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Diagnosis & Management of Painful Periods (Primary dysmenorrhea)

Despite its prevalence, primary dysmenorrhea is a treatable condition that is underdiagnosed.

Young woman suffering from strong abdominal pain while sitting on sofa at home

Painful menstruation, with the absence of an identifiable cause, is defined as primary dysmenorrhea. Dysmenorrhea is the most common gynecologic complaint, characterized by abdominal pain (cramps) during menstruation. This condition affects 50% – 90% of women. For half of these women, the pain they experience is moderate to severe. 

Secondary dysmenorrhea refers to the same clinical features of pain during menstruation, but is attributable to an identifiable cause such as endometriosis, fibroids, etc. (Figure 1). 

Managing primary dysmenorrhea involves diagnosing the potential causes of symptoms and identifying treatment options that work for the patient. Despite the prevalence of dysmenorrhea, this condition commonly goes undetected, is undertreated, and normalized. This is partially due to the fact that period pain is considered to be a normal side effect of menstruation. Frequent normalization and minimization of period pain can cause many patients to begin dismissing their own symptoms. Additionally, this mindset can perpetuate the myth that treatment for menstrual pain isn’t justified nor obtainable for patients. Health care providers, particularly gynecologists, need to proactively inquire about the impact of menstrual symptoms on the patient’s quality of life.

Primary dysmenorrhea typically starts when the patient is in adolescence and their menstrual cycle has been established. Patients with primary dysmenorrhea produce an excessive amount of prostanoids, including prostaglandins, and it’s theorized that these elevated levels of prostanoids is what causes their pain.

Dysmenorrhea has a significant impact on physical, social, emotional, and economic aspects of a patient’s life. 

According to a Candian survey, half of adult patients with primary dysmenorrhea described their symptoms as severe enough to limit their daily activities and 17% of respondents were absent from school or work as a result. As reported by The American College of Obstetricians and Gynecologists, period pain is the most prevalent cause of short-term school absence in teen girls. Furthermore, 1 out of 8 women aged 14 – 20 reported missing work or school due to period pain.

Other international cross-sectional studies have similar conclusions that patients with primary dysmenorrhea experience symptoms that affect their relationships, daily functioning, productivity, and attendance. Despite these significant impacts, patients often don’t seek medical treatment because they believe that pain is a natural part of menstruation.

Diagnosis 

Primary dysmenorrhea doesn’t need to be diagnosed by a specialist and patients will typically present their initial complaints to their primary care doctor (Figure 2). It’s important for gynecologists to raise awareness of dysmenorrhea and be a resource for treatment options as well as further evaluation. Typically, a diagnosis can be reached once the health care provider obtains the patient’s detailed medical history. 

Primary dysmenorrhea typically begins 6-24 months after the patient’s first period. If symptoms started less than six months after their first period, the patient should be screened for underlying causes.

For adult patients experiencing period pain for the first time, pelvic exams are recommended. This is due to the fact that late onset of symptoms increases the likelihood that the pain is a symptom of an underlying condition. In sexually active patients, sexually transmitted infections (STIs) should also be ruled out prior to investigating for an underlying condition. 

As long as there are no additional symptoms besides cramps, pelvic exams aren’t required for non-sexually active or teenage patients. This is because the pelvic exam will appear normal in patients with primary dysmenorrhea, unless they are menstruating, and to ensure the patient’s comfort. Localized pain or physical findings, that aren’t associated with menstruation, again increase the chance that the symptoms are being caused by an undiagnosed, underlying condition. 

A transvaginal ultrasound is the preferred technique for the initial assessment of the pelvic organs. In teenage or non-sexually active patients, a transabdominal pelvic ultrasound can be done instead to accommodate their comfort. Ultrasounds cannot typically be used to diagnose primary dysmenorrhea or early stage endometriosis. This is due to the fact that patients with primary dysmenorrhea or early stage endometriosis with no underlying conditions don’t have remarkably different ultrasound findings compared to patients without any conditions.

Treatment

Health care providers must do their best to change the norm where patients experience delays in diagnosis and treatment. Treating this condition involves providing adequate symptom relief and reducing the amount of disturbances the patient experiences in their daily life. For young and non-sexually active patients, a customized treatment plan should begin immediately without the need for a pelvic exam or further testing. Further evaluation will be needed to rule out secondary causes if the patient’s symptoms don’t improve after 90 days on the treatment plan. 

Sexually active, adult patients who are being screened for primary dysmenorrhea need to first be tested for STIs. Additionally, a pelvic exam should be performed to rule out secondary causes. Once STIs and secondary causes are both ruled out, treatment can begin prior to further testing.

When presenting a patient with treatment options, providers should take into account the patient’s physical and emotional needs. Nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives are both considered a first line of treatment and can be used independently or in combination. Other options, like naproxen or ibuprofen, are easily accessible, affordable, over-the-counter medications that can be effective in treating mild-to-moderate symptoms. It’s important to note that approximately 18% of patients with primary dysmenorrhea are resistant to NSAID therapy. 

Health care professionals should provide their patients with specific instructions on optimal dosage and frequency of medication. Particularly when working with younger patients since underdosing is common and can lead to perceived treatment failure. For mild-to-moderate pain, therapy should begin when symptoms or bleeding begins and should be taken on a scheduled basis for 2 or 3 days. For moderate-to-severe pain, patients can begin therapy a day or two prior to the onset of symptoms (Figure 3).

Further Evaluation

In spite of the fact that most patients see improvement after implementing first-line therapy, patients who do not experience improvement should be evaluated further. Treatment follow-up is essential in order to prevent diagnostic delays.

If a patient’s symptoms don’t improve after 3 months to 2 ½ years with empiric treatment and there are no signs of secondary causes, a treatment plan that includes laparoscopy and concurrent surgical management should be implemented. 

Future Directions

Along with many other gynecologic conditions, research and funding is very limited despite the high prevalence of the condition. Early research points to elevated levels of prostanoids as the cause of primary dysmenorrhea. However, there is still much that is yet to be understood regarding the mechanics of this condition. For example, NSAID therapies only work in 82% of patients, suggesting that prostanoids may not be the only culprit. Primary dysmenorrhea, like similar chronic pain conditions, impacts the processing of stimuli via altering the central and peripheral nervous systems. 

Conclusion

Despite its prevalence, primary dysmenorrhea is a treatable condition that is underdiagnosed. Normalization and minimization of period pain leads to delays in evaluations/diagnosis for patients. Health care providers, especially gynecologists, must do their best to spread awareness about this condition to ensure none of their patients have an undiagnosed condition that is silently impacting their quality of life. If symptoms worsen or are unresponsive to first-line treatment, patients should be screened thoroughly for secondary causes, like fibroids and endometriosis. Patients who report menstrual pain should never feel like their symptoms are being dismissed by professionals (or anyone else) nor that pain is an inevitable part of menstruation.

If you or child need resources for menstrual pain, give Mangrove Women’s Health a call at (530) 345-0064, Ext 281.

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