Background Information

Definition and Types

Dysmenorrhoea: painful lower abdominal cramping that occurs shortly before and/or during menstruation.

2 types of dysmenorrhoea:

• Primary dysmenorrhoea: absence of any identifiable underlying pelvic pathology + begins 6-12 months after menarche
  • Thought to be caused by the production of uterine prostaglandins during menstruation

• Secondary dysmenorrhoea: caused by an underlying pelvic pathology + begins after a few years of painless period

Causes

Causes of secondary dysmenorrhoea include:

• Endometriosis
• Adenomyosis
• Fibroids
• Pelvic inflammatory disease
• Intrauterine device insertion
• Ovarian / cervical cancer

Guidelines

Diagnosis

Primary dysmenorrhoea is a diagnosis of exclusion (secondary causes have to be ruled out clinically and/or via investigations)

Conduct:

• History
• Examinations: abdominal & pelvic

Consider the following

• Ultrasound
• If at risk of STIs → STI screen (inc. high vaginal & endocervical swabs)
• Pregnancy test

Features Indicating Primary Dysmenorrhoea

• Onset: typically 6-12 months after menarche
• Pain related to menstruation
  • Onset shortly before, improving as menses progresses, lasting up to 72 hours
• Absent gynaecological symptoms
  • Other non-gynaecological symptoms may occur
• Normal pelvic examination 

Features Indicating Secondary Dysmenorrhoea

• Onset: several years after painless periods
• Pain not consistently related to menstruation
  • May persist after menstruation finishes OR
  • Present throughout cycle, but exacerbated by menstruation
• Presence of gynaecological symptoms  
• Abnormal pelvic examination
  • NB – normal examination does NOT exclude secondary dysmenorrhoea

Management

Primary Dysmenorrhoea

Non-pharmacological Management

Consider:

• Local application of heat
• TENS

Pharmacological Management

1st line options:

• NSAID, or
• If patient does not wish to conceive: combined oral contraceptive for 3-6 months trial

If insufficient response to 1st line options → consider combining the 2 above and adding paracetamol.

Referral Criteria

Refer to gynaecologist if:

• Severe symptoms + no response to initial treatment within 3-6 months, or
• Doubt about diagnosis

Secondary Dysmenorrhoea

Refer all patients with suspected secondary dysmenorrhea to a gynecologist for further investigation & management

• Management depends on the underlying cause.

References

Original Guidelines