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 examination. Laboratory tests may include complete blood count, pregnancy test, and sexually transmitted infection screening if indicated.

• Key points to consider in the history and physical examination include:
  • Distinguishing between primary and secondary dysmenorrhea
  • Identifying associated symptoms such as heavy menstrual bleeding, dyspareunia, or dyschezia
  • Assessing the impact of symptoms on daily activities and quality of life
• Imaging studies, such as transvaginal ultrasound, can help identify underlying conditions that may be contributing to dysmenorrhea, including endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease, as discussed in the study by 1.
• In cases where endometriosis is suspected but not visualized on ultrasound, laparoscopy may be both diagnostic and therapeutic, as noted in the study 1.
• Treatment typically begins with NSAIDs like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) starting 1-2 days before menses and continuing through the first 2-3 days.
• Hormonal contraceptives are second-line therapy, with combined oral contraceptives, vaginal rings, or patches effectively reducing prostaglandin production and menstrual flow, as supported by the evidence 1.
• Lifestyle modifications including regular exercise, heat therapy, and stress reduction techniques may provide additional relief.

From the Research

Dysmenorrhea Workup

The workup for dysmenorrhea typically involves a combination of clinical evaluation, physical examination, and diagnostic testing to determine the underlying cause of the condition.

• A thorough medical history and physical examination, including a pelvic examination, are essential in evaluating patients with dysmenorrhea 2.
• Primary dysmenorrhea is characterized by menstrual pain in the absence of pelvic pathology, while secondary dysmenorrhea is associated with underlying pelvic disease 2, 3.
• The diagnosis of primary dysmenorrhea is primarily clinical, based on a typical history and normal physical examination findings 3, 4.

Diagnostic Testing

Diagnostic testing may be necessary to rule out underlying conditions that may be contributing to dysmenorrhea.

• Transvaginal ultrasonography is recommended if secondary dysmenorrhea is suspected 2.
• Endometriosis is a common cause of secondary dysmenorrhea, and symptoms such as dyspareunia, noncyclic pain, and changes in intensity and duration of pain may indicate underlying pathology 2, 5.
• Adenomyosis, characterized by dysmenorrhea, menorrhagia, and a uniformly enlarged uterus, may also be a contributing factor 2.

Evaluation of Secondary Dysmenorrhea

If the patient's symptoms do not improve with empiric treatment, further evaluation for secondary dysmenorrhea is necessary.

• A detailed medical history and physical examination can help identify potential causes of secondary dysmenorrhea 2, 4.
• Additional testing, such as imaging studies or laparoscopy, may be necessary to confirm the diagnosis of underlying conditions such as endometriosis or adenomyosis 5.