Dysmenorrhea

Dysmenorrhea: Definition & Types - Period Pain Primer

• Definition: Painful menstruation, typically cramping in the lower abdomen, occurring just before or during menses.
• Types:
  • Primary: No underlying pelvic pathology. Common in adolescents.

    ⭐ Primary dysmenorrhea typically begins 6-12 months after menarche, coinciding with the onset of ovulatory cycles.

  • Secondary: Due to underlying pelvic pathology (e.g., endometriosis, fibroids, adenomyosis, PID). More common in women aged >25 years.
• Prevalence: Affects up to 90% of adolescent girls and 25-50% of reproductive-age women globally; a leading cause of recurrent short-term school/work absenteeism.

Primary Dysmenorrhea: Pathophys & Features - Prostaglandin Party Poopers

• Pathophysiology:
  • ↑ Prostaglandins (esp. $PGF_{2\alpha}$, $PGE_2$) & leukotrienes released from shedding endometrium during menses.
  • Causes intense uterine hypercontractility, ↓ uterine blood flow & myometrial ischemia → colicky pain.
• Clinical Features:
  • Crampy, spasmodic, midline lower abdominal/suprapubic pain.
  • Often radiates to the lower back or inner thighs.
  • Onset: Usually a few hours prior to or with menses; lasts 1-3 days, typically peaks at 24-48 hrs.
  • Associated symptoms: Nausea, vomiting, diarrhea, headache, fatigue, dizziness.

⭐ Increased levels of $PGF_{2\alpha}$ in menstrual fluid are directly correlated with the severity of primary dysmenorrhea.

Secondary Dysmenorrhea: Causes & Clues - Underlying Culprits Unmasked

Dysmenorrhea: Diagnosis & Workup - Detective Work

• History: Detailed pain characteristics (onset, duration, severity, cycle relation, impact), associated symptoms, menstrual history, sexual history.
• Red Flags: New onset after age 25, Abnormal Uterine Bleeding (AUB), infertility, deep dyspareunia, failure to respond to NSAIDs/OCPs.
• Examination: General, abdominal, and pelvic (bimanual for uterine/adnexal assessment, speculum for cervical/vaginal view).
• Investigations:
  • Transvaginal Ultrasound (TVS): Initial imaging of choice.
  • MRI or Hysteroscopy: For complex cases or if TVS is non-diagnostic.
  • Laparoscopy: Gold standard for endometriosis or pelvic adhesions.

⭐ New onset dysmenorrhea after the age of 25 years strongly suggests a secondary cause.

Dysmenorrhea: Management Strategies - Pain Relief Playbook

• Primary Dysmenorrhea:
  • NSAIDs: Mefenamic acid (500mg TDS), Ibuprofen (400-600mg TDS). Start 1-2 days before menses.
  • COCs, Progestogens (DMPA, LNG-IUS).
  • Non-pharmacological: Heat, exercise, TENS.
• Secondary Dysmenorrhea: Treat underlying cause.
  • Endometriosis: GnRH agonists, surgery.
  • Fibroids: Myomectomy.
  • PID: Antibiotics.
  • Hysterectomy (last resort).

⭐ NSAIDs are first-line for primary dysmenorrhea, most effective when started 1-2 days before menses and continued for 2-3 days of bleeding.

High‑Yield Points - ⚡ Biggest Takeaways

• Primary dysmenorrhea: Excess prostaglandins; onset 6-12 months post-menarche with ovulatory cycles.
• Secondary dysmenorrhea: Due to pelvic pathology (endometriosis, adenomyosis, fibroids, PID).
• NSAIDs are first-line treatment for primary dysmenorrhea, inhibiting prostaglandins.
• Combined oral contraceptives (COCs) reduce pain by inhibiting ovulation and endometrial growth.
• Endometriosis: Common cause of progressive dysmenorrhea, dyspareunia, infertility.
• Adenomyosis: Presents with dysmenorrhea & menorrhagia; uterus symmetrically enlarged.
• Laparoscopy: Gold standard to diagnose endometriosis or pelvic adhesions causing secondary dysmenorrhea.