Dysmenorrhea: Diagnosis and Treatment

Diagnosis

• A complete history and physical is necessary for all patients, including menstrual, gynecologic, sexual, and dietary history. Abdominal, pelvic, and rectal examinations may reveal conditions that are responsible for the pain.
  
• Laboratory testing may include a pregnancy test, Pap smear, urine analysis, and blood tests.
  
• Testing for sexually transmitted diseases, including cultures for gonorrhea and Chlamydia, is normally conducted. However, negative cultures do not exclude pelvic infection.
  
• Pelvic and vaginal ultrasound may be necessary to check for underlying disorders, such as fibroids.
  
• In some cases, surgical laparoscopy may be needed for the diagnosis and removal of fibroids, endometriosis, cysts, or other abdominal or pelvic disorders.

Treatment

Primary dysmenorrhea may require a multidisciplinary approach that may include medical, lifestyle, and nutritional interventions.

• Nutritional interventions, such as a low–fat vegan diet, vitamin E, magnesium, and other supplements, decreased alcohol and caffeine intake, and weight loss may be useful (see Nutritional Considerations below).
  
• Regular exercise reduces blood estrogen concentrations, which would be expected to reduce the risk of dysmenorrhea. In some studies, women who exercise appear to have milder menstrual symptoms, compared with women who do not exercise.
  
• Smoking cessation may be helpful.
  
• Heat applied to the lower abdomen may be as effective as acetaminophen (Tylenol) and ibuprofen for pain relief.
  
• Acupuncture and electrical nerve stimulation may be beneficial. Limited evidence from controlled trials indicates that acupuncture produces significant pain relief and decreases the need for pain medications.
• Nonsteroidal anti–inflammatory drugs (e.g., ibuprofen and naproxen) are often effective in treating pain. Treatment is more effective if begun before the expected onset of symptoms and continued throughout the menstrual period.
  
• Oral contraceptive pills are often effective.
  
• Other medications, including calcium channel blockers, nitroglycerin, and nitric oxide, are under investigation.
  
• Women who do not respond to medications should be considered for treatment of endometriosis.
• In cases of secondary dysmenorrhea, treatment is based on the underlying problem. NSAIDs and oral contraceptive pills may be useful in some patients.