• Pain associated with menstrual flow characterized by spasmodic lower abdominal cramping with radiation to the back and anterior aspect of thighs
• Primary dysmenorrhea: pain with menstrual flow without evidence of organic pelvic disease
• Secondary dysmenorrhea: pain with menses secondary to an organic disease such as endometriosis, ovarian cysts, adhesions, genital tract abnormalities or pelvic inflammatory disease

• Grade I: mild dysmenorrhea that does not interfere with participation in everyday activity
• Grade II: moderate dysmenorrhea, with minimal systemic symptoms; interferes with participation in some activities
• Grade III: severe discomfort, often associated with systemic symptoms; individual is unable to participate in normal activities for several days

• Thought to be due to uterine contractions combined with prostaglandin excess

• Endometriosis
• Ovarian cysts
• Pelvic adhesions
• Pelvic inflammatory disease
• Reproductive tract malformations

• During menses the uterus undergoes infrequent labor-like contractions of 100 to 120 mm Hg, which can lead to dysmenorrhea. Higher basal uterine pressures and higher levels of uterine contractions and/or dysrhythmic contractions are found in patients who suffer from dysmenorrhea.
• Prostaglandins E₂ and F₂, synthesized in endometrial tissue, are believed to be responsible for dysmenorrhea. The former causes vasodilation and bleeding; and the latter, myometrial contractions, vasoconstriction, and ischemia. Higher levels of prostaglandins are found in the endometrium of patients with dysmenorrhea. Prostaglandin synthesis is enhanced by progesterone and the presence of a secretory endometrium.
• Primary dysmenorrhea usually does not begin until 2 to 4 years after the onset of menses, when the adolescent begins to ovulate regularly and produce progesterone.

• 43% to 90% of all women have some degree of dysmenorrhea. 10% of these women are incapacitated for 1 to 3 days a month.
• 38% of adolescents at Sexual Maturity Rating SMR-3, and 66% of those at SMR-5 experience dysmenorrhea.
• Risk factors for developing dysmenorrhea
  • Early age at menarche
  • Long menstrual periods
  • Smoking
  • Alcohol use
  • Weight >90th percentile

• Pain
• Interference with everyday activities
• Systemic symptoms (50%), including:
  • Nausea and vomiting (90%)
  • Fatigue (85%)
  • Nervousness (67%)
  • Dizziness (60%)
  • Diarrhea (60%)
  • Backache (60%)
  • Headache (50%)

• Endometritis
• Pelvic inflammatory disease

• Uterine polyps
• Fibroids

• Reproductive tract abnormalities

• Functional abdominal pain

• Endometriosis
• Intrauterine device (IUD)

• Age at menarche?
• Regularity of cycle?
• Amount of bleeding?
• Duration of bleeding?
• Day of cycle when pain begins and ends?
• Presence of large blood clots?

• Age at first coitus?
• Number of partners?
• Contraceptive method?
• Frequency of use of barrier methods?
• Pregnancy history?
• Sexually transmitted disease/pelvic inflammatory disease history?
• Dyspareunia?

• Dysuria or other urinary tract signs?
• Constipation, diarrhea, or other GI-tract signs?
• Gastrointestinal or genitourinary surgery?

• How bad are the cramps?
• Do the cramps interfere with going to school or other activities?
• Are there other symptoms that accompany the cramps?

• Evidence of endometriosis, endometritis, polyps, fibroids, or uterine or cervical abnormalities.
• If not sexually active, pelvic examination is indicated only if symptoms are not responsive to standard medical therapy.

• CBC
• ESR
• Endocervical cultures

• Grade I–II dysmenorrhea: aspirin, acetaminophen, or over-the-counter prostaglandin inhibitors (ibuprofen, naproxen sodium). If the patient wishes contraception, oral contraceptive pills will provide both contraception and relief from primary dysmenorrhea.
• Grade II–III dysmenorrhea: prescription prostaglandin inhibitors with or without oral contraceptive pills:
  • Tolmetin (Tolectin, McNeil, Fort Washington, PA), 400 mg t.i.d.
  • Sulindac (Clinoril, Merck, West Point, PA), 200 mg t.i.d.
  • Ibuprofen (Motrin, Hoffman Roche, Nutley, NJ), 400 to 600 mg t.i.d. to q.i.d.
  • Naproxen sodium (Anaprox), 550 mg to start then 275 mg t.i.d. to q.i.d.
• Fenamates
  • Mefenamic acid (Ponstel), 500 mg to start then 250 mg q.i.d.
  • Meclofenamate (Meclomen), 100 mg to start, then 50 to 100 mg q.i.d.
• Try one class of prostaglandin inhibitors for three cycles before switching to another class.
• Patients should start medication 1 to 2 days before menses begins.
• Other treatments:
  • Omega-3 fish oil
  • Calcium antagonists
  • Glyceryl trinitrate
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture
  • Herbal remedies

• Should see improvement within 3 to 4 menstrual cycles. If there is no response to medical management, referral to gynecologist for laparoscopic evaluation should be strongly considered.
• Monitor patients taking prostaglandin inhibitors for gastrointestinal distress.

• Regular exercise has been shown to decrease the severity of dysmenorrhea symptoms.
• Avoid high-salt diet and caffeine.

• Avoid missing diagnosis of PID.
• Consider endometriosis in adolescent patients. Recently, adolescents have been presenting more frequently with atypical endometriosis.

Q: When should I consider oral contraceptive pills for a patient with dysmenorrhea?
A: If the patient has Grade II or higher dysmenorrhea that is not responding to medication, or if she has many systemic symptoms. Oral contraceptives should also be suggested to sexually active adolescents with any grade of dysmenorrhea. The advantages are lessening of dysmenorrhea, less menstrual flow, and less iron-deficiency anemia.

Q: How do I distinguish primary from secondary dysmenorrhea?
A: Primary amenorrhea usually begins gradually 2 to 4 years after the onset of menses. In contrast, an adolescent with isolated atypical, painful, menstrual periods should be evaluated for complications of pregnancy and/or genital tract infections. The older adolescent with a long history of increasingly painful menstrual periods should be evaluated for endometriosis. Congenital malformations of the genital tract are very rare and usually cause severe pain with the first menstrual period, unlike primary dysmenorrhea and endometriosis. Most malformations that cause dysmenorrhea include some blood flow outlet obstruction, and pelvic masses are often detected by examination or ultrasound.

Q: What are the characteristics of endometriosis in adolescents?
A: Adolescents with endometriosis often display dysmenorrhea of increasing severity. Other symptoms include abnormal vaginal bleeding, dyspareunia, and intestinal and bladder dysfunction. They may have no findings on pelvic examination, but some display posterior cul de sac tenderness and a smaller percentage display posterior cul de sac nodularity. The diagnosis is best made by laparoscopic evaluation.

Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort. Arch Pediatr Adolesc Med 1997;151(9):905–913.

Coupey SM, Ahlstrom P. Common menstrual disorders. Pediatr Clin North Am 1989;36(3):551–558.

Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 4th ed. Philadelphia: Lippincott-Raven, 1998:371–375.

Gidwani GP. Longitudinal study of risk factors for occurrence, duration and severity of menstrual cramps in a cohort of college women. Clin Pediatr 1998;37(1):51.

Harel Z, Biro FM, Kottenhahn RK, Rosenthal SL. Supplementation with omega-3 polyunsaturated fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol 1996;174(4):1335–1338.

Hurd SJ, Adamson GD. Pelvic pain: endometriosis as a differential diagnosis. Adolesc Pediatr Gynecol 1992;5:3–7.

Kennedy S. Primary dysmenorrhea. Lancet 1997;349(9059):1116.

Neinstein LS. Adolescent health care: a practical guide. Baltimore: Urban & Schwarzenberg, 1991:653–657.