DYSMENORRHEA   40A

A 24-year-old woman presents to the clinic complaining of painful menses. She states that for the past several years, she has had cramping pain in the days preceding her menses as well as during her menses. In addition, she notes bloating and weight gain in the week before her menses, with swelling of her hands and feet. She has irritability and severe mood swings during that time; she cries easily and for no reason becomes enraged at her family or boyfriend. On review of systems, she denies urinary symptoms, vaginal discharge, and gastrointestinal symptoms. She has no significant medical history. She has never been pregnant and never had a sexually transmitted disease. She is monogamous with her long-standing boyfriend and states that they always use condoms. She takes no medications. Her physical examination findings are unremarkable.

What are the salient features of this patient’s problems? How do you think through her problems?

Salient features: Young woman; chronic painful menses that are cramping in character; bloating and weight gain with mood disturbance before menses; normal physical examination findings (suggests primary dysmenorrhea)

How to think through: Primary dysmenorrhea needs to be differentiated from secondary dysmenorrhea in this patient. Primary dysmenorrhea begins in adolescence. Symptoms begin 0 to 2 days before the onset of menses and last up to 3 days; associated symptoms of nausea, back pain, fatigue, and headache are characteristic. Exclusion of secondary causes of menstrual pain often does not require additional testing, but careful assessment of risk factors, history, and pelvic examination is needed. What history, not present in this case, would alert the clinician to possible secondary dysmenorrhea? (Onset after age 25 years, worsening of symptoms over time, unilateral pain, abnormal uterine bleeding.) Why is the low-risk sexual history important in this case? (Pelvic inflammatory disease [PID] is an important cause of secondary dysmenorrhea.) What are the other major secondary causes to consider? (Endometriosis is most common; adenomyosis.) What is the natural history of primary dysmenorrhea, and how should this patient be counseled? (Improvement over time is typical, often with marked improvement after parity.) What are the two major pharmacologic treatment strategies? (Hormonal contraception and nonsteroidal antiinflammatory drug [NSAIDs].) What nonpharmacologic treatments have the greatest evidentiary support? (Application of heat and physical activity.)

DYSMENORRHEA   40B

What are the essentials of diagnosis and general considerations regarding dysmenorrhea?

Essentials of Diagnosis

Primary dysmenorrhea is menstrual pain associated with ovular cycles in the absence of pathologic findings.

Secondary dysmenorrhea is menstrual pain for which an organic cause exists, such as endometriosis.

General Considerations

Primary dysmenorrhea usually occurs in young women; begins within 1 to 2 years of menarche; and is caused by uterine vasoconstriction, anoxia, and sustained contractions mediated by prostaglandins.

Secondary dysmenorrhea usually begins well after menarche even in the third or fourth decades of life.

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