Menstrual Pain

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









In most menstrual cycles, at least five of the following symptoms should be present for most of the last week of the luteal phase, remitted within a few days after onset of menses, and remain absent in the week after menses. At least one symptom must be 1, 2, 3, or 4.











The first three criteria must be confirmed by prospective daily ratings for at least two consecutive menstrual cycles.

Adapted from Yonkers KA, O’Brien PM, Eriksson E: Premenstrual syndrome. Lancet 371(9619):1201, 2008.


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.



Nature of Patient


Primary dysmenorrhea is common in adolescent girls and young women, with the greatest incidence in the late teens and early 20s. When dysmenorrhea begins within the first 2 to 3 years of menarche, primary dysmenorrhea is the most likely diagnosis. Primary dysmenorrhea usually occurs with ovulatory cycles, which normally begin 3 to 12 months after menarche, when ovulation occurs regularly. Primary dysmenorrhea usually begins within 6 months of menarche and becomes progressively more severe.


If a patient has gradually increasing monthly pain without menstruation, a congenital abnormality obstructing menstrual flow must be considered. These rare abnormalities may lead to hematocolpos, hematometra, and eventually intraperitoneal bleeding.


Secondary dysmenorrhea usually begins many years after menarche. Dysmenorrhea that develops after age 20 years is usually of the secondary type. A history of pelvic infection, menorrhagia, or intermenstrual bleeding suggests underlying pelvic pathology. Dysmenorrhea can often be caused by an IUD. If dysmenorrhea develops after cervical conization, cautery, or radiation, acquired cervical stenosis or cervical occlusion may be the cause. Dysmenorrhea after uterine curettage may be due to intrauterine synechiae (Asherman’s syndrome). Secondary dysmenorrhea due to endometriosis is usually late in onset (beginning when the patient is in her 30s) and worsens with age. Endometriosis is uncommon in teenagers. Adenomyosis may be a cause of secondary dysmenorrhea, particularly in parous women older than 40 years and if menorrhagia is present.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Menstrual Pain

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