Definition of Dysmenorrhea
Dysmenorrhea is menstrual pain that occurs during the menstrual cycle, classified as either primary (pain without identifiable pelvic pathology) or secondary (pain resulting from underlying pelvic disease such as endometriosis or adenomyosis). 1, 2
Primary Dysmenorrhea
Primary dysmenorrhea specifically refers to dysmenorrhea in the absence of any pelvic pathology 1. This is the most common form, affecting 50-90% of adolescent girls and women of reproductive age 3.
Key Diagnostic Features:
- Onset timing: May not start at menarche; symptoms can begin before or during menstrual blood loss 1
- No minimum duration required for diagnosis 1
- Pelvic examination is NOT required for diagnosis 1
- Severity assessment: Should use a verbal multidimensional scoring system (VMSS) of grade 2 or higher 1
- Systemic symptoms are NOT necessary for the diagnosis 1
Pathophysiology:
The pain results from cyclooxygenase pathway activation producing increased prostanoids, particularly prostaglandins, which cause uterine contractions that restrict blood flow and generate anaerobic metabolites that stimulate pain receptors 2.
Secondary Dysmenorrhea
Secondary dysmenorrhea indicates menstrual pain caused by identifiable pelvic pathology 2, 3.
Red Flags Suggesting Secondary Causes:
The diagnosis of primary dysmenorrhea requires absence or low clinical suspicion of:
- Sexually transmitted infections
- Pelvic inflammatory disease
- Congenital uterine anomalies
- Endometriosis
- Adenomyosis
- Fibroids 1
Clinical Features Suggesting Secondary Dysmenorrhea:
- Progressive worsening of pain over time
- Abnormal uterine bleeding
- Vaginal discharge
- Dyspareunia (painful intercourse)
- Noncyclic pain
- Changes in intensity and duration of pain
- Abnormal pelvic examination findings 3, 4
Clinical Impact
Dysmenorrhea is a leading cause of absenteeism and negatively affects quality of life, interfering with daily activities 2, 3. The economic burden is substantial, with healthcare spending comparable to other chronic diseases 5.