dysmenorrhea%20-%20primary
DYSMENORRHEA - PRIMARY
Primary dysmenorrhea is a painful menstruation without demonstrable pelvic disease.
Symptoms include intermittent painful spasms, crampy labor-like pain localized over the lower abdomen and the suprapubic area which may radiate to the lower back or inner thighs.
The pain may also be described as a dull ache or as a stabbing pain.
Accompanying symptoms include nausea and vomiting, diarrhea, headaches, lightheadedness, fatigue, fever, nervousness and fainting.

Diagnosis

  • Diagnosis is based on clinical presentation, history and physical exam

Alternative Diagnosis

  • Causes of secondary dysmenorrhea must be excluded, eg adenomyosis, endometriosis, leiomyomas, cervical stenosis, genital tract obstructive malformations 
  • Menstrual pain may also be caused by the following: Chronic salpingitis, use of intrauterine device (IUD), endometrial polyps, chronic pelvic inflammatory disease, pelvic adhesions, interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, myofascial pain, mood disorders

History

Important Points in the History

Menstrual History

  • Age at menarche
  • Time interval between menarche and the start of dysmenorrhea
  • Length and regularity of cycles
  • Dates of last 2 menses
  • Duration and amount of bleeding

Characteristics of Pain

  • Type, location, radiation, associated symptoms
  • Severity and duration
  • Relation of onset of pain to menstrual bleeding
  • Progression over time
  • Degree of patient’s disability resulting from pain
  • Presence of gastrointestinal (GI) or urinary symptoms that may suggest other causes of pelvic pain
  • Inquire about self-treatment with over-the-counter analgesics including nonsteroidal anti-inflammatory drugs (NSAIDs)

Others

  • Dyspareunia
  • Contraceptive use, eg IUD
  • History of sexually transmitted infections (STIs), multiple sexual partners, unprotected sex, sexual abuse, pelvic inflammatory disease, pelvic surgery, infertility, psychiatric disorders
  • Family history of endometriosis 

Physical Examination

Physical and Pelvic Exam

  • Intend to rule out secondary causes of dysmenorrhea (eg ovarian cysts or tumors, STIs)
  • General physical exam and routine pelvic exam during non-menstrual phase of cycle reveal no abnormalities
    • Virginal girl with mild cramps and a normal physical exam: Inspection of genitalia to exclude abnormality of hymen is all that is typically required
    • A careful pelvic exam is warranted in moderate or severe dysmenorrhea especially if it interferes with daily living
  • Further evaluation is required when history is inconsistent with primary dysmenorrhea, indicated also in cases of severe dysmenorrhea or if patient is unresponsive to initial empiric therapy
    • Careful bimanual pelvic exam and rectal exam may reveal abnormality associated with cause of secondary dysmenorrhea
      •  Bimanual pelvic exam may show a pelvic mass; an enlarged, irregular, or retroflexed uterus; tender uterus or adnexa; or uterosacral nodularity

If history is typical of primary dysmenorrhea and there are normal findings on routine physical and pelvic exam, further diagnostic evaluation is not usually warranted

Laboratory Tests

  • No lab tests are diagnostic or specific for dysmenorrhea
  • Some lab tests may be helpful
    • Complete blood count [elevated white blood cells (WBC) may be an indication of infection, or use blood count to evaluate if excessive bleeding has occurred]
    • Erythrocyte sedimentation rate to identify chronic inflammatory process
    • Human chorionic gonadotropin (hCG) to rule out ectopic pregnancy
    • Urinalysis to evaluate urinary symptoms
    • Vaginal and endocervical swabs may be done to screen for the presence of STIs, eg chlamydia and gonorrhea testing

Imaging

  • Pelvic ultrasonography, magnetic resonance imaging (MRI) and diagnostic laparoscopy may be considered
    • Ultrasonography and MRI are useful in evaluating genital tract abnormalities or obstruction
    • Transvaginal ultrasound can differentiate endometriomas from other adnexal masses
    • MRI can evaluate deep infiltrating or rectovaginal disease  
    • Diagnostic laparoscopy can confirm peritoneal endometriosis and adhesions
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