Dysmenorrhea: Diagnosis and Treatment

Diagnosis

Primary dysmenorrhea is a diagnosis of exclusion. A complete history and physical, including menstrual, gynecologic, psychosocial, and dietary history, is necessary for all patients. Abdominal, pelvic, and rectal examinations may reveal underlying disorders.

Laboratory testing may include pregnancy testing, Pap smear, urinalysis, and complete blood count.

Cultures for gonorrhea and chlamydia are generally indicated, but negative cultures do not exclude pelvic infection.

Imaging studies may include pelvic and vaginal ultrasound.

Laparoscopy may be indicated for the diagnosis and removal of fibroids, endometriosis, adhesions, ovarian cysts, or other abdominal or pelvic pathologies. However, laparoscopy has not been shown to be superior to medical therapy for the relief of pain.

Treatment

Primary dysmenorrhea is best treated with a multidisciplinary approach that may include medical, lifestyle, and nutritional interventions.

Nonpharmacologic Therapies

Nutritional interventions, such as a low–fat vegan diet, vitamin E, magnesium, and other supplements are described below (see Nutritional Considerations).

Regular exercise decreases blood estrogen concentrations,¹ which would be expected to decrease the risk of dysmenorrhea. In unblinded trials, women who exercise appear to have less severe menstrual symptoms, compared with women who do not exercise.²

Smoking cessation may be helpful.

Heat applied to the lower abdomen may be as effective as acetaminophen and ibuprofen.^3,4

Acupuncture⁵ and transcutaneous electrical nerve stimulation (TENS) may be beneficial.⁶ Limited evidence from controlled trials indicates that acupuncture produces significantly better pain relief compared to sham acupuncture and decreases the use of pain medications. Acupressure provides pain relief similar to that of nonsteroidal anti–inflammatory drugs (NSAIDs) when compared with sham acupressure treatment.⁷

Medical Therapies

NSAIDs (ibuprofen, naproxen, fenamates) are often effective in treating the pain of primary (and occasionally secondary) dysmenorrhea. Treatment is more effective if begun prior to the expected onset of symptoms and continued throughout menses.

Oral contraceptives are often effective and are commonly used for pain that results from NSAID therapy.

Calcium channel blockers, nitroglycerin, and nitric oxide are under investigation.

Women who do not respond to therapy should be considered for treatment of endometriosis.

Secondary Dysmenorrhea

Treatment is based on the underlying pathology. NSAIDs and oral contraceptive pills may be useful in some patients.