21 Menstrual Pain

Dysmenorrhea means painful menstruation. It may begin shortly before menstruation. Approximately 60% of postpubescent women experience dysmenorrhea; 10% of these women are incapacitated by pain for 1 to 3 days per month. It is the major cause of lost working hours and school days among young women and is associated with substantial economic losses to the entire community as well as to the patient. In some patients, anticipatory fear of the next menstrual period can cause anxiety during the intermenstrual period.

In evaluating a patient with pelvic pain at menstruation, the physician must first decide whether the patient has premenstrual syndrome (PMS) or dysmenorrhea. PMS usually begins 2 to 12 days before the menstrual period and subsides at the onset or early in the course of menstruation. The major symptoms of PMS are a diffuse, dull pelvic ache; mood changes (irritability, nervousness, headaches, depression); swelling of the breasts and extremities; occasional weight gain; and a sensation of abdominal bloating. PMS is quite common and causes minor mood changes, whereas premenstrual dysphoric disorder (PMDD) affects only 3% to 8% of women and is characterized by severe irritability, tension, dysphoria, and lability of mood that seriously interfere with lifestyle. Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV) diagnostic criteria for PMDD are presented in Table 21-1. The American College of Obstetrics and Gynecology also recommends charting symptoms for at least one menstrual cycle prior to making the diagnosis of PMS. Women with presumed PMS or PMDD should be evaluated for conditions such as depression, anxiety disorder, and hypothyroidism, symptoms of which can be similar. Patients should also be screened for domestic violence as well as substance abuse.

TABLE 21-1 Clinical Criteria for Premenstrual Dysphoric Disorder

Dysmenorrhea is classified as primary or secondary. Primary dysmenorrhea is the most common menstrual disorder, occurring in 30% to 50% of young women. Its prevalence decreases with age, with the highest prevalence being in those 20 to 24 years old. Dysmenorrhea is classified as primary (intrinsic, essential, or idiopathic) if it occurs in a woman who has no pelvic abnormality. About 95% of female adolescents have primary dysmenorrhea, and this problem is a major cause of school absenteeism. Primary dysmenorrhea is thought to be caused by the increased secretion of prostanoid and eicosanoid (hence, nonsteroidal anti-inflammatory drugs [NSAIDs] often provide relief), which in turn cause abnormal uterine contractions and uterine hypoxia,

Secondary dysmenorrhea (extrinsic or acquired) results from organic pelvic diseases such as endometriosis, fibroids, adenomyosis, bacterial infections, and infections caused by intrauterine contraceptive devices (IUDs). Because effective therapy is now available for primary and secondary dysmenorrhea, it is not sufficient to merely diagnose dysmenorrhea. The physician must distinguish among PMS, primary dysmenorrhea, and secondary dysmenorrhea.

Some women will not initiate a discussion of dysmenorrhea with their physician. They may have been taught that it is normal or that relief cannot be obtained. It is therefore essential that the practitioner ask the patient whether dysmenorrhea is a problem.

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