraine headache with aura) are limited to progestin-only methods. (See "Dysmenorrhea in adult females: Treatment", section on 'Progestin-only methods'.)

Adolescents' contraceptive preferences should be assessed, and patients should be counseled about methods that align with their preferences, such as timing of periods, frequency of dosing, contraceptive efficacy, and confidentiality. The relative benefits of these methods and data from studies on adults are discussed separately, as are other considerations for selection of a contraceptive method for adolescents, including contraindications to estrogen-containing contraceptives. (See "Dysmenorrhea in adult females: Treatment", section on 'Hormonal contraception' and "Contraception: Issues specific to adolescents".)

Inadequate response to hormonal method — If the patient does not have an adequate response after two to three menstrual cycles, we discuss trying one of the following (algorithm 1):

●Extended or continuous cycling – Increasing the interval between menstrual periods will reduce frequency of dysmenorrhea and may reduce severity. Options include the following:

•Combined oral contraceptive pills – Prescribing 84 daily active monophasic combined hormonal contraceptive pills followed by seven inactive pills, also known as tricycling, is a common option. Adolescents may also take an active pill daily and skip placebos entirely. (See "Contraception: Issues specific to adolescents", section on 'Combined oral contraceptives'.)

•Vaginal ring – The vaginal ring may be replaced every 3 weeks for a total of 12 weeks followed by seven days without the ring in place. Continuous cycling (no hormone-free interval) is also possible with the vaginal ring. (See "Contraception: Hormonal contraceptive vaginal rings", section on 'Insertion and use'.)

The adolescent should be warned that unscheduled breakthrough bleeding is common during the first year and generally decreases with prolonged use.

●Addition of NSAID – If hormonal therapy does not provide adequate relief, we usually add an NSAID to the treatment regimen. (See 'Patients who do not desire contraception' above.)

●Change to a different modality of hormone therapy – Contraceptive implants, levonorgestrel-releasing intrauterine devices, and depot medroxyprogesterone are very effective at treating dysmenorrhea. Patients should be counseled that unscheduled bleeding frequently occurs with these methods. (See "Dysmenorrhea in adult females: Treatment", section on 'Progestin-only methods'.)

FOLLOW-UP — Patients should be followed closely for the first few months after treatment is initiated to evaluate the response and adherence to therapy. If first- or second-line treatments are not effective, if the pain recurs, or if symptoms worsen, the patient should be reevaluated for the causes of secondary dysmenorrhea (table 2). Reevaluation includes clinical assessment, pelvic ultrasonography, and possible referral to an adolescent gynecologist or adolescent medicine specialist to further assess for underlying pelvic pathology and consider alternate forms of hormonal therapy (algorithm 1) [14,20].

COMPLEMENTARY OR ALTERNATIVE INTERVENTIONS — Complementary or alternative medicine approaches (eg, acupuncture) to pain relief are reasonable options but are based on limited evidence in adults. (See "Dysmenorrhea in adult females: Treatment", section on 'Complementary or alternative medicine'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dysmenorrhea".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Painful periods (The Basics)")

●Beyond the Basics topics (see "Patient education: Painful menstrual periods (dysmenorrhea) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition and clinical manifestations – Primary dysmenorrhea refers to recurrent, crampy lower abdominal pain that occurs during menstruation in the absence of pelvic pathology. It may be accompanied by nausea, vomiting, diarrhea, headache, dizziness, fatigue, and/or back pain. (See 'Clinical manifestations' above.)

●Evaluation – The evaluation includes a directed medical history and complete menstrual history to exclude secondary causes of dysmenorrhea (table 1 and table 2). Concerning features include pelvic pain that began at menarche, pelvic pain unrelated to menses, progressively worsening pain, or a history of pelvic infection. (See 'Evaluation' above and 'Differential diagnosis' above.)

●Physical examination – A pelvic examination and/or pelvic ultrasound should be performed to exclude the causes of secondary dysmenorrhea in all adolescents with severe symptoms (eg, grade 3 dysmenorrhea (table 3)). An internal pelvic examination is usually deferred in young, nonsexually active adolescents with only mild menstrual cramps. (See 'Physical examination' above.)

●Treatment – Adolescents with primary dysmenorrhea should be counseled to use heat and/or exercise for pain relief. For those who require pharmacologic treatment, we suggest nonsteroidal anti-inflammatory drugs (NSAIDs) and/or hormonal therapy rather than other analgesics (eg, acetaminophen) (Grade 2C).

Because no head-to-head trials have been conducted between NSAIDs and hormonal therapy, we base the decision about initial therapy on patient preferences, including whether the patient desires contraception (algorithm 1). (See 'Treatment' above.)

•Patients who do not desire contraception – For these patients, we usually start with ibuprofen or naproxen. If an NSAID of one class is not effective, it is reasonable to try an NSAID of a different class. (See 'Patients who do not desire contraception' above.)

For those patients who do not respond well to NSAIDs, the addition of a hormonal method can be offered. (See 'Inadequate response to NSAIDs' above.)

•Patients who desire contraception – For patients with no contraindications to estrogen (eg, migraine headache with aura) and who believe that they can remember to take a daily pill, we usually start with combined oral contraceptive pills. However, any hormonal contraceptive may be used. (See 'Choice of hormonal method' above.)

For those patients who do not respond well to treatment with hormonal methods, we discuss extended cycling and/or addition of an NSAID. (See 'Inadequate response to hormonal method' above.)

•Patients with severe pain – For patients whose dysmenorrhea is so severe as to interfere with daily function, we discuss starting treatment with both a hormonal method and an NSAID. (See 'Severe pain' above.)

●Referral – We refer patients to adolescent medicine specialists or gynecologists for further evaluation if they do not have an adequate response to these methods. (See 'Follow-up' above.)