Adolescent Medicine Case Synopsis: Dysmenorrhea
Heather Needham, MD, MPH, FAAP
Case: M.G. is a 15 year old female who presents to your office with a complaint of painful menstrual cycles. She had menarche at age 12 years, and has been getting a period regularly once a month for the past 18 months. Her periods last six days and are extremely painful the first 2 days of her period. It is not uncommon for her to miss one or two days of school every month due to her cramps when she is on her period. M.G. has tried Motrin for her pain with minimal resolution of her symptoms. She never has pain at times other than during her menstrual cycle, and she has never been sexually active.
Primary dysmenorrhea is the most common gynecological complaint in adolescent females. It is defined as recurrent crampy lower abdominal pain during menses and is not associated with pelvic pathology. Typically, adolescent females will start to experience menstrual cramps 1-3 years after menarche. The cramping can start within the first few hours of menses and is usually the most severe for the first 24-48 hours. Some adolescents may experience cramping 24-48 hours prior to the start of their cycle. Menstrual cramps can often be associated with nausea, vomiting, diarrhea, back pain, and fatigue.
Dysmenorrhea usually does not begin until the menstrual cycle becomes ovulatory. It is caused by an increased production of prostaglandins from the endometrium which can cause an increase in uterine contractility and dysrhythmic contractions. The increased levels of prostaglandins can also cause the systemic symptoms of nausea, vomiting, and diarrhea. Non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen and naproxen work well as a first line treatment because they have analgesic and anti-inflammatory properties, and also are prostaglandin synthetase inhibitors which help to reduce the production of prostaglandins.
The diagnosis of primary dysmenorrhea is made by taking a complete medical and menstrual history to rule out secondary dysmenorrhea as a cause for menstrual cramping. Some important information to gather while obtaining the history would include the following:
• age of menarche
• number of days of cycle and length of time between cycles
• age at onset of cramping
• number of days of cramping during cycle
• other symptoms associated with the cramping (nausea, vomiting, diarrhea, headache, or back pain)
• severity of cramping (missing school or other scheduled activities)
• Sexual activity (sexual history should be obtained without parents present)
It is also helpful to assess if the patient has tried any type of pain meds in the past and whether or not it was helpful. It is important to obtain the above information to exclude painful menstrual cycles due to pelvic pathology, such as endometriosis or a sexually transmitted infection. Clues that a patient may have secondary dysmenorrhea include cramps with the onset of menarche; persistent pelvic pain not related to the menstrual cycle; pain that is progressively worsening; and a history of having a pelvic infection such as gonorrhea or chlamydia.
Treatment of menstrual cramps often includes NSAIDs. If NSAIDs are not effective, combination contraceptive methods such as oral contraceptive pills, ortho-evra, or nuvaring are often utilized to suppress ovulation, which will subsequently reduce the production of endometrial prostaglandins. Another important aspect of treatment is education. In particular, discussing the importance of taking an adequate dose of an NSAID, and if they are prescribed a hormonal contraceptive method taking it regularly in order to get the maximum benefits. The goal of treatment is to reduce menstrual cramps and some of the associated symptoms, and decrease the impact of pain on daily activities such as attending school.