How should I evaluate and manage a woman who experiences chest pain and generalized body aches only during menstruation, including red‑flag assessment, NSAID therapy, hormonal options, and anemia work‑up?

Evaluation and Management of Menstruation-Associated Chest Pain and Body Aches

First, rule out acute coronary syndrome (ACS) with immediate ECG and troponin measurement, as women are at high risk for cardiac underdiagnosis even with atypical presentations, then consider menstruation-related angina or thoracic endometriosis syndrome if symptoms are strictly catamenial (cyclical with menses). 1, 2, 3

Immediate Red-Flag Assessment

Obtain a 12-lead ECG within 10 minutes of presentation to identify ST-segment elevation, ST-depression, or T-wave inversions indicating ACS. 1, 2, 4 Women presenting with chest pain are at particularly high risk for underdiagnosis because traditional risk assessment tools underestimate their cardiac risk. 1, 5

Critical History Elements for Cardiac Risk Stratification

• Document whether chest pain is pressure, squeezing, gripping, heaviness, or tightness (high probability of ischemia) versus sharp, stabbing, fleeting, or pleuritic (lower probability). 1, 2, 4
• Specifically ask about accompanying symptoms more common in women with ACS: nausea, fatigue, shortness of breath, jaw pain, neck pain, back pain, and diaphoresis. 1, 5
• Assess cardiovascular risk factors: age, diabetes, hypertension, hyperlipidemia, smoking history, and family history of premature coronary artery disease. 2, 4
• Measure high-sensitivity cardiac troponin as soon as possible if ACS is suspected (>90% sensitivity, >95% specificity for myocardial injury). 2, 4

Physical Examination Priorities

Perform a focused cardiovascular examination looking for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, new mitral regurgitation murmur, pulse differentials (aortic dissection), or subcutaneous emphysema (esophageal rupture). 1, 2, 4

Catamenial Pattern Recognition

If cardiac workup is negative and symptoms occur exclusively or predominantly during menstruation, consider menstruation-related angina or thoracic endometriosis syndrome (TES). 3, 6, 7

Menstruation-Related Angina

• This presents as recurrent nonexertional chest pain coinciding monthly with menstruation, often with troponin elevation despite normal or non-obstructive coronary angiography. 3, 8
• Two subtypes exist: cardiac syndrome X (perimenopausal/postmenopausal women) and catamenial angina (reproductive-age women with existing or predisposed coronary disease). 8
• Pathophysiology involves decreased estrogen levels during postovulation and menstruation, losing cardioprotective effects on cardiomyocytes, endothelial cells, and smooth muscle cells. 8

Thoracic Endometriosis Syndrome

• TES presents with catamenial chest pain, hemoptysis, pneumothorax, or pleural effusion in reproductive-age women, often with concurrent pelvic endometriosis. 6, 7
• Key diagnostic clue: symptoms peak during menstruation and may include right-sided pleural effusion, hydropneumothorax, or lung masses on imaging. 6
• Check CA-125 (elevated but nonspecific) and perform pelvic ultrasound to identify endometriomas. 6
• Consider family history, as genetic predisposition is a significant risk factor. 6

Management Algorithm

If Cardiac Workup is Positive or Indeterminate

• Transport immediately to emergency department by EMS (not personal automobile) if clinical evidence of ACS or life-threatening causes exists. 2, 4
• Administer aspirin 160-325 mg (chewed) immediately unless contraindicated. 2, 4
• Provide sublingual nitroglycerin if systolic blood pressure >90 mmHg and heart rate 50-100 bpm. 4

If Cardiac Workup is Negative and Pattern is Catamenial

For Menstruation-Related Angina:

• Initiate hormonal therapy as first-line treatment: combined oral contraceptives or GnRH agonists to suppress menstrual cycling and stabilize estrogen levels. 3, 7, 8
• Add nitrates with β-blockers for symptomatic relief during episodes. 8
• Provide analgesics for pain management (note: NSAIDs do not relieve FMF-associated chest pain but may help dysmenorrhea). 8, 9
• Counsel on nonpharmacologic measures: exercise training, smoking cessation, weight loss, and dietary modifications. 8

For Thoracic Endometriosis Syndrome:

• Initiate hormonal suppression therapy (GnRH agonists or combined oral contraceptives) as mainstay of treatment. 6, 7
• Consider surgical intervention (ovarian cystectomy, chest tube placement for recurrent pneumothorax) if medical management fails. 6, 7
• Monitor monthly to assess treatment efficacy and disease progression. 6

Anemia Work-Up

Check complete blood count, iron studies, and ferritin in all women with menstruation-associated symptoms, as heavy menstrual bleeding from endometriosis or hormonal imbalance can cause anemia contributing to chest pain and body aches. 6

Critical Pitfalls to Avoid

• Never dismiss chest pain as "atypical" or noncardiac based solely on age, cyclical pattern, or accompanying symptoms—women are systematically underdiagnosed with ACS. 1, 5
• Do not rely on nitroglycerin response as diagnostic for cardiac ischemia, as esophageal spasm and other conditions also respond. 1, 4
• Do not confuse catamenial chest pain with dysmenorrhea—patients can differentiate FMF attacks or endometriosis-related chest pain from menstrual cramps, and these do not respond to NSAIDs alone. 9
• Recognize that angioplasty may fail to resolve menstruation-related angina, as the mechanism is hormonal/microvascular rather than obstructive coronary disease. 3
• In regions with high tuberculosis prevalence, TES may mimic pulmonary tuberculosis—the key differentiator is strict catamenial timing of symptoms. 6