Dysmenorrhea: Primary and Secondary

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Chapter 20 Dysmenorrhea: Primary and Secondary

INTRODUCTION

Description: Primary dysmenorrhea is painful menstruation without a clinically identifiable cause. Secondary dysmenorrhea is recurrent menstrual pain resulting from a clinically identifiable cause or abnormality.
Prevalence: Of all women, 10% to 15% are unable to function because of pain; 90% have discomfort with at least one cycle.
Predominant Age: Late teens to early 30s (primary), prevalence follows the occurrence of underlying conditions for secondary dysmenorrhea. Dysmenorrhea that begins after the age of 25 is most often secondary.
Genetics: No genetic pattern, although some suggest a familial pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Primary—increased production of prostaglandin F2α (PGF2α) resulting in increased uterine contractions (dysrhythmic) and markedly elevated intrauterine pressures (up to 400 mm Hg); possible increased sensitivity to PGF2α as well. Secondary—uterine (adenomyosis, cervical stenosis and cervical lesions), congenital abnormalities (outflow obstructions, uterine anomalies), infection (chronic endometritis), intrauterine contraceptive devices, myomas (generally intracavitary or intramural), polyps; extrauterine (endometriosis, inflammation, and scarring [adhesions]); nongynecologic causes (musculoskeletal, gastrointestinal, urinary); “pelvic congestive syndrome” (debated); psychogenic (rare); tumors (myomas, benign or malignant tumors of ovary, bowel, or bladder).
Risk Factors: None known.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Primary—crampy, midline, lower abdominal pain (often demonstrated by a fist opening and closing)

• Nausea, vomiting, and diarrhea common
• Syncope
• Headache

• Secondary—midline lower abdominal or low back pain accompanying menstruation

• Pelvic heaviness or pressure
• Symptoms specifically associated with the underlying condition

DIAGNOSTIC APPROACH

Differential Diagnosis

• Endometriosis
• Irritable bowel syndrome
• Inflammatory bowel disease
• Somatization (rare)

Abrupt onset of painful menstruation should suggest the possibility of a complication of pregnancy (abortion or ectopic pregnancy).

Associated Conditions: Menorrhagia is commonly associated.

Workup and Evaluation

Laboratory: Infrequently required, based on suspected or confirmed cause.
Imaging: For selected patients with secondary dysmenorrhea, ultrasonography of the pelvic organs may be indicated.
Special Tests: None indicated. Sigmoidoscopy may be helpful in selected patients with secondary dysmenorrhea.
Diagnostic Procedures: The absence of abnormality on pelvic examination, combined with historical characteristics, is diagnostic of primary dysmenorrhea. A pelvic examination that reveals a possible cause defines secondary dysmenorrhea.

Pathologic Findings

Based on the causative condition.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Rest, analgesics (nonsteroidal antiinflammatory agents or pain relievers), heat (heating pad, hot water bottle, self-heating pads [ThermaCare]).
Specific Measures: Primary—medical management most effective, heat (heating pad, hot water bottle, or self-heating pads [ThermaCare]) appears comparable to medical management for many, transcutaneous electrical nerve stimulation (TENS) effective for selected patients, biofeedback suggested, but success poor or variable. Secondary—measures directed toward the underlying pathologic condition, modification of periods (oral contraceptives, menstrual suppression [depot medroxyprogesterone acetate, gonadotropic-releasing hormone (GnRH) agonists]), transcutaneous electrical nerve stimulation effective for selected patients, surgery for specific pathologic conditions.
Diet: No specific dietary changes indicated.
Activity: No restriction; based on patient comfort.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP046 (Dysmenorrhea), AP049 (Menstruation [Especially for Teens]), others related to underlying causes: AP013 (Important Facts About Endometriosis), AP074 (Uterine Fibroids), AP077 (Pelvic Inflammatory Disease), AP099 (Pelvic Pain).

Drug(s) of Choice

Primary—nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen 800 mg, two at onset of flow and one every 4 to 6 hours prn pain; naproxen sodium 275 mg, two at onset of flow and one every 6 to 8 hours prn pain; meclofenamate 100 mg, one at onset of flow and one every 4 to 6 hours prn pain, mefenamic acid 250 mg, two at onset of flow and one every 4 to 6 hours prn pain.
Secondary—based on pathophysiologic condition. NSAIDs or analgesics may be used.

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Contraindications: Aspirin-sensitive asthma, ulcers, inflammatory bowel disease.
Precautions: Some patients experience increased stomach upset with NSAIDs; this may be reduced by taking them with food.
Interactions: Other over-the-counter pain relievers containing NSAID compounds.

Alternative Drugs

Other rapidly acting NSAIDs may be used. Combination oral contraceptives generally provide milder periods (and contraception if necessary). Centrally acting analgesics may be added with care to avoid interaction with NSAIDs. Suppression of menstruation (depot medroxyprogesterone acetate, gonadotropic-releasing hormone agonists) may be indicated for patients with severe pain.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: None.
Possible Complications: Most commonly side effects of medication. Anemia (if menorrhagia is present), others based on underlying cause.
Expected Outcome: Primary dysmenorrhea—significant relief of symptoms with medical therapy. If medical therapy does not produce pronounced improvement, the diagnosis should be reevaluated. The prevalence of primary dysmenorrhea declines with time. Secondary dysmenorrhea—based on cause and mode of therapy, resolution of symptoms is generally possible with NSAIDs, analgesics, or period modification.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy.
ICD-9-CM Codes: 625.3, 302.76 (Psychogenic) (others based on underlying cause).

REFERENCES

Level I

Akin MD, Weingand KW, Hengehold DA, et al. Use of continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol. 2001;97:343.

Level III

American College of Obstetricians and Gynecologists. Dysmenorrhea. Technical Bulletin 68. Washington, DC: ACOG, 1983.

Dawood MY. Dysmenorrhea. Clin Obstet Gynecol. 1990;33:168.

Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108:428.

Deligeoroglou E, Tsimaris P, Deliveliotou A, et al. Menstrual disorders during adolescence. Pediatr Endocrinol Rev. 2006;3(Suppl 1):150.

Doty E, Attaran M. Managing primary dysmenorrhea. J Pediatr Adolesc Gynecol. 2006;19:341.

Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006;19:363.

Latthe PM, Proctor ML, Farquhar CM, et al. Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness. Acta Obstet Gynecol Scand. 2007;86:4. Review

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:901.

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332:1134.

Proctor ML, Farquhar CM. Dysmenorrhoea. Clin Evid. 2006;15:2429.

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