A young woman complains of crampy, labor-like pains which began before the visible bleeding of her menstrual period. The pain is focused in the lower abdomen, low back, suprapubic area or thighs, and may be associated with nausea, vomiting, increased defecation, headache, muscular cramps, and passage of clots. The pain is most severe on the first day of the menses, and may last from several hours to several days. Often, this is a recurrent problem, dating back to the first year after menarche. Rectal, vaginal and pelvic examination disclose nothing abnormal.
What to do:
Ask about the duration of symptoms and onset of
similar episodes (onset of dysmenorrhea after
menarche suggests other pelvic pathology). Ask
about appetite, diarrhea, dysuria, dyspareunia and
other symptoms suggestive of other pelvic
pathology.
Perform a thorough abdominal and speculum and
bimanual pelvic examination, looking for signs of
infection, pregnancy, or uterine or adnexal
disease.
Confirm that the patient is not pregnant with a
urine pregnancy test (or serum beta hCG if
available stat).
For uncomplicated dysmenorrhea, try nonsteroidal
antiinflammatory medications such as ibuprofen
(Motrin) 600-800mg, indomethacin (Indocin) 50mg,
or naproxen (Naprosyn) 500mg po initially,
tapering to maintenance doses (half the loading
dose q6h).
Arrange for workup of endometriosis or other
underlying causes and suggest aspirin or oral
contraceptives for prophylaxis.
What not to do:
Do not treat acute dysmenorrhea with aspirin
alone. Aspirin begun three days before the period,
650mg qid, is effective prophylaxis, but it is not
as good once symptoms exist.
Discussion
Prostaglandins E and F in menstrual blood appear
to stimulate uterine hyperactivity, and thus many
of the symptoms of dysmenorrhea.
