Dysmenorrhea is a common gynecological complaint characterized by painful menstruation. It is classified as primary or secondary based on the absence or presence of underlying pelvic pathology. Primary dysmenorrhea is caused by normal menstrual processes without pathology, while secondary dysmenorrhea has identifiable causes like endometriosis. Treatment involves NSAIDs for primary dysmenorrhea and treating the underlying condition for secondary dysmenorrhea. A history and exam are usually sufficient to diagnose primary dysmenorrhea, while secondary dysmenorrhea requires investigation to identify the cause and direct treatment.

1. APPROACH TO PATIENTS WITH
DYSMENORRHEA
Reem Ahmed Alyahya

2. INTRODUCTION
 Dysmenorrhea is considered to be the most common gynecologic
complaint in all ages and races and one of the most common causes
of pelvic pain.
 Estimates of the prevalence of dysmenorrhea vary widely (16.8% to
81%3), and rates as high as 90% have been recorded.
 Symptoms typically begin in adolescence and may lead to school and
work absenteeism, as well as limitations on social, academic, and
sports activities.

3. OBJECTIVES
 Definition
 Types
 Risk factors
 Pathogenesis
 Primary dysmenorrhea
 Secondary dysmenorrhea

4. DEFINITION
 Its defined as 'painful menstruation'
 Derived from the Greek words: dys, meaning painful; meno, meaning
monthly; and rhoe, meaning flow.
 It is experienced as uterine cramps and can occur a few days prior to
menstruation and/or during menstruation, and usually subsides at
the end of menstruation.

5. TYPES
Dysmenorrhea is further defined within 2 subcategories:
1. Primary dysmenorrhea: occurs in the absence of an underlying
pelvic pathology.
2. Secondary dysmenorrhea: occurs in the presence of pelvic
pathology.

6. RISK FACTORS
PROTECTIVE FACTORS
 Regular exercise
 Early child birth
 Oral contraceptive use

7. PATHOGENESIS

8. PRIMARY DYSMENORRHEA

9. PRIMARY DYSMENORRHEA Ionset
6 to 12 months
after menarche,
with peak
prevalence
occurring in the
late teens or early
twenties. Signsand
symptoms
Recurrent, crampy,
suprapubic pain
occurring just
before or during
menses and
lasting 2 to 3
days; pain may
radiate into the
lower back and
thighs.
Associated
symptoms
Nausea or
vomiting, fatigue,
bloating, Head-
ache, diarrhea,
and general
malaise

10. PRIMARY DYSMENORRHEA II
Physical examination :
Normal
Investigations:
urine tests should be
ordered to rule out
pregnancy or infection

11. •The pain is a result of normal physiologic process
and has no underlying pathology.
Clarification
•it’s a common problem reported by young females
and the therapy is available and simple.
•It is also common for the pain to either disappear
or substantially lessen after the birth of the first
child.
Reassurance
TREATMENT

12. TREATMENT: PHARMACOLOGICAL
 NSAIDs is the first line treatment for primary dysmenorrhea, as it will
inhibit prostaglandin synthesis.
 The choice of NSAID should be based on effectiveness and
tolerability for the individual patient.
 Medications should be taken one to two days before the anticipated
onset of menses, and continued on a fixed schedule for two to three
days.

13. TREATMENT: PHARMACOLOGICAL

14. TREATMENT: PHARMACOLOGICAL
 Oral, intravaginal, and intrauterine hormonal contraceptives have
been recommended for management of primary dysmenorrhea, as
they will inhibit ovulation.
 However, the evidence supporting their effectiveness is limited.
 Both 28-day and extended cycle oral contraceptives are reasonable
options in women with primary dysmenorrhea.

15. IT IS RECOMMENDED TO ALLOW AT LEAST THREE
FULL CYCLES TO ASSESS EFFICACY OF EITHER OF
THESE APPROACHES.

16. TREATMENT: NON-
PHARMACOLOGICAL
Strong evidence of effectiveness:
Topical heat
Moderate exercise
Nutritional interventions
(omega-3 , vitamin B2)
Insufficient evidence of
effectiveness:
Acupuncture
Yoga
massage

17. TREATMENT: SURGICAL OPTIONS
 If a patient continues to have significant dysmenorrhea with this
treatment, further testing for causes of secondary dysmenorrhea
should be considered, and surgical options, such as interruption of
pelvic nerve pathways, should be explored when applicable.
 e.g. uterosacral nerve ablation and pre-sacral neurectomy

18. SECONDARY
DYSMENORRHEA

19. SECONDARY DYSMENORRHEA Ionset
older women with
recent history of
dysmenorrhea
Signsand
symptoms
Pain is continuous
dull aching lower
abdominal pain
accompanied by
backache occurring
in parous women
after many years of
relatively painless
menstruation.
Associated
symptoms
menorrhagia,
intermenstrual
bleeding,
dyspareunia, post-
coital bleeding, and
infertility.

20. SECONDARY DYSMENORRHEA II
Suspected condition Physical examination
findings
Investigations required
Endometriosis:
deep dyspareunia, dysuria,
dyschezia, and subfertility
fixed or retroverted uterus
or reduced uterine
mobility, adnexal masses,
and uterosacral nodularity.
 Transvaginal and pelvic
ultrasonography
 laparoscopy with biopsy
and histology is the
preferred diagnostic test
Pelvic inflammatory
disease: History of lower
abdominal pain in sexually
active patients
cervical motion
tenderness, uterine
tenderness, and/or
adnexal tenderness, fever
and abnormal cervical or
vaginal mucopurulent
discharge.
 Saline microscopy of
vaginal fluid may show
organism.
 elevated inflammatory
markers

21. SECONDARY DYSMENORRHEA III
Suspected condition Physical examination
findings
Investigations required
Adenomyosis:
Usually associated with
menorrhagia and
intermenstrual bleeding.
enlarged, tender, boggy
uterus
 Transvaginal
ultrasonography will
detect endometrial
tissue within the
myometrium.
Leiomyomata “ fibroid “ :
Cyclic pelvic pain with
menorrhagia and
dyspareunia
firm, enlarged, and
irregularly shaped uterus
 Transvaginal
ultrasonography

22. TREATMENT
Treatment of the underlying
pathology.

23. CONCLUSION
1. Dysmenorrhea is one of the most common causes of pelvic pain,
and It negatively affects patients’ quality of life and results in
activity restriction.
2. A history and physical examination is usually the only things
needed to diagnose primary dysmenorrhea.
3. The presence of menorrhagia, intermenstrual bleeding,
dyspareunia, post- coital bleeding, and infertility should raise the
physician’s suspicion to the presence of a secondary cause.

24. REFERENCES
 American and family physician: Diagnosis and Initial Management
of Dysmenorrhea
 Current diagnosis and treatment in family medicine, 4th edition
 BMJ : Assessment of dysmenorrhea

25. THANK YOU FOR
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