Updated: 11/29/2021

Primary Dysmenorrhea

Review Topic
  • Snapshot
    • An 18-year-old nulligravid college woman complains of recurrent and cramping lower abdominal pain during menses for the past 3 years. She has nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pelvic exam is normal. She is recommended to take ibuprofen at the start of menses.
  • Summary
    • Overview
      • dysmenorrhea is painful menses
      • primary dysmenorrhea
        • crampy, lower abdominal pain occurring during menses without any clear disease that can explain the symptoms
      • secondary dysmenorrhea
        • pain can be explained by other conditions (e.g., uterine fibroids, endometriosis, adenomyosis, and pelvic inflammatory disease)
  • Epidemiology
    • prevalence
      • 50-90% of reproductive-age women worldwide
      • most common gynecologic condition in women
    • demographics
      • onset typically a few months to years after menarche
      • most commonly in those 16-24 years of age and prevalence declines progressively after 30
    • risk factors
      • age < 30
      • body mass index (BMI) < 20 kg/m2
      • smoking
      • long, heavy, or irregular periods
      • decreased age at menarche
      • sexual abuse
  • Etiology
    • Pathogenesis
      • excess prostaglandins produced by the endometrium at the beginning of menses, causing high frequency uterine contractions, and increased intrauterine pressures
      • when uterine pressure is greater than arterial pressure, there is uterine ischemia and the accumulated metabolites stimulate type C neural pain fibers resulting in dysmenorrhea
  • Presentation
    • History
      • episodes usually first appear during adolescence, 6-12 months after menarche
      • crampy, intermittent midline lower abdominal pain, which may radiate to lower back or thighs
      • pain begins 1-2 days before menses and lasts up to 72 hours
    • Symptoms
      • crampy lower abdominal pain
      • nausea
      • vomiting
      • headache
      • fatigue
      • diarrhea
      • bloating
    • Physical exam
      • normal
  • Differential
    • Secondary dysmenorrhea (adenomyosis, endometriosis, and leiomyoma)
      • key distinguishing factors
        • will usually present > 25 years of age with abnormal uterine bleeding, dyspareunia, dyschezia, infertility, and an abnormal pevlic exam
        • will have no response to treatment for primary dysmennorhea
    • Pelvic inflammatory disease
      • key distinguishing factors
        • may present with fever
        • will have abnormal pevlic exam findings such as cervical discharge, cervical motion tenderness, and adnexal or uterine tenderness
    • Midcycle pain (mittelschmerz)
      • key distinguishing factors
        • will have unilateral abdominal pain
        • will occur in the middle of the menstrual cycle, 10-14 days after menses start
        • due to ovulation
          • enlargement and rupture of follicular cyst causes irritation to the peritoneum
    • Ovarian torsion
      • key distinguishing factors
        • will present with adnexal mass
        • pain will have no relation to menses
  • Treatment
    • Management approach
      • patients with no response to therapy should be re-evaluated for secondary dysmenorrhea
    • Lifestyle
      • heat packs
      • exercise
    • Medical
      • nonsteroidal anti-inflammatory drugs (NSAIDS)
        • indications
          • considered first-line treatment for primary dysmenorrhea
        • mechanism
          • inhibition of prostaglandin synthesis
      • combined hormonal or progestin-only contraceptives
        • indications
          • first-line treatment for primary dysmenorrhea in sexually active patients who also want to prevent pregnancy
          • second-line treatment for those who do not respond to or cannot tolerate NSAIDs
        • mechanism
          • suppress ovulation, leading to decreased endometrial prostaglandin synthesis
    • Surgical
      • diagnostic laparoscopy
        • indications
          • option for patients with inadequate relief after 3-6 months of NSAID and/or hormonal contraceptive therapy to identify hidden endometriosis or pelvic pathology
  • Complications
    • Persistent pain
  • Prognosis
    • Natural history of disease
      • tends to improve with age and childbirth
    • Majority of cases respond to treatment
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(M2.GN.17.4740) A 15-year-old female presents to her pediatrician’s office for severe menstrual cramping. The patient underwent menarche at age 11, and her periods were irregular every 2-3 months for two years. After that, her cycles became roughly regular every 28-35 days, but she has had extremely painful cramps and often has to miss school. The cramps are intermittent and feel like a dull ache in the center of her abdomen, and there is usually accompanying back pain. The patient has been using heating pads with limited relief. She reports some periods being “really heavy” and requires a superabsorbent pad every 6 hours for 2 days each cycle, but this does not limit her activities. She denies any bowel or bladder changes. The patient had normal development throughout childhood, is on the soccer team at school, and is not sexually active. Her father has hypertension and her mother has endometriosis and heavy periods. On exam, the patient is 5 feet 5 inches and weighs 158 pounds (BMI 26.3 kg/m^2). She is well appearing and has no abdominal tenderness. She has Tanner IV breasts and Tanner IV pubic hair, and external genitalia are normal. Which of the following is the best next step for this patient’s menstrual cramps?

QID: 108647

Von Willebrand factor antigen assay



Pelvic ultrasound



MRI of the pelvis






Increased exercise



M 7 D

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