Managing dysmenorrhoea in primary care
A common cause of pelvic pain in women, dysmenorrhoea is characterized by cramping in the lower abdomen that is cyclical, occurring before and/or during menstruation. Audrey Abella speaks with Dr Seet Meei Jiun, consultant from the Department of Obstetrics and Gynaecology at KK Women’s and Children’s Hospital, Singapore, to share insight on managing dysmenorrhoea in primary care.
Up to 90 percent of reproductive-age women experience dysmenorrhoea, and up to 29 percent report having severe pain. Despite the high prevalence and impact on quality of life (QoL), few women seek medical treatment, and some accept it as a normal part of a menstrual cycle.
Two types of dysmenorrhoea
1. Primary – this occurs in young females in the absence of any identifiable underlying pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation. This stimulates uterine myometrial contractions, leading to decreased blood flow, uterine hypoxia, and pain. Leukotrienes and vasopressin may also play a role in the aetiology of primary dysmenorrhoea.
2. Secondary – this is caused by an underlying pathology, such as endometriosis (the most common cause), adenomyosis, fibroids, endometrial polyps, pelvic inflammatory disease (PID), congenital anatomic abnormalities, or intra-uterine device insertion. Left untreated, some of these pathological conditions may affect fertility in the future.
Given its high prevalence, dysmenorrhoea is a public health burden. Apart from the physical symptoms, it also adversely affects women’s general wellbeing, and can lead to restrictions in daily activities, absenteeism, low mood, and poor sleep quality. It may also increase women’s susceptibility to other chronic pain conditions, such as fibromyalgia.
A good history taking is critical in establishing the diagnosis of dysmenorrhoea and in differentiating between primary and secondary dysmenorrhoea.
Primary dysmenorrhea typically starts 6–12 months after menarche, with peak prevalence occurring in the late teens or early 20s. The pain is usually in the lower abdomen but may radiate to the lower back or thighs and seldom lasts more than 48–72 hours. Pelvic examination usually reveals normal findings and should only be performed in adolescents who have had vaginal intercourse.
Secondary dysmenorrhoea often starts after several years of relatively painless periods and is not always related to menstruation alone. It may persist after menstruation ends, or may be present throughout the menstrual cycle and exacerbated by menstruation. Other gynaecological symptoms, such as abnormal uterine bleeding or dyspareunia, are often present. Pelvic examination may show abnormal findings, but the presence of normal physical findings does not preclude secondary dysmenorrhoea.
Patients with endometriosis may have reduced uterine mobility, adnexal masses, and uterosacral nodularity on vaginal examination. Those with PID may have mucopurulent cervical or vaginal discharge and cervical motion tenderness, and those with fibroids or adenomyosis may have an enlarged uterus on examination.
Often, pelvic pathologies can be confidently excluded based on history, examination, and response to initial simple treatment alone without the need for further investigation, especially in younger females presenting with dysmenorrhoea.
If secondary dysmenorrhoea is suspected, a pelvic ultrasound should be performed. Other laboratory and radiologic investigations will only be necessary based on clinical assessment and suspicion – swabs for chlamydia and gonorrhoeal infection if PID is suspected; MRI, laparoscopy, or hysteroscopy in cases where initial investigation is inconclusive.
Other causes of chronic pelvic pain, such as irritable bowel syndrome, interstitial cystitis, adhesions, musculoskeletal pain, nerve entrapment, psychological issues, and sexual and physical abuse should be explored and considered as differential diagnoses.
Some “red flag” symptoms to look out for include rectal bleeding, new bowel symptoms, pelvic mass, suicidal ideations, excessive weight loss, irregular vaginal bleeding at >40 years of age, and post-coital bleeding. If the history suggests a specific non-gynaecological component to the pain, referral to relevant specialists should be considered.
GPs often face challenges in discussing topics related to menstruation and sexual health, particularly with teenagers, due to feelings of embarrassment and worry about the stigma in terms of social deviance. Many women also consider dysmenorrhoea a norm. Adequate time should be allowed for initial assessment and building the doctor-patient rapport.
There are no published local clinical practice guidelines for diagnosing or managing dysmenorrhoea. GPs may refer to articles on the diagnosis and initial management of dysmenorrhoea from reputable journals (ie, American Family Physician, Australian Family Physician).
Patients with secondary dysmenorrhoea requiring surgical intervention should be referred to gynaecologists for further assessment and treatment. Those with primary dysmenorrhoea that is unresponsive to initial management may also merit referral to a specialist.
Generally, the mainstay of treatment for primary dysmenorrhoea is symptomatic relief. Most adolescents will respond well to empiric treatment with NSAIDs or hormonal suppression, or both.
Hormonal contraceptives (eg, combined oral contraceptive pill, contraceptive patch, vaginal ring, contraceptive progestin implant, depot medroxyprogesterone acetate injection, and the levonorgestrel-releasing intra-uterine system) may be used to treat primary dysmenorrhoea after discussing the benefit-risk profiles with the patient. The mechanism of action of hormonal methods is likely related to the prevention of endometrial proliferation and/or ovulation, thus decreasing prostaglandin and leukotriene production.
However, before suggesting any treatment involving hormonal contraceptives, it is important to consider patients’ fertility wishes. Some may have misconceptions and may worry about the adverse effects of hormone treatment on future fertility. Overcoming patients’ perception on hormone use could be a major challenge in the management of dysmenorrhoea.
For teenagers, parents may not be prepared to consider hormonal contraceptives due to fear of promoting sexual promiscuity or its potential impact on their daughters’ future fertility.
As such, women need reassurance from their treating physicians that hormonal contraceptives are effective and safe alternatives for managing dysmenorrhoea.
Other complementary and alternative therapies that may also have potential benefits include exercise and topical heat therapy. Surgical treatment is generally reserved for certain causes of secondary dysmenorrhoea or for refractory cases.
Primary dysmenorrhoea is highly prevalent and frequently undertreated. Effective treatment is widely available and can improve QoL. It is important to exclude causes of secondary dysmenorrhoea that may impair fertility and cause morbidity in the future.