Evidence-Based Strategies for Common Clinical Questions
Author: Lauren Arney, MD | Resident of Pediatrics
Column Editor: Kathleen Berg, MD | Co-Director, Office of Evidence-Based Practice | Pediatric Hospitalist, Division of Pediatric Hospital Medicine | Associate Professor of Pediatrics, UMKC School of Medicine
Dysmenorrhea is experienced by 50%-90% of young women, with approximately half describing their pain as moderate to severe.1 An estimated 12% of women 14-20 years of age are in so much pain that they miss school or work each month.2 With the challenges already faced by many teens, the avoidable stress of recurrent pain should be addressed by pediatric providers. A targeted strategy should be used to identify, diagnose and treat dysmenorrhea to keep young women in school and living with less pain.
A detailed history is needed to distinguish primary dysmenorrhea (no pelvic pathology) from secondary dysmenorrhea (pelvic pathology or recognized medical condition).1-4 Privacy is key in this part of the history and physical, as it should include a complete sexual history to identify alternative diagnoses, such as pelvic inflammatory disease or pregnancy. Mental health should also be explored, as depression is commonly associated with dysmenorrhea.5 When asking about pain with periods, it is important to characterize onset and duration of pain. It is critical to know if pain causes missed school or other activities. While teens may find it difficult to report these details in person, they typically navigate their phones with ease. Therefore, suggesting the use of a period tracking app such as the Clue Period & Cycle app or the Sisterhood app can be helpful. Family history can also be important because endometriosis, the leading cause of secondary dysmenorrhea, has a hereditary link.6
Primary dysmenorrhea is diagnosed when no specific pelvic pathology is identified. However, it is helpful to share with women experiencing this pain that there is a direct correlation between dysmenorrhea and levels of inflammatory modulators. The level of prostaglandin factor 2a can be twice as high in the menstrual blood of those experiencing dysmenorrhea as compared to those without.5 Increased prostaglandins and leukotrienes cause increased myometrial contraction and vasoconstriction, increasing pain and cramping.1,2 This pathophysiology is best treated with nonsteroidal anti-inflammatory drugs (NSAIDs).1,2 As direct modulators of the inflammatory process, NSAIDs can be remarkably helpful at appropriate doses. In a meta-analysis of 35 trials, NSAIDs were effective and safe in treating primary dysmenorrhea.7 According to the American College of Obstetricians and Gynecologists Committee on Adolescent Health Care, ibuprofen should be given at 800 mg initially followed by 400-800 mg every eight hours as needed, starting one to two days before menses and then continuing two to three days into bleeding.2 Opioids are strongly discouraged due to risk of dependence and ineffectiveness at treating the underlying physiology of dysmenorrhea.
If NSAIDs prove ineffective at reducing pain to a manageable level, then hormonal agents such as oral contraceptive pills or long-acting reversible contraceptives should be added.1,2 Hormonal therapy should be considered in the initial treatment plan if women are already missing school or activities when first presenting with dysmenorrhea. Adjuvant therapies include heat, yoga, acupuncture and biofeedback.2,8 Smaller studies suggest that exercise is helpful in reducing dysmenorrhea with endorphins decreasing stress and increasing mood, and vasodilation reducing uterine contraction.9,10
Secondary dysmenorrhea should be considered in the following situations: 1) lack of improvement with NSAIDs and hormonal therapy after three to six months despite medication adherence, 2) severe pain immediately after menarche, 3) progressively worsening pain, 4) abnormal uterine bleeding, 5) family history of endometriosis, and 6) known congenital anomalies.2 The most common cause of secondary dysmenorrhea is endometriosis, characterized by endometrial glands and stroma outside the uterine cavity.1,2 Two-thirds of adolescents diagnosed with endometriosis as adults had symptoms starting in their teen years.3 This disease has significant impact on an adolescent’s quality of life.11 Pelvic exam and ultrasound may identify reproductive tract anomalies, but are of little value in diagnosing endometriosis. Referral to pediatric gynecology for endoscopy with biopsy may be needed.2
Dysmenorrhea is a common adolescent diagnosis that deserves careful history taking, evidence-based treatment, and close follow-up. The underlying pathophysiology of elevated pro-inflammatory modulators indicates NSAIDs as the most appropriate first-line treatment. Hormonal therapy may also be needed. If these therapeutic interventions are ineffective, secondary dysmenorrhea, particularly endometriosis, should be considered, and referral to pediatric gynecology is recommended.
- Kho KA, Shields JK. Diagnosis and management of primary dysmenorrhea. JAMA. 2020;323(3):268-269. doi:10.1001/jama.2019.16921
- ACOG Committee Opinion No. 760: dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018;132(6):e249-e258. doi:10.1097/AOG.0000000000002978
- Sachedina A, Todd N. Dysmenorrhea, endometriosis and chronic pelvic pain in adolescents. J Clin Res Pediatr Endocrinol. 2020;12(Suppl 1):7-17. doi:10.4274/jcrpe.galenos.2019.2019.S0217
- Shim JY, Laufer MR. Adolescent endometriosis: an update. J Pediatr Adolesc Gynecol. 2020;33(2):112-119. doi:10.1016/j.jpag.2019.11.011
- Damle LF, Gomez-Lobo V. Pelvic pain in adolescents. J Pediatr Adolesc Gynecol. 2011;24(3):172-5. doi:10.1016/j.jpag.2011.02.002. PMID: 21751453.
- Hirsch M, Dhillon-Smith R, Cutner AS, Yap M, Creighton SM. The prevalence of endometriosis in adolescents with pelvic pain: a systematic review. J Pediatr Adolesc Gynecol. 2020;33(6):623-630. doi:10.1016/j.jpag.2020.07.011
- Nie W, Xu P, Hao C, Chen Y, Yin Y, Wang L. Efficacy and safety of over-the-counter analgesics for primary dysmenorrhea: a network meta-analysis. Medicine (Baltimore). 2020;99(19):e19881. doi:10.1097/MD.0000000000019881
- Potur DC, Kömürcü N. The effects of local low-dose heat application on dysmenorrhea. J Pediatr Adolesc Gynecol. 2014;27(4):216-221. doi:10.1016/j.jpag.2013.11.003
- Daley AJ. Exercise and primary dysmenorrhea: a comprehensive and critical review of the literature. Sports Med. 2008;38(8):659-670. doi:10.2165/00007256-200838080-00004
- Kannan P, Chapple CM, Miller D, Claydon-Mueller L, Baxter GD. Effectiveness of a treadmill-based aerobic exercise intervention on pain, daily functioning, and quality of life in women with primary dysmenorrhea: a randomized controlled trial. Contemp Clin Trials. 2019;81:80-86. doi:10.1016/j.cct.2019.05.004
- Gallagher JS, DiVasta AD, Vitonis AF, Sarda V, Laufer MR, Missmer SA. The impact of endometriosis on quality of life in adolescents. J Adolesc Health. 2018;63(6):766-772. doi:10.1016/j.jadohealth.2018.06.027