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Dysmenorrhea Cheat Sheet (DRAFT) by

Primary and Secondary Dysmenorrhea

This is a draft cheat sheet. It is a work in progress and is not finished yet.


- Pelvic disease considered in patients who do not respond to NSAIDs or CCs or combin­ation of these agents
- The diagnosis should also be considered when symptoms appear after many years of painless menses
- cervical stenosis
- endome­triosis
- adenom­yosis
- fibroids
- pelvic inflam­mation
- pelvic conges­tion, congenital obstru­ctive Mullerian malfor­mat­ions, diseases of the gastro­int­estinal tract, and mental health conditions


A cyclic, painful cramping sensation in the lower abdomen accomp­anied by other biologic symptoms
Primary dysmen­orrhea refers to pain with no obvious pathologic pelvic disease. It is currently recognized that these patients are suffering from the effects of endogenous prosta­gla­ndin.
Secondary dysmen­orrhea is associated with pelvic conditions or pathology that causes pelvic pain in conjun­ction with the menses


approx­imately 75%
younger age at first childb­irth, high parity, and physical exercise
pregnancy itself without actual birth does not seem to alleviate dysmen­orrhea


- age less than 30
- BMI less than 20
- premen­strual syndrome
- steril­ization
- history of sexual assault
- heavy smoking


- elevated prosta­glandin F2a (PGF2a) levels in the secretory endome­trium and the symptoms of dysmen­orrhea
- arachi­donic acid, has been found in increased amounts on the endome­trium during ovulatory cycles
- converted to PGF2a, PGE2, and leukot­rienes
- PGF2a and PGE2 correlate with the severity of dysmen­orrhea
- nausea, vomiting, and diarrhea


- History and physical exam
- midline, crampy, lower abdominal pain, which begins with the onset of menstr­ation
- the pain can be severe and can also involve the lower back and thighs. Pain does not occur at tines other than menses and only occurs during ovulatory cycles
- diarrhea, headache, fatigue, and malaise
- normal pelvic examin­ation
- no laboratory or imaging abnorm­alities


- treatment for primary dysmen­orrhea begins with providing patient education and reassu­rance
- indivi­dua­lized, supportive therapy can be tailored to the patient's specific symptoms, degree of disability from those symptoms, and other health care consid­era­tions, such as need for contra­ception
- exercise
- heat
- behavioral interv­entions
- vitamins and diet
- prosta­glandin synthase inhibitors (PGSIs)
- these substances are non-st­eroidal and anti-i­nfl­amm­atory
- arylca­rbo­xylic acids, which include acetyl­sal­icylic acid (aspirin) and fenamates (mefenamic acid)
- arylal­kanoic acids, including the arylpr­opionic acids (ibupr­ofen, naproxen, and ketopr­ofen) and the indole­acetic acids (indom­eth­acin)
- Cycloo­xyg­enase (COX2) inhibitors have similarly been shown to alleviate the primary dysmen­orrheal symptoms
- reduction of contra­ctility
- COX-2 expression in the uterine glandular epithelium was maximal during menstr­uation in one trial of ovulatory women
- COX-2 inhibitors may be considered for women with gastro­int­estinal toxicity due to NSAISs
- Estrogen and proges­terone will relieve the symptoms of primary dysmen­orrhea in approx­imately 905 of patients
- Suppress ovulation and endome­trial prolif­eration and the progestin component also blocks the production of the precursor to prosta­glandin formation
- The thinned endome­trium from CCs then contains less arachi­donic acid, which is the precursor to prosta­gla­ndins
- If the woman also requires contra­cep­tion, CC therapy may prove to be the treatment of choice
- The vaginal ring CC reduce dysmen­orrhea in a similar fashion as COCs
- Dysmen­orrhea was not, however, as well controlled in women using the transd­ermal CC patch as compared with COCs
- Depot medrox­ypr­oge­ste­rone, a long-a­cting injectable contra­cep­tive, has been studied specif­ically for primary dysmen­orrhea
- The 20ug levono­rge­strel releasing intrau­terine system (LNGIUS) has been shown in randomized controlled trails to reduce menstrual pain
- Copper T380A intrau­terine device (IUD)
- Etonog­est­rel­-re­leasing contra­ceptive (Implanon) / Nexplanon
- tocolytics may be beneficial in the treatment of dysmen­orrhea
- nifedipine at a dose of 20-40mg orally
- glyceryl trinitrate and magnesium
- not often utilized for contem­porary management of dysmen­orrhea
- narcotic analgesics
- acupun­cture
- laparo­scopic uterine nerve ablation (LUNA) or laparo­scopic presacral neurectomy (LPSN)


- Pelvic disease considered in patients who do not respond to NSAIDs or CCs or combin­­ation of these agents
- The diagnosis should also be considered when symptoms appear after many years of painless menses
- cervical stenosis
- endome­­tr­iosis
- adenom­­yosis
- fibroids
- pelvic inflam­­mation
- pelvic conges­­tion, congenital obstru­­ctive Mullerian malfor­­ma­t­ions, diseases of the gastro­­in­t­e­stinal tract, and mental health conditions


- Severe narrowing of the cervical canal causing an increase in intrau­terine pressure at the time of menses
- Associated with pelvic endome­triosis
- Congenital or secondary to cervical injury
- Inflam­matory process
- History of scant menstrual flow and if severe cramping continues throughout the menstrual period
- Diagnosis is generally documented by the inability to pass a thin probe of a few millim­eters' diameter through the internal os or by a hyster­osa­lpi­ngo­gram, which demost­rates a thin, string­y-a­ppe­aring canal
- Treatment consists of dilating the cervix
- often recurs after therapy, necess­itating repeat procedures


- presence of endome­trial glands and stroma outside of the uterus defines endome­triosis
- genera­lized pelvic pain, cyclic pain, dysmen­orrhea, infert­ility, and bowel or bladder dysfun­ction
- history of pain becoming more severe during menses
- presence of endome­trial glands and stroma in the myometrium
- this ectopic endome­trial tissue may induce hypert­rophy and hyperp­lasia of the adjacent myometrium
- manifest in heavy
- painful menses that tends to be progre­ssive
- Prosta­glandin level in endome­triosis implants increase painful menstr­uation


- Pelvic congestion syndrome (PCS), which was first described by Taylor in 1949, results from the engorg­ement of pelvic vascul­ature
- Chronic pelvic discomfort (often burning or throbbing in nature) worsened by prolonged standing and interc­ourse in women who have periov­arian varico­sities on imaging studies
- Etiology is unclear and optimum treatment is uncertain
- Pelvic pain, dysuria, dysmen­orrhea, and dyspar­eunia


- A group of mild to moderate symptoms, physical and behavi­oral, that occur in the second half of the menstrual cycle and that may interfere with work and personal relati­onships
- Breast tender­ness, bloating, and headache
- These are followed by a period entirely free of symptoms
- Family history of PMS in the mother, personal past or current psychi­atric illness involving mood or anxiety disorders, history of alcohol abuse, and history of postpartum depression


- A more severe disorder, with marked behavioral and emotional symptoms.
- PMDD differs from PMS in the severity of symptoms and the fact that women with PMDD must have one severe affective symptom.
- Markedly depressed mood or hopele­ssness, anxiety or tension, affective lability, or persistent anger, which occur regularly during the last week of the luteal phase in most menstrual cycles
- PMDD also differs from PMS because there is substa­ntial impairment in personal functi­oning
- PMS and PMDD are similar in that the symptoms manifest in the luteal phase of the menstrual cycle and resolve during menses
- Premen­strual symptoms occur in 75% of women at some point in their reprod­uctive lives. The incidence of clinically relevant PMS occurs in 3% to 8% of women and 2% of reprod­uct­ive-age women will suffer from PMDD
- Abdominal bloating, breast tender­ness, and various pain conste­lla­tions, such as headache
- Fatigue, irrita­bility, and tension to anxiety, labile mood, and depression
- Depression
- Causes
- Estrogen excess
- Imbalance of estrogen and proges­terone, endogenous hormone allergy, hypogl­ycemia, vitamin B6 defici­ency, prolactin excess, fluid retention, inappr­opriate prosta­glandin activity, elevated monoamine oxidase (MAO) levels, endorphin malfun­ction, and a number of psycho­logical distur­bances.
- History of two consec­utive menstrual cycles demons­trating luteal phase symptoms of PMS and PMDD.
- After a complete history and physical examin­ation, the physician should rule out any medical problems that could be influe­ncing the sympto­mat­ology
- DSM-V criteria, which require 5 of 11 symptoms of PMS, including one affective symptom
- feeling sad or hopeless or having self-d­epr­ecating thoughts, anxiety or tension, mood lability and crying, and persistent irrita­bility, anger, and increased interp­ersonal conflicts



Pharma­cologic Agents
- Psycho­active Drugs
- SSRIs have been shown to be extremely effective for treating PMS and have become first-line treatment for PMDD
Hormonal Suppre­ssion
- Proges­terone
- Oral Contra­cep­tives
- Nonste­roidal Anti-i­nfl­amm­atory Drugs
- Diuretics
- Bromoc­riptine
- Gonado­tro­pin­-Re­leasing Hormone Agonists
Surgical Treatment: Bilateral Oophor­ectomy with or without Hyster­ectomy
- For women with severe, disabling symptoms who have been refractory to other medical therapies, surgical management may be considered
- Reasonable altern­ative for select patients for whom all other treatment regimens have failed.
- GnRH analogue for 3 to 6 months, with or without estrogen add-back