Dysmenorrhea is uterine pain around the time of menses. Pain may occur with menses or precede menses by 1 to 3 days. Pain tends to peak 24 hours after onset of menses and subside after 2 to 3 days. It is often crampy or a dull constant ache but may be sharp or throbbing; it may radiate to the back or legs.
Headache, nausea, constipation or diarrhea, lower back pain, and urinary frequency are commonly associated with dysmenorrhea; vomiting occurs occasionally.
Sometimes dysmenorrhea is accompanied by symptoms of premenstrual syndrome or heavy menstrual bleeding and passage of blood clots.
Dysmenorrhea interferes with daily activities in 30% or more of women and may result in absence from school or work (1). Women with dysmenorrhea have an increased likelihood of having chronic pelvic pain or other chronic pain conditions (2).
General references
1. Schoep ME, Nieboer TE, van der Zanden M, Braat DDM, Nap AW. The impact of menstrual symptoms on everyday life: a survey among 42,879 women. Am J Obstet Gynecol. 2019;220(6):569.e1-569.e7. doi:10.1016/j.ajog.2019.02.048
2. Li R, Li B, Kreher DA, Benjamin AR, Gubbels A, Smith SM. Association between dysmenorrhea and chronic pain: a systematic review and meta-analysis of population-based studies. Am J Obstet Gynecol. 2020;223(3):350-371. doi:10.1016/j.ajog.2020.03.002
Etiology of Dysmenorrhea
Dysmenorrhea can be
Primary (absence of an organic cause, more common)
Secondary (due to other underlying pelvic pathology)
Primary dysmenorrhea
Primary dysmenorrhea is idiopathic and cannot be explained by other gynecologic disorders (1). Pain is thought to result from uterine contractions and ischemia, probably mediated by prostaglandins (eg, prostaglandin F2-alpha, a potent myometrial stimulant and vasoconstrictor) and other inflammatory mediators produced in secretory endometrium and possibly associated with prolonged uterine contractions and decreased blood flow to the myometrium (2).
Contributing factors may include the following:
High levels of prostaglandin F2-alpha in menstrual fluid
Uterine flexion or angle; anteflexion, retroflexion, and retroversion may be associated with dysmenorrhea (anteflexed or retroflexed uterus) (3, 4)
Anxiety
Primary dysmenorrhea typically begins within a year after menarche and occurs almost invariably in ovulatory cycles. The pain usually begins when menses start (or just before) and persists for the first 1 to 2 days; this pain, described as spasmodic, is superimposed over constant lower abdominal pain, which may radiate to the back or thigh. Patients may also have malaise, fatigue, nausea, vomiting, diarrhea, low back pain, or headache.
Risk factors for severe symptoms include the following:
Early age at menarche
Long or heavy menstrual periods
Nulliparity
Age < 30
Depression, anxiety, or high levels of stress
Cigarette smoking
Excessive alcohol use
A family history of dysmenorrhea
Symptoms tend to lessen with increasing age and after a first pregnancy.
Secondary dysmenorrhea
Symptoms of secondary dysmenorrhea are due to pelvic abnormalities. Almost any abnormality or process that can affect the pelvic viscera can cause dysmenorrhea.
Common causes of secondary dysmenorrhea include
Endometriosis (the most common cause)
Less common causes include congenital malformations (eg, bicornuate uterus, subseptate uterus, transverse vaginal septum), ovarian cysts and tumors, history of pelvic inflammatory disease, pelvic congestion, intrauterine adhesions, and intrauterine devices (IUDs), particularly copper IUDs.
In a few women, pain occurs when the uterus attempts to expel tissue through an extremely tight cervical os (secondary to conization, loop electrosurgical excision procedure [LEEP], or cryotherapy). Rarely, pain results from a pedunculated submucosal fibroid or an endometrial polyp protruding through the cervix.
Risk factors for severe secondary dysmenorrhea are the same as those for primary.
Secondary dysmenorrhea usually begins during adulthood unless caused by congenital malformations.
Etiology references
1. Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: A critical review. Hum Reprod Update 21 (6):762–778, 2015. doi: 10.1093/humupd/dmv039. Epub 2015 Sep 7.
2. Bernardi M, Lazzeri L, Perelli F, Reis FM, Petraglia F. Dysmenorrhea and related disorders. F1000Res. 2017;6:1645. Published 2017 Sep 5. doi:10.12688/f1000research.11682.1
3. Cagnacci A, Grandi G, Cannoletta M, Xholli A, Piacenti I, Volpe A. Intensity of menstrual pain and estimated angle of uterine flexion. Acta Obstet Gynecol Scand. 2014;93(1):58-63. doi:10.1111/aogs.12266
4. Fauconnier A, Dubuisson JB, Foulot H, et al. Mobile uterine retroversion is associated with dyspareunia and dysmenorrhea in an unselected population of women. Eur J Obstet Gynecol Reprod Biol. 2006;127(2):252-256. doi:10.1016/j.ejogrb.2005.11.026
Evaluation of Dysmenorrhea
Clinicians can identify dysmenorrhea based on symptoms and then determine whether dysmenorrhea is primary or secondary.
History
History of present illness should cover complete menstrual history, including age at onset of menses, duration and amount of flow, time between menses, variability of timing, and relation of menses to symptoms.
Clinicians should also ask about:
The age at which symptoms began
Their nature and severity
Factors that relieve or worsen symptoms (including the effects of contraceptives)
Degree of disruption of daily life
Effect on sexual activity
Presence of pelvic pain unrelated to menses
Response to nonsteroidal anti-inflammatory drugs (NSAIDs)
History of dyspareunia or infertility (associated with endometriosis)
Review of systems should include accompanying symptoms such as cyclic nausea, vomiting, bloating, diarrhea, and fatigue.
Past medical history should identify known causes, including endometriosis, uterine adenomyosis, or fibroids. Method of contraception should be ascertained, specifically asking about IUD use.
Past surgical history should identify procedures that increase risk of dysmenorrhea, such as cervical conization and endometrial ablation.
Physical examination
Pelvic examination focuses on detecting causes of secondary dysmenorrhea. The cervix is examined for tenderness, discharge, cervical stenosis, or a prolapsed polyp or fibroid. Bimanual examination is performed to check for uterine masses and uterine consistency (a boggy uterus occurs in adenomyosis), adnexal masses, thickening of the rectovaginal septum, induration of the cul-de-sac, and nodularity of the uterosacral ligament.
The abdomen is examined for evidence of abnormal findings, including signs of peritonitis.
Red flags
The following findings are of particular concern in patients with dysmenorrhea:
New or sudden-onset pain
Unremitting pain
Fever
Purulent cervical discharge
Evidence of peritonitis
Interpretation of findings
Red flag findings suggest a cause of pelvic pain other than dysmenorrhea.
Primary dysmenorrhea is suspected if:
Symptoms begin soon after menarche or during adolescence.
Secondary dysmenorrhea is suspected if:
Symptoms begin after adolescence.
Pain is diffuse, constant, and not always in sync with menses onset (1).
Patients have known causes, including uterine adenomyosis, fibroids, a tight cervical os, a mass protruding from the cervical os, or, particularly, endometriosis.
Endometriosis is considered in patients with adnexal masses, thickening of the rectovaginal septum, induration of the cul-de-sac, nodularity of the uterosacral ligament, or, occasionally, nonspecific vaginal, vulvar, or cervical lesions.
Testing
Testing aims to exclude structural gynecologic disorders. Most patients should have:
Pregnancy testing
Pelvic ultrasound
Pregnancy testing should be done in all women of reproductive age who present with pelvic pain. If pelvic inflammatory disease is suspected, cervical cultures are done.
Pelvic ultrasound is highly sensitive for pelvic masses (eg, ovarian cysts, fibroids, endometriosis, uterine adenomyosis) and can locate abnormally located IUDs.
If these tests are inconclusive and symptoms persist, hysterosalpingography or sonohysterography may be done to identify endometrial polyps, submucous fibroids, or congenital abnormalities. MRI may be required to fully characterize congenital anomalies.
If results of all other tests are inconclusive, laparoscopy may be done, particularly if endometriosis is suspected.
Evaluation reference
1. Bernardi M, Lazzeri L, Perelli F, Reis FM, Petraglia F. Dysmenorrhea and related disorders. F1000Res. 2017;6:1645. Published 2017 Sep 5. doi:10.12688/f1000research.11682.1
Treatment of Dysmenorrhea
Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first line therapy, as prostaglandin release is involved in pathophysiology of dysmenorrhea
Often hormonal contraceptives
Treatment of underlying disorders
If identified, disorders causing dysmenorrhea are treated (eg, surgery to remove fibroids).
General measures
Measures to improve the patient's general well-being (eg, adequate rest and sleep, regular exercise) may be helpful. Some patients find that a heating pad (used safely to avoid burns) applied to the lower abdomen or abdominal massage alleviates pain.
Other interventions have been suggested as potentially effective. They include a low-fat diet and nutritional supplements, such as omega-3 fatty acids, flaxseed, magnesium, vitamin B1, vitamin E, and zinc. Few data support the usefulness of these interventions; however, they are low risk.Other interventions have been suggested as potentially effective. They include a low-fat diet and nutritional supplements, such as omega-3 fatty acids, flaxseed, magnesium, vitamin B1, vitamin E, and zinc. Few data support the usefulness of these interventions; however, they are low risk.
Women with primary dysmenorrhea are reassured about the absence of other gynecologic disorders.
Medications
If pain is bothersome, NSAIDs (which relieve pain and inhibit prostaglandins) are typically tried. NSAIDs are usually started 24 to 48 hours before and continued until 1 or 2 days after menses begin. There is little evidence for superiority of any individual NSAID for pain relief or safety and no evidence that COX-2 specific inhibitors are more effective (1).
Estrogen/progestin contraceptive is usually effective (2). Estrogen prevents ovulation and progestin thins the endometrial lining leading to less arachidonic acid to be used for prostaglandin synthesis, thus reducing both blood flow and contractions during menses (3).
Other hormone therapy may also be effective for primary dysmenorrhea or as treatment of secondary dysmenorrhea due to endometriosis. Progestin therapy options include oral progestins (eg, progestin-only oral contraceptives, oral dienogest), levonorgestrel intrauterine device, etonogestrel implant, or depot medroxyprogesterone acetate. Gonadotropin-releasing hormone agonists (GNRH) were effective at decreasing dysmenorrhea but may have low estrogen side effects (Other hormone therapy may also be effective for primary dysmenorrhea or as treatment of secondary dysmenorrhea due to endometriosis. Progestin therapy options include oral progestins (eg, progestin-only oral contraceptives, oral dienogest), levonorgestrel intrauterine device, etonogestrel implant, or depot medroxyprogesterone acetate. Gonadotropin-releasing hormone agonists (GNRH) were effective at decreasing dysmenorrhea but may have low estrogen side effects (4). Danazol is also an option, but is rarely used due to androgenic adverse effects.). Danazol is also an option, but is rarely used due to androgenic adverse effects.
Tocolytic medications (eg, transdermal nitroglycerin patches, calcium channel blockers), which inhibit uterine contractions, have not been well-studied but may benefit some patients (Tocolytic medications (eg, transdermal nitroglycerin patches, calcium channel blockers), which inhibit uterine contractions, have not been well-studied but may benefit some patients (5).
Other treatments
Surgical procedures are options to treat gynecologic causes of secondary dysmenorrhea. Endometriosis may be treated surgically with fulguration of lesions. Uterine leiomyomas may be treated with uterine artery embolization or myomectomy. Cervical stenosis may be treated with mechanical cervical dilation. Endometrial ablation may be effective if dysmenorrhea is associated with heavy menstrual bleeding. Hysterectomy is definitive therapy for dysmenorrhea.
Treatments to modulate or ablate nerve pathways are options for some patients. Transcutaneous electrical nerve stimulation has been found to be effective (6). For intractable pain of unknown origin, laparoscopic presacral neurectomy or uterosacral nerve ablation has been efficacious in some patients for as long as 12 months (7).
Lifestyle or complementary care approaches that have been evaluated include exercise, yoga, hypnosis, acupuncture, acupressure, chiropractic therapy, and heat therapy.
Use of dietary supplements (eg, ginger, vitamin E) and cannabinoids have also been proposed but require further study.(eg, ginger, vitamin E) and cannabinoids have also been proposed but require further study.
Treatment references
1. Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015;2015(7):CD001751. Published 2015 Jul 30. doi:10.1002/14651858.CD001751.pub3
2. Ferries-Rowe E, Corey E, Archer JS. Primary dysmenorrhea: Diagnosis and therapy. Obstet Gynecol 136 (5):1047–1058, 2020. doi: 10.1097/AOG.0000000000004096
3. Schroll JB, Black AY, Farquhar C, Chen I. Combined oral contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev. 2023;7(7):CD002120. Published 2023 Jul 31. doi:10.1002/14651858.CD002120.pub4
4. Yan H, Shi J, Li X, et al. Oral gonadotropin-releasing hormone antagonists for treating endometriosis-associated pain: a systematic review and network meta-analysis. Fertil Steril. 2022;118(6):1102-1116. doi:10.1016/j.fertnstert.2022.08.856
5. Kirsch E, Rahman S, Kerolus K, et al. Dysmenorrhea, a Narrative Review of Therapeutic Options. J Pain Res. 2024;17:2657-2666. Published 2024 Aug 15. doi:10.2147/JPR.S459584
6. Proctor ML, Smith CA, Farquhar CM, Stones RW. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev. 2002;2002(1):CD002123. doi:10.1002/14651858.CD002123
7. Daniels J, Gray R, Hills RK, et al. Laparoscopic uterosacral nerve ablation for alleviating chronic pelvic pain: a randomized controlled trial. JAMA. 2009;302(9):955-961. doi:10.1001/jama.2009.1268
Guidelines for Dysmenorrhea
The following is a list of professional medical society or government clinical practice guidelines regarding this medical issue (this is not a comprehensive list):
American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin. Dysmenorrhea and Endometriosis in the Adolescent. 2018 (reaffirmed 2021).
ACOG Committee Opinion. Management of Acute Obstructive Uterovaginal Anomalies. 2019 (reaffirmed 2021).
Key Points
Dysmenorrhea is uterine pain around the time of menses. Pain may occur with menses or precede menses by 1 to 3 days.
Most cases of dysmenorrhea are primary (idiopathic).
Common causes of secondary dysmenorrhea include endometriosis, uterine adenomyosis, leiomyomas, and cervical stenosis.
Evaluate with history, pelvic examination, and, usually, transvaginal ultrasound.
Treat with an NSAID and/or estrogen/progestin contraceptive. Other hormone therapies that suppress ovulation and/or reduce menstrual flow may also be effective.
Lifestyle or complementary care approaches have not been proven, but are low-risk (eg, exercise, hypnosis).
Surgical intervention or nerve ablation should be reserved for failure of medical management or patients who desire definitive treatment.
Drugs Mentioned In This Article
