What is the workup for dysmenorrhea (painful menstruation)?

From the Guidelines

The workup for dysmenorrhea should begin with a thorough history and physical examination, followed by transvaginal ultrasound as the first-line imaging study to evaluate for conditions like endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease, as recommended by recent guidelines 1.

The history should include pain characteristics, timing relative to menstrual cycle, associated symptoms, and impact on daily activities. Physical examination should include abdominal and pelvic exams to assess for tenderness, masses, or other abnormalities. Laboratory tests may include a complete blood count, pregnancy test, and sexually transmitted infection screening if indicated.

For suspected secondary dysmenorrhea, expanded protocol transvaginal ultrasound (TVUS) studies have been developed to identify and “map” deep endometriosis (DE), and have been shown to have a significantly higher sensitivity than routine pelvic US 1. These studies are typically performed by a physician or expert in endometriosis imaging and include anatomy and scanning maneuvers that are not part of the female pelvic US.

In cases where endometriosis is strongly suspected but not visualized on ultrasound, MRI protocol tailored for detection of DE, with moderate bladder distention and vaginal contrast, may be considered for further evaluation 1. Treatment can begin empirically with NSAIDs (ibuprofen 400-600mg every 6 hours or naproxen 500mg twice daily) starting 1-2 days before menses and continuing through the first 2-3 days of flow. Hormonal contraceptives are also effective first-line treatments. If symptoms persist despite these interventions or if secondary dysmenorrhea is suspected, referral to gynecology for further evaluation and management is appropriate.

Some key points to consider in the workup and management of dysmenorrhea include:

• Distinguishing between primary and secondary dysmenorrhea to guide further evaluation and treatment
• Using transvaginal ultrasound as the first-line imaging study to evaluate for conditions like endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease
• Considering expanded protocol TVUS studies or MRI protocol tailored for detection of DE in cases where endometriosis is strongly suspected
• Starting empirical treatment with NSAIDs or hormonal contraceptives, and referring to gynecology if symptoms persist or if secondary dysmenorrhea is suspected.

From the FDA Drug Label

Dysmenorrhea: For the treatment of dysmenorrhea, beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain. The work up for dysmenorrhea may include the use of ibuprofen 400 mg every 4 hours as necessary for the relief of pain, starting from the earliest onset of pain.

• The dose should be tailored to each patient, and may be lowered or raised depending on the severity of symptoms. Key points to consider are:
• Dose: 400 mg every 4 hours
• Timing: beginning with the earliest onset of pain
• Adjustment: dose may be adjusted based on patient response 2

From the Research

Dysmenorrhea Workup

• The initial workup for dysmenorrhea should include a menstrual history and pregnancy test for patients who are sexually active 3.
• A history and physical examination, including a pelvic examination in patients who have had vaginal intercourse, may reveal the cause of dysmenorrhea 4.
• Primary dysmenorrhea is diagnosed based on clinical history and normal physical examination, and it is essential to exclude secondary causes of dysmenorrhea 5.
• Symptoms and signs of underlying pathology, such as abnormal uterine bleeding, dyspareunia, noncyclic pain, changes in intensity and duration of pain, and abnormal pelvic examination findings, suggest secondary dysmenorrhea and require further investigation 4.
• Transvaginal ultrasonography should be performed if secondary dysmenorrhea is suspected 4.

Diagnostic Considerations

• Endometriosis is the most common cause of secondary dysmenorrhea 4.
• Adenomyosis is another potential cause of secondary dysmenorrhea, characterized by dysmenorrhea, menorrhagia, and a uniformly enlarged uterus 4.
• A thorough history and physical examination can help identify the underlying cause of dysmenorrhea and guide further evaluation and treatment 3, 5, 4.

Further Evaluation

• If secondary dysmenorrhea is suspected, further workup should include pelvic examination and ultrasonography 3.
• Referral to an obstetrician-gynecologist may be warranted for further evaluation and treatment of dysmenorrhea 3.
• The physician should initiate an evaluation for secondary dysmenorrhea if the patient does not report improved symptomatology after being compliant with their medical regimen 6.