Diagnosis and Initial Managementof DysmenorrheaAMIMI S. OSAYANDE, MD, and SUARNA MEHULIC, MD, University of Texas Southwestern Medical Center, Dallas, TexasDysmenorrhea is one of the most common causes of pelvic pain. It negatively affects patients’ quality of life and sometimes results in activity restriction. A history and physical examination, including a pelvic examination in patients whohave had vaginal intercourse, may reveal the cause. Primary dysmenorrhea is menstrual pain in the absence of pelvicpathology. Abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and duration of pain, andabnormal pelvic examination findings suggest underlying pathology (secondary dysmenorrhea) and require furtherinvestigation. Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected. Endometriosis is the most common cause of secondary dysmenorrhea. Symptoms and signs of adenomyosis include dysmenorrhea,menorrhagia, and a uniformly enlarged uterus. Management options for primary dysmenorrhea include nonsteroidal anti-inflammatory drugs and hormonal contraceptives. Hormonal contraceptives are the first-line treatment fordysmenorrhea caused by endometriosis. Topical heat, exercise, and nutritional supplementation may be beneficial inpatients who have dysmenorrhea; however, there is not enough evidence to support the use of yoga, acupuncture, ormassage. (Am Fam Physician. 2014;89(5):341-346. Copyright 2014 American Academy of Family Physicians.)CME This clinical contentconforms to AAFP criteriafor continuing medicaleducation (CME). SeeCME Quiz Questions onpage 327.Author disclosure: No relevant financial affiliations. Patient information: A handout onthis topic is available a, defined as painfulcramps that occur with menstruation, is the most commongynecologic problem in womenof all ages and races,1 and one of the mostcommon causes of pelvic pain.2 Estimates ofthe prevalence of dysmenorrhea vary widely(16.8% to 81%3), and rates as high as 90%have been recorded.4 Symptoms typicallybegin in adolescence and may lead to schooland work absenteeism, as well as limitationson social, academic, and sports activities.5Dysmenorrhea is considered primary inthe absence of underlying pathology. Onsetis typically six to 12 months after menarche,with peak prevalence occurring in the lateteens or early twenties. Secondary dysmenorrhea results from specific pelvic pathology.It should be suspected in older women withno history of dysmenorrhea until provenotherwise.6 Symptoms include menorrhagia,intermenstrual bleeding, dyspareunia, postcoital bleeding, and infertility.Endometriosis is the most common causeof secondary dysmenorrhea.7 The incidenceis highest among women 25 to 29 years ofage and lowest among women older than 44years. Black women have a 40% lower incidence of endometriosis compared with whitewomen.8 Table 1 lists risk factors for thedevelopment of dysmenorrhea; protectivefactors include regular exercise, oral contraceptive use, and early childbirth.6DiagnosisWHICH SYMPTOMS SUGGEST PRIMARYDYSMENORRHEA?Characteristic symptoms of primary dysmenorrhea include lower abdominal or pelvic pain with or without radiation to the backTable 1. Risk Factors forDysmenorrheaRisk factorOdds ratioHeavy menstrual lossPremenstrual symptomsIrregular menstrual cyclesAge younger than 30 years4. suspected pelvicinflammatory diseaseSexual abuseMenarche before 12 yearsof ageLow body mass indexSterilization1. from reference 6.March1, 2014Volume89, FamilyNumber5 website at American Academy of FamilyAmericanFamily341Downloadedfrom theAmericanPhysicianCopyright 2013Physicians.For thePhysicianprivate, noncommercial use of one individual user of the website. All other rights reserved. Contact copyrig[email protected] for copyright questions and/or permission requests.

DysmenorrheaTable 2. Differential Diagnosis of DysmenorrheaSuspectedconditionClinical presentationDiagnostic evaluationPrimarydysmenorrheaRecurrent, crampy, suprapubic pain occurring just beforeor during menses and lasting two to three days; painmay radiate into the lower back and thighs, and maybe associated with nausea, fatigue, bloating, andgeneral malaise; normal pelvic examination findings1Diagnosis is clinical; urine tests should be orderedto rule out pregnancy or infection9EndometriosisCyclic (can be noncyclic) pelvic pain with menstruation;may be associated with deep dyspareunia, dysuria,dyschezia, and subfertility; rectovaginal examinationfindings include fixed or retroverted uterus or reduceduterine mobility, adnexal masses, and uterosacralnodularity10,11Transvaginal and pelvic ultrasonography arehighly accurate for detecting ovarian andbowel endometriomas; magnetic resonanceimaging may be indicated for deeply infiltratingendometriosis11,12; laparoscopy with biopsy andhistology is the preferred diagnostic test11,13-16PelvicinflammatorydiseaseHistory of lower abdominal pain in sexually activepatients; abnormal pelvic examination findingsconsisting of cervical motion tenderness, uterinetenderness, and/or adnexal tenderness; otherassociated clinical features include oral temperature 101 F (38.3 C) and abnormal cervical or vaginalmucopurulent discharge17Saline microscopy of vaginal fluid may showorganism; elevated erythrocyte sedimentationrate or C-reactive protein level suggests infection;laboratory documentation of cervical infectionwith Neisseria gonorrhoeae or Chlamydiatrachomatis is confirmatory; transvaginalultrasonography is not usually indicated but mayshow thickened tubes with fluid collection, freepelvic fluid, or tubo-ovarian complex17AdenomyosisUsually associated with menorrhagia; may includeintermenstrual bleeding; physical examination findingsinclude enlarged, tender, boggy uterusTransvaginal ultrasonography and, if necessary,magnetic resonance imaging will usually detectendometrial tissue within the myometrium18LeiomyomataCyclic pelvic pain with menorrhagia and occasionallydyspareunia, particularly with anterior and fundalfibroidsTransvaginal ultrasonography can identify fibroidsEctopicpregnancyHistory of amenorrhea, abnormal uterine bleeding,severe sharp lower abdominal pain, and/or crampingon the affected side of the pelvis; may present withcomplications (e.g., hypotension, shock)Positive urinary human chorionic gonadotropinpregnancy test; pelvic or transvaginalultrasonography demonstrating extrauterinegestational sacInterstitialcystitisHistory of suprapubic pain (usually noncyclic) associatedwith urinary symptoms (e.g., frequency, nocturia); painmay radiate into the groin and rectum and is usuallyrelieved by voiding; negative pelvic examinationfindingsUrinalysis; cystoscopy with hydrodistension andbiopsy, which may show irritation of the bladderwall mucosa10Chronic pelvicpainHistory of noncyclic pelvic pain for at least six months;pain may radiate anteriorly toward the vagina orposteriorly toward the rectum and is worsened byanxiety; may be associated with dyspareunia anddifficulty with defecation; pelvic examination findingsmay be normal, but burning pain exacerbated byunilateral rectal palpation suggests pudendal nerveentrapment of the affected side10Pelvic magnetic resonance imaging along thepudendal nerve to assess the nerve andsurrounding structures; if findings on workupare negative, the diagnosis is based on clinicalhistory10NOTE:Conditions are listed in approximate order of decreasing frequency.Information from references 1, and 9 through 18.or legs, with initial onset six to 12 monthsafter menarche (Table 2).1,9-18 Pain typicallylasts eight to 72 hours and usually occurs atthe onset of menstrual flow. Other associated342 American Family may include low back pain, headache, diarrhea, fatigue, nausea, or vomiting.1 Afamily history may be helpful in differentiating primary from secondary dysmenorrhea;Volume 89, Number 5 March 1, 2014

Dysmenorrheapatients with a family history of endometriosis in first-degree relatives are more likelyto have secondary dysmenorrhea.1About 10% of young adults and adolescents with dysmenorrhea have secondarydysmenorrhea; the most common causeis endometriosis.19 Changes in timing andintensity of the pain or dyspareunia maysuggest endometriosis, and menstrualflow abnormalities may be associated withadenomyosis or leiomyomata. A historyof sexually transmitted infection or vaginal discharge associated with dyspareuniaraises suspicion for pelvic inflammatorydisease (PID). Asking about a history of sexual trauma is also recommended.10WHICH CLINICAL FEATURES DISTINGUISH PIDFROM DYSMENORRHEA?ARE PELVIC EXAMINATIONS NECESSARY INALL WOMEN WITH DYSMENORRHEA?The diagnosis of primary dysmenorrheais based on the clinical history and physical examination.9 Laparoscopy is indicatedif the etiology remains unknown after anappropriate noninvasive evaluation hasbeen completed.14A pelvic examination should be performedin adolescents who have had vaginal intercourse because of the high risk of PID inthis population. A pelvic examination isnot essential for adolescents with symptoms of primary dysmenorrhea who havenever had vaginal intercourse.20 However, if endometriosis is suspected, pelvicand rectovaginal examinations (Figure 1)should be performed.11 Pelvic examinationhas a 76% sensitivity, 74% specificity, 67%positive predictive value, and 81% negativepredictive value for endometriosis.13 Findings are usually normal in patients withprimary dysmenorrhea. Findings in thosewith secondary dysmenorrhea include afixed uterus or reduced uterine mobility,adnexal masses, and uterosacral nodularityin patients with endometriosis; mucopurulent cervical discharge in those with PID;and uterine enlargement or asymmetry inpatients with adenomyosis.10One or more findings of uterine tenderness,adnexal tenderness, or cervical motion tenderness should raise the suspicion for PID.17Additional criteria include oral temperaturegreater than 101 F (38.3 C), abnormal cervical or vaginal mucopurulent discharge,abundant white blood cells on saline microscopy of vaginal fluid, elevated erythrocytesedimentation rate, elevated C-reactive protein level, and laboratory documentation ofcervical infection with Neisseria gonorrhoeaeor Chlamydia trachomatis.WHICH TESTS ARE INDICATED IN THEEVALUATION OF DYSMENORRHEA?Adenomyosis is the presence of endometrialglands and stroma within the myometrium.Symptoms and signs include dysmenorrhea,menorrhagia, and a uniformly enlargeduterus. Diagnosis is usually confirmedthrough transvaginal ultrasonography andmagnetic resonance imaging.18March 1, 2014 Volume 89, Number 5ILLUSTRATION BY ENID HATTONWHEN SHOULD ADENOMYOSIS BESUSPECTED?Figure 1. Rectovaginal examination method to detect American Family Physician 343

DysmenorrheaEvaluation and Treatment of DysmenorrheaHistory consistent with primary dysmenorrhea, normalfindings from pelvic examination, negative results onurinary human chorionic gonadotropin pregnancy testTrial of nonsteroidal anti-inflammatorydrugs or oral contraceptivesSymptoms relieved?YesNoContinue therapy andreassess every six monthsLaboratory testing (e.g., gonorrhea andchlamydia testing, urinalysis, erythrocytesedimentation rate, complete blood count)Positive findings?YesNoTreat pelvicinflammatorydiseasePelvic ultrasonographyPositive findings?YesTreatmentTreat pathologyNoReassess clinical history for changesComputed tomography, magneticresonance imaging, hysteroscopy, orlaparoscopy based on clinical suspicionPositive findings?Yesof 0.09 for detection of bowel endometriosis.16 It also has a high degree of accuracy fordetection of ovarian endometriomas.13 Otheruseful tests include a urinary human chorionic gonadotropin pregnancy test; vaginaland endocervical swabs, a complete bloodcount, erythrocyte sedimentation rate, andurinalysis. Cervical cytology should also beperformed to rule out malignancy. Magnetic resonance imaging may be considered as a second-line diagnostic option ifadnexal torsion, deep pelvic endometriosis,or adenomyosis is still suspected after inconclusive or negative findings on transvaginalultrasonography.11,12,18,21Treat pathologyNoConsider chronic pelvic painand multidisciplinary approachFigure 2. Algorithm for management of dysmenorrhea.Transvaginal ultrasonography should beperformed if secondary dysmenorrhea issuspected10,15 (Figure 2). It has a 91% sensitivity and 98% specificity, a positive likelihoodratio of 30, and a negative likelihood ratioWHICH MEDICATIONS ARE FIRST-LINETHERAPY FOR PRIMARY DYSMENORRHEA?A Cochrane review of 73 randomized controlled trials (RCTs) demonstrated strongevidence to support nonsteroidal antiinflammatory drugs (NSAIDs) as the firstline treatment for primary dysmenorrhea22(Table 323). The choice of NSAID should bebased on effectiveness and tolerability forthe individual patient, because no NSAIDhas been proven more effective than others. Medications should be taken one to twodays before the anticipated onset of menses,and continued on a fixed schedule for two tothree days.19,22WHAT IS THE ROLE OF HORMONALCONTRACEPTIVES?Primary Dysmenorrhea. Oral, intravaginal,and intrauterine hormonal contraceptivesTable 3. Nonsteroidal Anti-Inflammatory Drugs Used in the Treatment of Primary DysmenorrheaDrugDosageCost*Celecoxib (Celebrex)†IbuprofenMefenamic acidNaproxen400 mg initially, then 200 mg every 12 hours200 to 600 mg every six hours500 mg initially, then 250 mg every six hours440 to 550 mg initially, then 220 to 275 mg every 12 hours 65 for 10 200-mg capsules 3 for 24 200-mg tablets 137 for 12 250-mg capsules 4 for 24 220-mg capsules*—Estimated retail price based on information obtained at and (accessed October 28, 2013).†—For use in women older than 18 years.In

01.03.2014 · Volume 89, Number 5 March 1, 2014. or legs, with initial onset six to 12 months after menarche (Table 2). 1,9-18. Pain typically lasts eight to 72 hours and usually occurs at the onset of .