Dysmenorrhea

Dysmenorrhea — painful menstruation — affects more than 50% of menstruating women; in fact, it's the leading cause of lost time from school and work among women of childbearing age. Dysmenorrhea may involve sharp, intermittent pain or dull, aching pain. It's usually characterized by mild to severe cramping or colicky pain in the pelvis or lower abdomen that may radiate to the thighs and lower sacrum. This pain may precede menstruation by several days or may accompany it. The pain gradually subsides as bleeding tapers off.

Dysmenorrhea may be idiopathic, as in premenstrual syndrome (PMS) and primary dysmenorrhea. It commonly results from endometriosis and other pelvic disorders. It may also result from structural abnormalities such as an imperforate hymen. Stress and poor health may aggravate dysmenorrhea; rest and mild exercise may relieve it.

History and physical examination

If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.

Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.

Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.

Medical causes

Adenomyosis.

In adenomyosis, endometrial tissue invades the myometrium, resulting in severe dysmenorrhea with pain radiating to the back or rectum, menorrhagia, and a symmetrically enlarged, globular uterus that's usually softer on palpation than a uterine myoma.

Cervical stenosis.

Cervical stenosis is a structural disorder that causes dysmenorrhea and scant or absent menstrual flow.

Endometriosis

Endometriosis typically produces steady, aching pain that begins before menses and peaks at the height of menstrual flow; however, the pain may also occur between menstrual periods. The pain may arise at the endometrial deposit site or may radiate to the perineum or rectum. Associated signs and symptoms include premenstrual spotting, dyspareunia, infertility, nausea and vomiting, painful defecation, and rectal bleeding and hematuria during menses. A tender, fixed adnexal mass is usually palpable on bimanual examination.

Pelvic inflammatory disease

Chronic infection produces dysmenorrhea accompanied by a fever; malaise; foul-smelling, purulent vaginal discharge; menorrhagia; dyspareunia; severe abdominal pain; nausea and vomiting; and diarrhea. A pelvic examination may reveal cervical motion tenderness and bilateral adnexal tenderness.

PMS

The cramping pain of PMS usually begins with menstrual flow and persists for several hours or days, diminishing with decreasing flow. Common associated effects precede menses by several days to 2 weeks: abdominal bloating, breast tenderness, palpitations, diaphoresis, flushing, depression, and irritability. Other findings include nausea, vomiting, diarrhea, and a headache. Because PMS usually follows an ovulatory cycle, it rarely occurs during the first 12 months of menses, which may be anovulatory.

Primary (idiopathic) dysmenorrhea

Increased prostaglandin secretion intensifies uterine contractions, apparently causing mild to severe spasmodic cramping pain in the lower abdomen, which radiates to the sacrum and inner thighs. The cramping abdominal pain peaks a few hours before menses. Patients may also experience nausea and vomiting, fatigue, diarrhea, and a headache.

Uterine leiomyomas

If these tumors twist or degenerate after circulatory occlusion or infection or if the uterus contracts in an attempt to expel them, the tumors may cause constant or intermittent lower abdominal pain that worsens with menses. Associated signs and symptoms include backache, constipation, menorrhagia, and urinary frequency or retention. Palpation may reveal the tumor mass and an enlarged uterus. The tumors are almost always nontender.

Other causes

Intrauterine devices (IUDs)

IUDs may cause severe cramping and heavy menstrual flow.

Special considerations

In the past, a woman with dysmenorrhea was considered neurotic. Although current research suggests that prostaglandins contribute to this symptom, old attitudes persist. Encourage the patient to view dysmenorrhea as a medical problem — not as a sign of maladjustment — and explain her treatment options. ( ">.)

Pediatric pointers

Dysmenorrhea is rare during the first year of menstruation, before the menstrual cycle becomes ovulatory. However, the incidence of dysmenorrhea is generally higher among adolescents than older women. Teach the adolescent about dysmenorrhea. Dispel myths about it, and inform her that it's a common medical problem. Encourage good hygiene, nutrition, and exercise.

Pictures

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Dysmenorrhea

Read excerpts from these other book chapters related to Dysmenorrhea:

Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Dysmenorrhea

• Back to symptom: Dysmenorrhea: Introduction (review 56 causes)
• Next Book Extract About Dysmenorrhea: Amenorrhea (A Pocket Manual of Differential Diagnosis)
• All Book Extracts: All Online Book Extracts for Dysmenorrhea

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

 » Next page: Amenorrhea (A Pocket Manual of Differential Diagnosis)

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