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 & 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 & fainting.

Diagnosis

  • Diagnosis is based on clinical presentation, history and physical exam
    • Secondary causes of dysmenorrhea must be excluded [adenomyosis, endometriosis, leiomyomas, cervical stenosis, chronic salpingitis, use of intrauterine device, endometrial polyps, genital tract obstructive malformations, chronic pelvic inflammatory disease (PID), pelvic adhesions]

History

Important Points in the History

Menstrual History

  • Age at menarche
  • 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
  • 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
  • History of sexually transmitted infections (STIs), PID, infertility
  • 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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