INTRODUCTION — Primary dysmenorrhea refers to recurrent, crampy lower abdominal pain that occurs 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 to 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 adult women is 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 refers to the presence of recurrent, crampy lower abdominal pain that occurs during menses in the absence of demonstrable disease that could account for these symptoms.
●Secondary dysmenorrhea has the same clinical features but occurs in women with a disorder that could account for their symptoms, such as endometriosis (table 2B). Secondary dysmenorrhea is more common among women 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, sporting events, 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 .
Dysmenorrhea generally does not occur until 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 . 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 women with primary dysmenorrhea . 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 antiinflammatory 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 1). 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 female 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 2B).
History — A complete history should include the following information (table 2A):
•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
•Initial onset of symptoms and progression over time.
•Relation of symptoms to periods.
•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 – 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 1) .
•Current sexual activity and type of contraception used
•History of sexually transmitted infections and history of pelvic inflammatory disease
●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 and/or pelvic ultrasound should be performed in all females with severe symptoms (eg, grade 3 dysmenorrhea (table 1)) to exclude the causes of secondary dysmenorrhea. A pelvic examination is also suggested for all sexually active adolescents with dysmenorrhea, even if the symptoms are mild, but may be deferred if the history is typical for primary dysmenorrhea. In nonsexually active females, a pelvic examination may be deferred unless symptoms persist despite treatment .
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) have 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 is sufficient to distinguish primary dysmenorrhea from secondary dysmenorrhea (table 2A-B) and from other disorders. As examples:
●Anatomic abnormalities – A history of painful menses commencing at menarche is unlikely to be primary dysmenorrhea because most females 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 3). (See "Evaluation of acute pelvic pain in the adolescent female", section on 'Differential diagnosis'.)
TREATMENT — The severity of menstrual pain and limitation of daily activities will help guide treatment decisions (table 1). General measures for therapy include patient reassurance and education about options for medications and their appropriate use.
Nonsteroidal antiinflammatory drugs — For patients who do not desire contraception, nonsteroidal antiinflammatory drugs (NSAIDs) are considered first-line therapy [14-17]. NSAIDs are also good adjuncts for patients who choose hormonal contraception. In randomized trials of NSAIDs, approximately 70 to 90 percent of patients have effective pain relief, a value that is greater than that with placebo [8-12,18,19]. NSAIDs are also generally more effective than acetaminophen for treatment of dysmenorrhea.
NSAIDs should be started at the onset of menses 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 effects on prostaglandin synthetase. Patients with severe symptoms should begin taking NSAIDs one to two days prior to the onset of menses. If an NSAID of one class is not effective, it is reasonable to switch to an NSAID of a different class. This is because patients vary in their response to a particular drug, perhaps because of differences in pharmacodynamics. Ibuprofen and naproxen (from the propionic acid group of NSAIDs) are used commonly for the treatment of dysmenorrhea in clinical practice. Mefenamic acid (from the fenamate class) is unique in that it both inhibits prostaglandin synthetase and blocks the action of the prostaglandins that are already formed . A trial of mefenamic acid should be considered for patients who do not respond to the propionic acid group of medications. (See "NSAIDs: Therapeutic use and variability of response in adults".)
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".)
Hormonal therapy — Hormonal therapies such as oral contraceptives (OCs) are appropriate as second-line therapy for patients who are not sexually active but for whom NSAID therapy is not effective or not tolerated . They may also be appropriate for first-line therapy in patients who are sexually active because they prevent both dysmenorrhea and pregnancy .
OCs prevent menstrual pain by suppressing ovulation, thereby decreasing uterine prostaglandin levels. An additional mechanism may result from the reduction of menstrual flow after several months of use. Randomized trials in adults and adolescents demonstrate moderate efficacy in pain relief [21,22]. The efficacy of OCs for primary dysmenorrhea has not been directly compared with NSAIDs. Any OC is likely to be effective, and cycle selection is determined by patient preference. If conventional formulations (21 days of medication/7 days of placebo) do not provide sufficient relief, formulations with a reduced hormone-free interval or an extended cycle may be beneficial. (See "Dysmenorrhea in adult females: Treatment", section on 'Hormonal contraception'.)
Other hormonal contraceptives that are useful for dysmenorrhea include transdermal patch or vaginal ring, injectable or implantable contraceptives, or levonorgestrel-releasing intrauterine devices. The relative benefits of these methods and data from studies on adults are discussed separately (see "Dysmenorrhea in adult females: Treatment", section on 'Hormonal contraception'), as are other considerations for selection of a contraceptive method for adolescents, including contraindications to estrogen-containing contraceptives. (See "Contraception: Issues specific to adolescents".)
Approaches if treatment is not effective — If treatment with one of these modalities (ie, NSAIDs or hormonal contraception) is not effective after two or three menstrual cycles, the first step is to assess and address any problems with adherence to the therapy. If adherence does not seem to be the problem, we suggest a course of treatment with addition of the other modality. Treatment with both hormonal contraceptives and NSAIDs may be effective in women who remain symptomatic on either drug alone. Other treatment options include changing to a different modality of hormonal therapy, such as long-acting progesterone implants or depot medroxyprogesterone. (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 and possibly referred to an adolescent gynecologist or adolescent medicine specialist to further assess for underlying pelvic pathology (secondary dysmenorrhea (table 2B)) and consideration of alternate forms of hormonal therapy [14,17].
OTHER INTERVENTIONS — Other approaches to pain relief are based on limited evidence in adults:
●Self-care approaches to pain relief (eg, heat therapy and exercise) (see "Dysmenorrhea in adult females: Treatment", section on 'Baseline interventions')
●Complementary or alternative medicine (eg, acupuncture) (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 5th to 6th 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 10th to 12th 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. Nausea, vomiting, diarrhea, headache, dizziness, fatigue, and/or back pain may accompany the crampy abdominal pain. (See 'Clinical manifestations' above.)
●Evaluation – The evaluation includes a directed medical history and complete menstrual history to exclude secondary causes of dysmenorrhea (table 2B). Features that suggest a cause other than primary dysmenorrhea 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 females with severe symptoms (eg, grade 3 dysmenorrhea (table 1)). An internal pelvic examination is usually deferred in young, nonsexually active adolescents with only mild menstrual cramps. (See 'Physical examination' above.)
●Treatment – Treatment decisions depend on the severity of menstrual symptoms and limitation of daily activities (table 1). For adolescents with primary dysmenorrhea who require treatment, nonsteroidal antiinflammatory drugs (NSAIDs) and hormonal therapy, including contraceptives, are the mainstays of treatment. (See 'Treatment' above.)
•NSAIDs – For those who choose not to or should not use hormonal contraception, we suggest a trial of treatment with an NSAID (Grade 2B). Ibuprofen and naproxen are used commonly for the treatment of dysmenorrhea in clinical practice. If an NSAID of one class is not effective, it is reasonable to do a trial of an NSAID of a different class. (See 'Nonsteroidal antiinflammatory drugs' above.)
•Hormonal therapy – For those who desire contraception, or for those who do not respond to or do not tolerate NSAIDs, we suggest treatment with hormonal therapy (Grade 2C). (See 'Hormonal therapy' above.)
•Next steps – If treatment with one of these modalities is not successful, we suggest assessing adherence and consideration of a course of treatment with the other modality (Grade 2C). Treatment with both a hormonal contraceptive and NSAID may be effective in women who remain symptomatic on either drug alone. (See 'Approaches if treatment is not effective' above.)
2 : A survey of adolescent dysmenorrhea and premenstrual symptom frequency. A model program for prevention, detection, and treatment.
5 : Primary dysmenorrhea in young Western Australian women: prevalence, impact, and knowledge of treatment.
10 : Prostaglandins in primary dysmenorrhea. Comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives.
11 : The treatment of dysmenorrhea with naproxen sodium: a report on two independent double-blind trials.
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