CLINICAL CASE 45

Dysmenorrhea

A 14-year-old female comes to your office complaining of severe dysmenorrhea (painful

periods) for the past six months. She began menstruating 10 months ago with her first
two periods occurring about 2 months apart without pain or any other symptoms. Since
then, she menstruates every 28 days and also notices nausea, diarrhea and headaches
during her periods. The pain has gotten so bad for 3 days each month that she often
misses school.

You speak to the patient without her mother and ask if she has ever been sexually active
in any way. The patient denies this activity and you believe her. She is a good student, is
involved in sports and after school programs, and you think it is unlikely that she is
pretending to have dysmenorrhea to get out of school. She denies use of drugs or
alcohol, and you believe it is unlikely she is drug seeking. She says that she gets partial
relief by using 3-4 Advil, two or three times a day during her period.

The review of systems, past medical history and social history are noncontributory. The

Physical exam:

e. Abdominal exam reveals no

masses or organomegaly, and no tenderness or rebound. Because the patient is virginal
and you do not want to induce undue pain, you defer the pelvic exam and do a rectal
exam showing a normal size non-tender uterus, which is mobile and anteflexed. There
are no nodules on the back of the uterus, and there are no adnexal masses or
tenderness.

Laboratory:

Urinalysis is negative for blood, nitrites and leukocytes.

Diagnosis:

High likelihood of primary dysmenorrhea based on the onset of pain and associated
systemic symptoms with regular cycles, and partial response to Advil.

Secondary dysmenorrhea due to endometriosis is possible, but less likely based on the
normal uterus and ovaries at the time of physical exam, and the short time this patient
has been menstruating. However, this is a familial condition and her mother has
endometriosis.
Management:

Regular use of non-steroidal anti-inflammatory agents starting just before or at the

beginning of menstruation are likely to give this patient relief.

If this is not sufficient or if she develops gastric upset with this treatment, combined
oral contraception are very likely to help this condition (whether it is primary
dysmenorrhea or secondary dysmenorrhea due to endometriosis. However, her mother
may be concerned about the use of oral contraceptives, worrying that it might increase
the likelihood of sexual activity. You can tell her there is data showing that medical use
of oral contraceptives is not associated with increased sexual activity.

If these two treatments are not successful, you plan on referring her to a gynecologist
for further workup.

Teaching points:

1. Dysmenorrhea is painful menstruation. This condition is quite common and is

estimated to contribute to recurrent disability in 10-15% of women in their
early reproductive years.

2. Dysmenorrhea can be divided into two types:

Primary dysmenorrhea: Onset is usually in the teens to twenties with the onset of
ovulation. Some studies indicate it is present in up to 90% of teenagers. Because it is
believed to be due to an excess of prostaglandin F2AlPHA (PGF2a)production in the
endometrium. This potent smooth-muscle stimulant causes intense uterine
contractions and resulting pain. It also gets into the systemic circulation resulting in (by
decreasing frequency) nausea, tiredness, nervousness, dizziness, diarrhea and
headache in up to 45% of patients. There are no abnormal physical findings in the
gynecological exam for primary dysmenorrhea. The diagnosis is one of exclusion.

Treatment of primary dysmenorrhea: Non-steroidal anti-inflammatory agents (NSAIDs)

and, if needed, combination oral contraceptives are extremely effective. NSAIDs are
prostaglandin-synthetase inhibitors, while oral contraceptives inhibit ovulation and
progesterone stimulation of prostaglandin production. Within three months of starting
combined oral contraceptives, 90% of women have a marked decrease in pain. Long
acting progesterone (depo-Provera) is a birth control method that is also effective in
dysmenorrhea. Failure of these regimens should lead to a reevaluation for a possible
secondary cause.

Secondary dysmenorrhea: are due to causes other than excess production of

prostaglandins. Causes can be divided into the following categories:

Extrauterine causes
Endometriosis (endometrial glands outside the uterus)
 Tumors (benign or malignant) or cysts
Inflammation
Adhesions
Psychogenic (rare)
Non-gynecologic causes
Intramural causes
Adenomyosis (endometrial glands in the wall of the uterus)
Leiomyomata (fibroids/benign tumors in the wall of the uterus)
Intrauterine causes
Leiomyomata
Polyps
Intrauterine contraceptive devices (IUDs)
Infection
Cervical stenosis and cervical lesions

The diagnosis of secondary dysmenorrhea is more difficult than primary dysmenorrhea

because the symptoms and physical findings are variable. Symptoms often include
menorrhagia (heavy periods) and/or pain throughout the menstrual cycle. Abnormal
findings on abdominal or pelvic exam should raise suspicion of a secondary etiology or
pathology.

Treatment of secondary dysmenorrhea: depends on the etiology and often requires

imaging studies, office procedures, or surgery for diagnosis and treatment. A referral to
a gynecologist is often useful in this situation. One of the most common causes of
secondary dysmenorrhea is endometriosis, which has been found in up to 50% of
premenopausal women and 71-87% of women with chronic pelvic pain including
dysmenorrhea. This topic is discussed elsewhere in this series. Treatment for secondary
dysmenorrhea includes medical induction of menopause, laparoscopic surgery for
removal of endometriosis or adhesions, laparoscopic nerve ablation supplying to the
uterus, or hysterectomy.