Dysmenorrhoea

• Dysmenorrhoea


  Lower abdominal pain associated with menstruation
• Types of dysmenorrhoea


  • Primary dysmenorrhoea
  • Secondary dysmenorrhoea
• Primary dysmenorrhoea


  Menstrual pain without organic pathology, i.e. pain in the absence of pelvic/uterine disease
• Secondary dysmenorrhoea


  Pain associated with/caused by pelvic/uterine disease
• Dysmenorrhoea is common, affecting 1 in 2 women, with 1 in 10 experiencing severe symptoms</b>
• Dysmenorrhoea starts in teenagers and pain lessens with age
• Aetiology of primary dysmenorrhoea

  • Overproduction of uterine prostaglandins E₂ and F₂α
  • Progesterone levels decrease before menstruation, allowing prostaglandin production to increase
  • Ovulation inhibition can improve symptoms by reducing menstrual fluid volume and prostaglandin production
  • Oversensitivity of uterus to prostaglandins
  • Over-contraction leads to reduced blood supply which causes pain
• Dysmenorrhoea is typically associated with young women who have recently (6-12 months) started having regular periods
• Anovulatory cycles are usually pain free
• Questions to ask for primary vs secondary dysmenorrhoea

  • Age: Primary dysmenorrhoea is most common in adolescents and women in their early 20s, while secondary dysmenorrhoea usually affects women many years after the menarche, typically after the age of 30 years
  • Nature of pain: Primary dysmenorrhoea results in cramping, whereas secondary causes are usually described as dull, continuous, diffuse pain
  • Severity of pain: Pain is rarely severe in primary dysmenorrhoea; the severity decreases with the onset of menses. Any patient presenting with moderate to severe lower abdominal pain should be referred
  • Onset of pain: Primary dysmenorrhoea starts very shortly before or within 24 hours of the onset of menses and rarely lasts for more than 3 days, while pain associated with secondary dysmenorrhoea typically starts a few days before the onset of menses
• Management/Treatment


  1. NSAIDs: Inhibit prostaglandin synthesis/activity, reduce amount of bleeding

  2. Ibuprofen: Max daily OTC dose is 1200mg, take after food, generally well tolerated but can cause gastric irritation and bronchospasm in asthmatics

  3. Aspirin: Also inhibits prostaglandin synthesis, not as effective as ibuprofen, more likely to cause GI upset

  4. Paracetamol: Alone or in combination with NSAID or codeine, useful when NSAID contraindicated

  5. Hyoscine: Antispasmodic to relieve cramping, no evidence of efficacy, potential anticholinergic side effects

  6. Caffeine: Some evidence of additive effect with ibuprofen, OTC products contain 15-65mg, similar effect from caffeine containing drinks

  7. Practical measures: Warmth (hot water bottle, warm bath), TENS machine, some evidence for acupuncture, fish-oils, herbal remedies, exercise, supplements
• When to refer: Heavy or unexplained bleeding, pain experienced days before menses, pain that increases at the onset of menses, women 30 years with new or worsening symptoms, accompanying systemic symptoms, vaginal bleeding in postmenopausal women