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Primary dysmenorrhea in adolescents
Author
Chantay Banikarim, MD, MPH

Section Editors
Amy B Middleman, MD, MPH, MS Ed
Mitchell Geffner, MD

Deputy Editor
Alison G Hoppin, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2014. | This topic last updated: Oct 02, 2013.
INTRODUCTION Primary dysmenorrhea refers to recurrent, crampy lower abdominal pain that occurs during
menstruation in the absence of pelvic pathology. It is the most common gynecologic complaint among adolescent
females. Secondary dysmenorrhea refers to painful menstruation in the presence of pelvic pathology. It is more common
among women in the fourth and fifth decades of life.
The diagnosis and treatment of primary dysmenorrhea in adolescents will be discussed in this topic review. Treatment of
primary dysmenorrhea in adult women is reviewed separately. (See "Treatment of primary dysmenorrhea in adult
women".)
CLINICAL MANIFESTATIONS Nausea, vomiting, diarrhea, headache, dizziness, or back pain may accompany the
crampy abdominal pain. The pain and associated symptoms typically begin several hours prior to the onset of
menstruation and continue for one to three days. The severity of the disorder can be categorized by a grading system
based upon the degree of menstrual pain, presence of systemic symptoms, and impact on daily activities (table 1) [1].
EPIDEMIOLOGY Dysmenorrhea generally does not occur until ovulatory menstrual cycles are established.
Maturation of the hypothalamic-pituitary-gonadal axis leading to ovulation occurs at different rates; approximately 18 to
45 percent of teens have ovulatory cycles two years postmenarche, 45 to 70 percent by two to four years, and 80
percent by four to five years [2]. Dysmenorrhea occasionally accompanies anovulatory cycles, especially if heavy
bleeding and clots are present. (See "Physiology of the normal menstrual cycle".)
The prevalence of dysmenorrhea among adolescent females ranges from 60 to 93 percent [3-6]. Many adolescents
report limitations on daily activities, such as missing school, sporting events, and other social activities, because of
dysmenorrhea [4-7]. However, only 15 percent of females seek medical advice for menstrual pain, signifying the
importance of screening all adolescent females for dysmenorrhea [5].
MECHANISMS Dysmenorrhea appears to be caused by excess production of endometrial prostaglandin (PG) F2
alpha or an elevated PGF2 alpha:PGE2 ratio. Excessive levels of endometrial, but not plasma, PGE2 and PGF2 alpha
have been detected in women with primary dysmenorrhea [8]. These compounds can cause dysrhythmic uterine
contractions, hypercontractility, and increased uterine muscle tone leading to uterine ischemia. They also can account
for nausea, vomiting, and diarrhea via stimulation of the gastrointestinal tract. The role of prostaglandins in the
pathogenesis of primary dysmenorrhea is supported by the observation that nonsteroidal antiinflammatory drugs
(NSAIDS) (ie, prostaglandin synthetase inhibitors) often alleviate the symptoms of primary dysmenorrhea [9-13]. (See
'Treatment' below.)
APPROACH TO THE PATIENT The evaluation of an adolescent female presenting with menstrual cramps begins
with a complete medical and menstrual history to exclude secondary causes of dysmenorrhea.
History A complete history should include the following information:
Age at menarche
Duration of menstrual cycles

Interval between menstrual periods (from first day of one period to the first day of the following period)
Date of last two menstrual periods
Onset and duration of cramps
Presence or absence of nausea, vomiting, diarrhea, back pain, dizziness, or headache during menstruation
Severity of symptoms (ie, the impact of symptoms on daily activities such as school attendance, sports
participation, and other social activities)
Medication use Type, dose, timing in relation to the onset of cramps and perceived effectiveness in terms of
pain relief and ability to engage in all daily activities
Sexual history Current sexual activity, type of contraception, history of sexually transmitted diseases, and
history of pelvic inflammatory disease
Typical symptoms Typical features of primary dysmenorrhea are menstrual pain that is crampy or dull and
localized to the lower quadrants of the abdomen. There may be associated nausea, vomiting, diarrhea, fatigue, back
pain, headache, or dizziness. The pain and related discomforts typically occur at the onset of or a few days prior to the
onset of menstruation, persist for one to three days, and are of variable severity.
Differential diagnosis These historical features can help distinguish primary dysmenorrhea from secondary
disease (table 2) and from other disorders. As examples:
A history of painful menses occurring at menarche is unlikely to be primary dysmenorrhea, because most females
are anovulatory for several months to several years after menarche. The presence of pelvic pain unrelated to
menses also suggests secondary dysmenorrhea.
Menstrual pain that has become progressively worse over time is characteristic of endometriosis, which may
present as cyclic or noncyclic pain. (See "Diagnosis and treatment of endometriosis in adolescents".)
Adolescents who have had pelvic infections (eg, gonorrhea, chlamydia) may develop adhesions that result in
pelvic pain, especially during menstruation. (See "Clinical features and diagnosis of pelvic inflammatory disease".)
Physical examination A pelvic examination should be performed in all females with significant symptoms to exclude
the causes of secondary dysmenorrhea. An internal pelvic examination may be deferred in young, nonsexually active
adolescents with only mild menstrual cramps.
DIAGNOSIS A clinical diagnosis of primary dysmenorrhea can be made if the characteristic clinical symptoms
develop in an ovulatory adolescent and the pelvic examination is normal. Primary dysmenorrhea is diagnosed after the
causes of secondary dysmenorrhea (ie, painful menstruation in the presence of pelvic pathology) have been excluded.
TREATMENT The severity of menstrual pain and limitation of daily activities will help guide treatment decisions (table
1). General measures for therapy include patient reassurance and education.
First line treatment NSAIDs are considered the first line of therapy [14-16]. In randomized trials of NSAIDs,
approximately 70 to 90 percent of patients have effective pain relief (table 3), a value that is greater than that with
placebo [9-13,17,18]. NSAIDs are also generally more effective than acetaminophen for treatment of dysmenorrhea.
NSAIDs should be started at the onset of menses and continued for the first one to two days of the menstrual cycle or for
the usual duration of crampy pain. Patients with severe symptoms should begin taking NSAIDs one to two days prior to
the onset of menses. They should be taken with food to minimize side effects such as gastrointestinal irritation or
bleeding. Generally, we use NSAIDs that are COX-1 inhibitors, because of the uterotonic effects reported with COX-2
inhibitors and possible associations with serious adverse events. (See "Nonselective NSAIDs: Overview of adverse
effects".)
Because of observed variations in patient response that may result in part from the pharmacodynamics of a particular
drug, the current thought is that if a patient fails an NSAID of one class, the substitution of an NSAID of a different class
is a reasonable therapeutic option. Ibuprofen and naproxen are used commonly for the treatment of dysmenorrhea in

clinical practice. Mefenamic acid is unique in that it both inhibits prostaglandin synthetase and blocks the action of the
prostaglandins that are already formed [19]. A trial of mefenamic acid should be considered for patients who do not
respond to the propionic acid group of medications.
Second line treatment Combination oral contraceptive pills (OCPs) can be given to patients who fail to respond to or
cannot tolerate NSAIDs [20]. OCPs prevent menstrual pain by suppressing ovulation, thereby decreasing uterine
prostaglandin levels. An additional mechanism may result from the reduction of menstrual flow after several months of
use. Randomized trials in adults and adolescents demonstrate moderate efficacy in pain relief [20,21]. The efficacy of
OCPs for primary dysmenorrhea has not been directly compared to NSAIDs. (See "Treatment of primary dysmenorrhea
in adult women", section on 'Hormonal contraception'.)
In a sexually active female, OCPs may be considered for first line of therapy because they serve a dual purpose:
prevention of both pregnancy and dysmenorrhea. (See "Overview of the use of estrogen-progestin contraceptives".)
Treatment failure If treatment with one of these modalities (ie, NSAIDS or hormonal contraception) fails after two or
three menstrual cycles, we suggest a course of treatment with the other modality. Treatment with both hormonal
contraceptives and NSAIDs may be effective in women who remain symptomatic on either drug alone.
FOLLOW-UP Patients should be followed closely for the first few months after treatment is initiated to evaluate the
response and compliance to therapy. Adolescents who fail to respond to first or second line treatments, have recurrent
pain, or have symptoms that worsen should be reevaluated for the causes of secondary dysmenorrhea (table 2) [16].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond
the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and
the keyword(s) of interest.)
Basics topics (see "Patient information: Painful periods (The Basics)")
Beyond the Basics topics (see "Patient information: Painful menstrual periods (dysmenorrhea) (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
Primary dysmenorrhea (PD) refers to recurrent, crampy lower abdominal pain that occurs during menstruation in
the absence of pelvic pathology. Nausea, vomiting, diarrhea, headache, dizziness, or back pain may accompany
the crampy abdominal pain. (See 'Clinical manifestations' above.)
The evaluation includes a directed medical history and complete menstrual history to exclude secondary causes
of dysmenorrhea (table 2). Features that suggest a cause other than PD include pelvic pain that began at
menarche, pelvic pain unrelated to menses, progressively worsening pain, or a history of pelvic infection. (See
'History' above.)
A pelvic examination should be performed to exclude the causes of secondary dysmenorrhea in all females with
significant symptoms. An internal pelvic examination may be deferred in young, nonsexually active adolescents
with only mild menstrual cramps. (See 'Physical examination' above.)
The severity of menstrual symptoms and limitation of daily activities will help guide treatment decisions (table 1).
For adolescents with PD who require treatment, nonsteroidal anti-inflammatory drugs (NSAIDs) and combination

estrogen-progestin contraceptives are the mainstays of treatment. (See 'Treatment' above.)

For those who choose not to or should not use hormonal contraception, we suggest a trial of treatment with a
NSAID (Grade 2B). Ibuprofen and naproxen are used commonly for the treatment of dysmenorrhea in clinical
practice (table 3). (See 'First line treatment' above.)
For those who desire contraception, or for those who do not respond to or do not tolerate NSAIDs, we
suggest treatment with a combination estrogen-progestin contraceptive (Grade 2C). (See 'Second line
treatment' above.)
If treatment with one of these modalities fails, we suggest a course of treatment with the other modality
(Grade 2C). Treatment with both hormonal contraceptives and NSAIDs may be effective in women who
remain symptomatic on either drug alone.
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Topic 5847 Version 7.0

GRAPHICS
Verbal multidimensional scoring system for assessment of
dysmenorrhea
Grade
Grade 0: Menstruation is not painful and daily activity

Working

Systemic

ability

symptoms

Analgesics

Unaffected

None

None required

Rarely
affected

None

Rarely
required

Grade 2: Daily activity is affected; analgesics required

Moderately

Few

Required

and give sufficient relief so that absence from school is

affected
Apparent

Poor effect

is unaffected
Grade 1: Menstruation is painful but seldom inhibits
normal activity; analgesics are seldom required; mild
pain

unusual; moderate pain

Grade 3: Activity clearly inhibited; poor effect of

Clearly

analgesics; vegetative symptoms (headache, fatigue,

vomiting, and diarrhea); severe pain

inhibited

Adapted from Andersch, B, Milsom, I, Am J Obstet Gynecol 1982; 144:655.

Graphic 65347 Version 1.0

Causes of secondary dysmenorrhea

Gynecologic
Endometriosis
Adenomyosis
Fibroids
Ovarian cysts
Intrauterine or pelvic adhesions
Chronic pelvic inflammatory disease
Obstructive endometrial polyps
Congenital obstructive mllerian malformations
Cervical stenosis
Use of an intrauterine contraceptive device
Pelvic congestion syndrome

Nongynecologic
Inflammatory bowel disease
Irritable bowel syndrome
Uteropelvic junction obstruction
Psychogenic disorders
Graphic 78903 Version 3.0

Suggested dosages for medical therapy of dysmenorrhea

Drug

Initial dose, mg

Subsequent dose in mg, as needed

Acetic acids (Type I)

Indomethacin

25

25 tid

Tolmetin

400

400 tid

Sulindac

200

200 bid

Diflunisal

1000

500 every 12 h

Diclofenac

75

75 bid

Etodolac

400

400 every 6-8 h (maximum dose 1200 mg/24 h)

Ketoralac

10

10 every 4-6 h (maximum dose 40 mg/24 h)

Propionic acids (Type I)

Ibuprofen

400

400 every 6 h

Naproxen

500

250 every 6-8 h (maximum dose 1250 mg/24 h)

Naproxen sodium

550

275 every 6-8 h

Fenoprofen calcium

200

200 every 4-6 h

Ketoprofen

75

75 tid

Mefenamic acid

500

250 every 4 h

Meclofenamate

100

50-100 every 6 h

20

20 once a day

Fenamates (Type I)

Oxicans (Type II)

Piroxicam

bid: twice a day; tid: three times a day.

Adapted from Smith, R. Obstet Gynecol Clin North Am 1993; 761.
Graphic 71912 Version 1.0