How to investigate and manage patients with dysmenorrhea (pain during menstruation) as an endocrinologist?

Investigation and Management of Dysmenorrhea in Endocrinology Practice

A comprehensive approach to investigating dysmenorrhea should include a thorough history, physical examination, and appropriate diagnostic testing to identify underlying causes, with treatment focused on both symptom relief and addressing any underlying pathology.

Initial Assessment

• Take a detailed menstrual history including pain characteristics (onset, duration, severity), relationship to menstrual cycle, and impact on daily activities 1, 2
• Document whether pain is cyclical (related to menstrual cycle) or non-cyclical, as this helps distinguish primary from secondary dysmenorrhea 1, 2
• Inquire about associated symptoms such as heavy bleeding, dyspareunia, or non-menstrual pelvic pain that may suggest secondary causes 2
• For transgender and gender-diverse patients, include an organ inventory (e.g., uterus, ovaries, cervix) to ensure appropriate medical care regardless of gender identity 1

Physical Examination

• Perform a complete abdominal examination to assess for tenderness, masses, or organomegaly 2
• Consider pelvic examination in sexually active patients to evaluate for cervical motion tenderness, uterine enlargement, adnexal masses, or nodularity suggestive of endometriosis 1, 2
• For transgender patients, use a trauma-informed approach with clear communication, explicit permission, and guided contact during examination 1
• Recommend a chaperone during sensitive examinations, particularly for transgender patients who may have experienced past discrimination or trauma 1

Diagnostic Testing

• Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected based on history or physical examination findings 2
• Consider measuring serum CA-125 levels in patients with suspected moderate to severe endometriosis, though its utility is limited in mild disease 1
• For patients with severe or treatment-resistant pain, diagnostic laparoscopy may be necessary to confirm endometriosis 1
• For transgender patients with dysmenorrhea, consider the psychological impact of these symptoms on gender dysphoria when planning diagnostic workup 1

Differential Diagnosis

• Primary dysmenorrhea: menstrual pain without identifiable pathology, typically beginning 2-3 years after menarche 3
• Secondary dysmenorrhea causes:
  • Endometriosis: most common cause, characterized by ectopic endometrial tissue 1, 2
  • Adenomyosis: presence of endometrial tissue within the myometrium, presenting with dysmenorrhea and menorrhagia 2
  • Pelvic inflammatory disease: may cause cyclic or non-cyclic pain 2
  • Fibroids or polyps: can cause menstrual pain and heavy bleeding 4

Treatment Approach

First-Line Treatments

• NSAIDs are first-line therapy for primary dysmenorrhea:

  • Ibuprofen 400mg every 4-6 hours as needed for pain relief 5
  • Mefenamic acid 500mg as initial dose followed by 250mg every 6 hours 6
  • Start NSAIDs at the onset of bleeding or pain, whichever begins first 6

• Hormonal contraceptives are effective for both primary dysmenorrhea and endometriosis-related pain:

  • Combined oral contraceptives reduce prostaglandin production and endometrial growth 1, 2
  • For transgender patients, hormonal treatments may help with both dysmenorrhea and gender dysphoria 1

Second-Line and Adjunctive Treatments

• For endometriosis-related pain resistant to first-line therapy, consider GnRH agonists with add-back therapy to prevent bone mineral loss 1, 7
• Non-pharmacologic approaches with evidence of benefit:
  • Heat therapy applied to the lower abdomen 7
  • Regular physical exercise 7
  • Consider referral to gynecologic specialists for patients with severe or persistent symptoms 1

Special Considerations for Transgender Patients

• Dysmenorrhea and menorrhagia can severely exacerbate gender dysphoria in transgender patients with uteruses 1
• Consider referral to gynecologic specialists who can offer additional care including hormonal treatment or laparoscopic evaluation 1
• A multidisciplinary approach addressing both physical symptoms and psychological impact is essential 1
• Document gender identity, sex assigned at birth, and organ inventory in medical records to ensure appropriate care 1

Follow-Up and Monitoring

• Reassess symptoms after 3 months of treatment 1
• If no improvement with empiric treatment, investigate for secondary causes 8
• For patients with confirmed endometriosis, regular follow-up is needed to monitor treatment response and disease progression 1
• Consider surgical options (endometrial ablation, presacral neurectomy) for patients who fail medical management 7

Common Pitfalls to Avoid

• Failing to distinguish between primary and secondary dysmenorrhea, leading to delayed diagnosis of underlying conditions 2
• Overlooking the psychological impact of dysmenorrhea, particularly in transgender patients 1
• Inadequate dosing or timing of NSAIDs, which should be started at the onset of symptoms for maximum effectiveness 6, 5
• Dismissing the severity of pain and its impact on quality of life 8, 7