Clinical Review for Healthcare Professionals

Dysmenorrhea, defined as painful menstruation, affects over 50% of menstruating women and is a leading cause of absenteeism from school and work among women of reproductive age. It typically presents as mild to severe pelvic or lower abdominal cramping pain that may radiate to the thighs or lower back. Pain may precede or coincide with menstruation and usually subsides as bleeding tapers.

Pathophysiology

Dysmenorrhea, particularly primary dysmenorrhea, results from excessive production of prostaglandins—especially prostaglandin F2α—in the endometrium during menstruation. These prostaglandins increase uterine smooth muscle contractions, leading to uterine ischemia and pain. The heightened contractions cause spasm and reduced blood flow to the myometrium, which stimulates pain fibers and results in the characteristic cramping pain.

Secondary dysmenorrhea arises from identifiable pelvic pathology such as endometriosis, adenomyosis, pelvic inflammatory disease, or structural abnormalities. In these cases, inflammation, ectopic endometrial tissue, or anatomical distortions cause persistent or recurrent pelvic pain, often accompanied by additional symptoms like dyspareunia or abnormal bleeding.

Additional factors that may exacerbate dysmenorrhea include increased leukotrienes and vasopressin levels, contributing to vascular constriction and heightened nociceptive signaling.

History and Physical Examination

A thorough history should characterize the pain: onset, duration, quality (sharp, cramping, aching), location, radiation, severity, and timing relative to the menstrual cycle. Investigate associated symptoms such as nausea, vomiting, bowel or urinary changes, bloating, fatigue, irritability, and mood alterations. Assess menstrual history including flow volume, intermenstrual discharge, dyspareunia, contraceptive use, and history of pelvic infections. Screen for pregnancy with human chorionic gonadotropin if indicated.

Physical examination includes vital signs, abdominal inspection and palpation for tenderness or masses, and costovertebral angle tenderness assessment. A pelvic exam may be necessary if pelvic pathology is suspected.

Medical Causes

Diagnosis

Primarily clinical based on history and examination. Pregnancy tests should exclude ectopic or miscarriage. Imaging (ultrasound or MRI) may identify structural causes such as fibroids or endometriosis. Laboratory tests help diagnose infections or systemic causes.

Management

• Pharmacologic: NSAIDs (e.g., ibuprofen, naproxen) are first-line treatment; they inhibit prostaglandin synthesis, reducing uterine contractions and pain. Patients should be counseled on adverse effects such as gastrointestinal discomfort and advised to take medications with food or milk.

• Non-pharmacologic: Rest, heat application, mild exercise, stress reduction.

• Other interventions: Hormonal contraceptives may reduce dysmenorrhea by suppressing ovulation and endometrial proliferation.

• Treatment of underlying cause: Surgical or medical treatment for endometriosis, PID, or structural abnormalities as indicated.

Patient counseling

Educate patients that dysmenorrhea is a common medical condition, not a sign of emotional or psychological instability. Discuss treatment options, possible side effects, and the importance of adherence. Encourage lifestyle modifications like exercise and stress management.

Pediatric considerations

Dysmenorrhea is uncommon in the first year of menstruation before ovulatory cycles establish. Incidence peaks in adolescence. Education about normal menstrual function and dispelling myths is essential. Promote hygiene, nutrition, and physical activity.