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Dysmenorrhea in adult females: Clinical features and diagnosis

Dysmenorrhea in adult females: Clinical features and diagnosis
Authors:
Roger P Smith, MD
Andrew M Kaunitz, MD
Section Editor:
Robert L Barbieri, MD
Deputy Editor:
Kristen Eckler, MD, FACOG
Literature review current through: Dec 2022. | This topic last updated: Nov 02, 2022.

INTRODUCTION — Dysmenorrhea, or painful menstruation, is a common problem experienced by females in their reproductive years. Dysmenorrhea can be a primary process or secondary to other pelvic pathology. When severe, in addition to impairing quality of life, it interferes with the performance of daily activities, often leading to absenteeism or decreased productivity involving school, work, and other responsibilities.

This topic will review the clinical manifestations, diagnostic evaluation, and diagnosis of dysmenorrhea in adult females. Related content on the treatment of dysmenorrhea in adults and primary dysmenorrhea in adolescents can be found separately.

(See "Dysmenorrhea in adult females: Treatment".)

(See "Primary dysmenorrhea in adolescents".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

TERMINOLOGY — For clinical purposes, dysmenorrhea is divided into two broad categories, primary and secondary:

Primary dysmenorrhea refers to the presence of recurrent, crampy, lower abdominal pain that occurs during menses in the absence of demonstrable disease that could account for these symptoms. The diagnosis of primary dysmenorrhea, which is one of exclusion, is made more often in adolescents and young females.

Secondary dysmenorrhea refers to the same pain symptoms but occurs in females with a disorder that could account for their symptoms, such as endometriosis, adenomyosis, or uterine fibroids. Females with these diseases often have clinical features that separate them from primary dysmenorrhea, including an enlarged uterus, pain with intercourse, and resistance to effective treatments. (See "Dysmenorrhea in adult females: Treatment".)

EPIDEMIOLOGY AND PHYSIOLOGY

Prevalence and impact — In surveys, 50 to 90 percent of reproductive-age women worldwide describe experiencing painful menstrual periods [1-12]. The majority of these patients are young and have primary dysmenorrhea. The prevalence of primary dysmenorrhea decreases with advancing age while secondary dysmenorrhea tends to develop later in life [13]. As dysmenorrhea affects younger females, the impact on school attendance and work productivity is significant. School absenteeism rates of 10 to 20 percent or more have been reported globally [3,10,14-16]. An internet-based survey of over 32,000 Dutch women ages 15 to 45 years reported mean work absenteeism of 1.3 days per year with a mean reduction of productivity of 23.2 days per year. The study did not differentiate between primary and secondary dysmenorrhea [17]. Dysmenorrhea is underdiagnosed and undertreated, which underscores the importance of clinicians being proactive in inquiring regarding this prevalent condition.

Risk factors — Risk factors associated with dysmenorrhea include younger age (particularly adolescents), smoking, and stress [11,18]. There appears to be a (small) familial predisposition to primary dysmenorrhea [11,19]. Risk reduction is associated with younger age at first childbirth, higher parity, and use of hormonal contraceptives [11].

Pathogenesis — Prostaglandins released from endometrial sloughing at the beginning of menses play a major role in inducing uterine contractions [20-22]. These contractions are nonrhythmic or incoordinate, occur at a high frequency (more than four or five per 10 minutes), often begin from an elevated basal tone (more than 10 mmHg), and result in high intrauterine pressures (frequently more than 150 to 180 mmHg, sometimes exceeding 400 mmHg) [20]. When uterine pressure exceeds arterial pressure, uterine ischemia develops, and anaerobic metabolites accumulate, which stimulate type C pain neurons resulting in dysmenorrhea. Activation of stretch receptors likely also play a role in the perception of pain.

This hypothesis is supported by multiple lines of evidence:

Endometrial concentrations of prostaglandin E2 and prostaglandin F2 alpha in menstrual fluid and endometrial tissue are elevated in patients with primary dysmenorrhea and correlate with the severity of pain [23-25].

Doppler studies show that individuals with primary dysmenorrhea have elevated uterine artery Doppler indices (ie, higher resistance to blood flow in the uterine arteries) during menses compared with those without dysmenorrhea [26,27].

Individuals with primary dysmenorrhea treated with nonsteroidal anti-inflammatory drugs note an improvement in symptoms over time in parallel with the decrease in intrauterine pressure/contractility (figure 1) and menstrual fluid prostaglandin levels [22,23,28,29].

CLINICAL FEATURES

Presentation — Recurrent, crampy, lower abdominal pain that occurs during menses can develop at any time during the patient's reproductive years. Primary dysmenorrhea typically begins during adolescence, after ovulatory cycles first become established. Maturation of the hypothalamic-pituitary-gonadal axis leading to ovulation occurs at different rates; approximately 18 to 45 percent of adolescents have ovulatory cycles two years postmenarche, 45 to 70 percent by two to four years, and 80 percent by four to five years [30]. As secondary dysmenorrhea is menstrual pain resulting from another process, the symptom onset typically occurs later in life and correlates with the development of the underlying pathology, such as endometriosis, adenomyosis, or leiomyoma.

(See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Clinical features'.)

(See "Uterine adenomyosis".)

(See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history".)

Patients with dysmenorrhea typically describe the following pain characteristics:

Timing – The pain typically starts one to two days before or with the onset of menstrual bleeding and then gradually diminishes over 12 to 72 hours. It is recurrent, occurring in most, if not all, menstrual cycles. The pain is usually crampy and intermittently intense but may be a continuous dull ache.

Location – It is usually confined to the lower abdomen and suprapubic area. Although the pain is usually strongest in the midline, some patients also have severe back and/or thigh pain. Non-midline pain, especially if unilateral, suggests a uterine anomaly or alternative diagnosis [31,32].

Severity – The severity of the pain ranges from mild to severe (table 1) [6]. When Canadian researchers interviewed a random sample of 934 women ≥18 years old with primary dysmenorrhea, 60 percent described their pain as moderate or severe, 50 percent reported limiting their activity, and 17 percent reported missing school or work because of dysmenorrhea [5]. A later review of 15 studies found that 2 to 29 percent of the women studied reported severe pain [11].

Additional symptoms – Nausea, diarrhea, fatigue, headache, and a general sense of malaise often accompany the pain.

Natural history — Primary dysmenorrhea tends to improve with advancing age and often improves after childbirth [33], though the effect of childbirth independent of other factors remains weak. By contrast, secondary dysmenorrhea tends to begin later in life, worsens over time, and improves with treatment or resolution of the underlying etiology [34].

DIAGNOSTIC EVALUATION — As primary dysmenorrhea is a clinical diagnosis of exclusion, evaluation should, in general, include a detailed history and physical examination to look for signs and symptoms suggestive of pelvic pathologies, such as pelvic inflammatory disease (PID), endometriosis, adenomyosis, or fibroids. Laboratory tests, imaging studies, and laparoscopy are performed, as indicated, if pelvic disease is suspected and/or clinical response to initial treatment with nonsteroidal anti-inflammatory drugs (NSAIDs)/hormonal contraception is inadequate.

History — We use the history to confirm the presence or absence of symptoms suggestive of dysmenorrhea and then evaluate for possible causes of secondary dysmenorrhea.

Initial questions to help identify dysmenorrhea and possible contributors include:

Menstrual history – We ask about the onset of menarche, the beginning of symptoms in relation to menarche, and the relationship of pain to the current menstrual cycle. Patients with primary dysmenorrhea tend to be younger, closer in age to menarche, and often have had pain with menses that started within the first year after menarche. We also inquire about duration of menstrual bleeding and interval between pain and onset of flow.

Timing of pain – Dysmenorrhea is characterized by pain that begins just prior to or with the onset of menstrual flow and typically resolves within 12 to 72 hours. Pain that is constant, waxes and wanes throughout the cycle, or is not related to the timing of menses is unlikely to be dysmenorrhea.

Characteristics and severity of pain – The pain of dysmenorrhea is typically crampy, midline lower abdominal or suprapubic pain. Patients may also describe pain radiating to the lower back or thighs. While pain severity does not confirm or exclude dysmenorrhea, it is helpful to understand the symptom's impact on the patient's daily activities and quality of life. Grading dysmenorrhea according to the severity of pain and limitation of daily activities may help the clinician understand the severity of the patient's symptoms and resultant reduction in function beyond the information gained from the history alone, although comparative data are not available (table 1). (See "Dysmenorrhea in adult females: Treatment".)

Associated symptoms – Patients with dysmenorrhea often report nausea, diarrhea, fatigue, headache, and a general sense of malaise that accompany the pain. These symptoms suggest that underlying prostaglandin production represents the cause of dysmenorrhea. (See 'Pathogenesis' above.)

Sexual history – A sexual history helps the clinician understand patient contraceptive needs as well as risk factors for sexually transmitted infections and PID, which can result in secondary dysmenorrhea.

Past medical history – We ask about other medical conditions, chronic pain syndromes, and mental health disorders. We also inquire about patient safety, as current or past abuse can worsen symptoms.

Prior treatments – We ask if, and what, the patient has tried to relieve her symptoms. Pain that responds to NSAIDs or hormonal contraception is suggestive of dysmenorrhea, although approximately 20 percent of patients with dysmenorrhea do not improve with NSAID therapy [35].

The following history suggests the presence of pelvic pathology consistent with secondary dysmenorrhea:

Onset of dysmenorrhea after age 25. However, endometriosis may occur in adolescents (see "Endometriosis in adolescents: Diagnosis and treatment"), and a congenital uterine outlet obstruction can cause dysmenorrhea shortly after menarche.

Abnormal uterine bleeding (eg, heavy menstrual bleeding, irregular/infrequent bleeding, or intermenstrual bleeding).

Non-midline pelvic pain.

Absence of nausea, vomiting, diarrhea, back pain, dizziness, or headache during menstruation.

Presence of dyspareunia or dyschezia.

Progression in symptom severity.

Physical examination — Physical examination is typically performed in adult patients. In non-sexually active adolescents in whom the history suggests primary dysmenorrhea and in patients who do not report abnormal uterine bleeding or symptoms suggestive of infection, pelvic examination does not need to be performed unless symptoms fail to respond to treatment. (See "Primary dysmenorrhea in adolescents".)

For patients with primary dysmenorrhea, there are no associated physical findings, and the pelvic examination is normal. Individuals with secondary dysmenorrhea more typically have pelvic examination findings suggestive of the underlying pathology, although the pelvic examination can also be normal.

Approximately 40 percent of women with secondary dysmenorrhea due to endometriosis have physical findings on pelvic examination that suggest the presence of pelvic disease [36-38] (see "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Physical examination'):

Uterosacral ligament abnormalities, such as nodularity, thickening, or focal tenderness

Lateral displacement of the cervix due to asymmetric involvement of one uterosacral ligament by endometriosis, causing it to shorten (figure 2)

Cervical stenosis

Adnexal enlargement from an endometrioma

Adenomyosis may be associated with a bulky, globular, mildly tender uterus. (See "Uterine adenomyosis".)

Fibroids typically result in an enlarged, irregularly shaped, nontender uterus, which may also be palpable abdominally. (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Physical examination'.)

Findings in PID include [39] (see "Pelvic inflammatory disease: Clinical manifestations and diagnosis"):

Purulent endocervical discharge

Acute cervical motion and adnexal tenderness

Oral temperature >101°F (>38°C)

Cervical or vaginal anomalies increase the likelihood of a congenital obstructed uterine abnormality, such as a rudimentary uterine horn. (See "Benign cervical lesions and congenital anomalies of the cervix".)

Vulvar varices may occur in pelvic congestion syndrome. (See "Vulvovaginal varicosities and pelvic congestion syndrome".)

Laboratory testing — Primary dysmenorrhea is not associated with any laboratory abnormalities or abnormal findings on imaging studies. If secondary dysmenorrhea is suspected, then laboratory testing targeted at the presumed underlying etiology is performed. Possible tests may include:

Testing for gonorrhea and chlamydia should be performed in all sexually active patients as well as in patients suspected of having cervicitis or PID.

(See "Acute cervicitis", section on 'Diagnostic evaluation'.)

(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Point-of-care and laboratory tests'.)

Urine testing for urinary tract infection. (See "Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults".)

Imaging — For patients with primary dysmenorrhea, there are no definitive imaging studies or diagnostic abnormalities. Routine ultrasound imaging is not required in a nonobese patient who has an unremarkable pelvic examination, as it is unlikely to be abnormal. However, as transvaginal ultrasonography is commonly available and reasonably inexpensive, many patients undergo pelvic ultrasonography to exclude underlying pathology even if the physical examination is unremarkable. Transvaginal ultrasonography examination is the appropriate initial imaging choice for patients in whom an underlying anatomic abnormality is suspected by history (ie, secondary dysmenorrhea) or physical examination and cannot be confirmed by other clinical means. Transvaginal ultrasonography can be useful in patients with obesity if the physical examination is limited by body habitus. For patients in whom transvaginal ultrasonography may not be acceptable, such as younger adolescents, transabdominal imaging can be performed, although the diagnostic utility may be lower. For such patients, performing transabdominal pelvic sonography instead of a bimanual examination to exclude pelvic pathology is appropriate if the clinical history is atypical or initial treatment does not reduce symptoms. (See "Primary dysmenorrhea in adolescents".)

Transvaginal ultrasonography is highly sensitive for detecting adnexal masses (eg, endometrioma, ovarian cyst, abscess, ovarian neoplasia, hydrosalpinges), leiomyoma (ie, fibroids), and uterine anomalies but only moderately sensitive for diagnosis of adenomyosis. Pelvic ultrasonography has limited ability to identify small endometriotic implants.

(See "Approach to the patient with an adnexal mass", section on 'Role of additional imaging'.)

(See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging and endoscopy'.)

(See "Uterine adenomyosis", section on 'Imaging'.)

(See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Imaging'.)

In the setting of dysmenorrhea, magnetic resonance imaging (MRI) or computed tomography have limited roles. Preoperative MRI may be useful when myomectomy is planned or if there is concern for underlying anomaly of the reproductive tract.

(See "Congenital uterine anomalies: Clinical manifestations and diagnosis".)

(See "Congenital anomalies of the hymen and vagina".)

Role of laparoscopy — Diagnostic laparoscopy is rarely required because the cause of dysmenorrhea can almost always be determined by history and physical examination and supplemented by imaging studies when indicated. Laparoscopy has a role in diagnosis and treatment of endometriosis and chronic pelvic pain, but the timing of laparoscopy depends on several factors, including the age of the woman, symptom response to empiric therapy, and fertility desires.

(See "Endometriosis: Clinical features, evaluation, and diagnosis", section on 'Diagnosis'.)

(See "Chronic pelvic pain in adult females: Evaluation", section on 'Role of laparoscopy'.)

DIAGNOSIS

Primary dysmenorrhea — Primary dysmenorrhea is a clinical diagnosis made in patients who experience recurrent, crampy, midline, pelvic pain that starts just before or with the onset of menstrual bleeding and then gradually diminishes over 12 to 72 hours and who have no evidence of other disorders that could account for the pain. Symptoms are similar from one menstrual cycle to the next. The diagnosis of primary dysmenorrhea is made when all other potential etiologies, including those that cause secondary dysmenorrhea, have been excluded.

Secondary dysmenorrhea — If an underlying etiology for dysmenorrhea is identified, then the diagnosis becomes secondary dysmenorrhea. Gynecologic processes that can cause secondary dysmenorrhea are included in the table (table 2).

Indications for urgent evaluation and treatment — For patients in whom an underlying gynecologic cause is suspected or diagnosed, processes that warrant immediate evaluation and treatment, with referral as needed, include:

Pelvic inflammatory disease (PID) and/or tubo-ovarian abscess – PID is most common in women 15 to 25 years of age [40,41]. It is characterized by lower abdominal pain, which is usually bilateral and ranges from mild to severe [42]. In contrast with the recurrent menstrual pain of dysmenorrhea, the onset of pain is often during or shortly after menses and may worsen during coitus or with jarring movement [43]. Abnormal uterine bleeding occurs in one-third or more of patients [44]. New vaginal discharge, urethritis, fever, and chills can be associated signs but are neither sensitive nor specific for the diagnosis. Tubo-ovarian abscess, which is often a complication of PID, generally has a similar presentation. These patients require timely treatment with antibiotics at a minimum.

(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)

(See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

(See "Management and complications of tubo-ovarian abscess".)

Anomalies of the reproductive tract – Structural abnormalities of the uterus, vagina, and hymen that partially obstruct menstrual flow can present with severe dysmenorrhea soon after menarche and typically by age 30 [45-48]. Pain may also occur pre- and post-menses. Physical examination may detect a tender mass on the uterus. Imaging studies are useful for diagnosis. These patients require diagnosis and possible surgical intervention to relieve obstruction (eg, hematometra), if present.

(See "Congenital uterine anomalies: Clinical manifestations and diagnosis".)

(See "Congenital anomalies of the hymen and vagina".)

Nonurgent causes

Endometriosis – While the prevalence varies with the population being studied, approximately 10 percent of reproductive-aged women globally have endometriosis, and it is one of the most common gynecologic causes of secondary dysmenorrhea [49-51]. Individuals with endometriosis typically report pelvic pain that is both related to menses and occurs at times other than menses. They may have premenstrual spotting, dyspareunia, dyschezia, poor relief of symptoms with nonsteroidal anti-inflammatory drugs, progressively worsening symptoms, and the inability to attend work or school during menses. (See "Endometriosis: Pathogenesis, epidemiology, and clinical impact".)

Adenomyosis – Persons with adenomyosis typically present with dysmenorrhea after age 35 years, while women with primary dysmenorrhea typically develop symptoms before 25 years of age. The pain associated with adenomyosis is often limited to menses, but noncyclic chronic pelvic pain also occurs. Heavy menstrual bleeding is also typically present. While the definitive diagnosis of adenomyosis is histologic, transvaginal ultrasonography or magnetic resonance imaging may suggest this condition. (See "Uterine adenomyosis".)

Leiomyoma (fibroids) – Leiomyomas are rare in adolescents but become common by age 35 [52]. Dyspareunia, bulk symptoms, and noncyclic pelvic pain are more common manifestations of leiomyoma-related pain than is dysmenorrhea, which is usually mild [53]. In individuals with symptomatic uterine leiomyoma, worsening dysmenorrhea is characteristically accompanied by increasing menstrual flow (heavy menstrual bleeding). (See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history".)

Hematometra – Hematometra should be suspected in a patient with a history of an endometrial ablation or other uterine surgery who presents with amenorrhea and cyclic crampy pain, even remote from the procedure. (See "Overview of endometrial ablation".)

DIFFERENTIAL DIAGNOSIS — As dysmenorrhea is recurrent, crampy, lower abdominal pain that occurs during menses, the differential diagnosis includes any process or abnormality that can create or contribute to such pain. Identifying features that suggest dysmenorrhea include the recurrent nature of the pain and timing relative to menses, in addition to the pain itself.

Obstetric causes – The combination of crampy pelvic pain and uterine bleeding is also characteristic of pregnancy loss (miscarriage) and ectopic pregnancy. These disorders should be suspected in a woman with new onset of pain and recent menstrual irregularity and are readily excluded by a negative pregnancy test.

(See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

Chronic pelvic pain syndromes – There are many causes of chronic pelvic pain that can overlap with menses (table 3 and table 4). Patients with chronic pelvic pain syndromes typically describe pain that persists throughout the menstrual cycle, although it may worsen with menses.

(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

(See "Chronic pelvic pain in adult females: Evaluation".)

Urologic – Patients with urinary tract infection, bladder pain syndrome/interstitial cystitis, or ureteral/bladder stones may have crampy midline pain. However, the pain generally has no relation to menses, is not recurrent, and is accompanied by other identifying symptoms related to voiding, such as dysuria or bladder discomfort. Symptoms of bladder pain syndrome/interstitial cystitis may worsen in the luteal phase of the cycle.

(See "Acute simple cystitis in females".)

(See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

(See "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis".)

Gastrointestinal – Gastrointestinal causes of crampy pelvic pain can include appendicitis, irritable bowel disease, inflammatory bowel disease, diverticulitis, or infectious colitis, among others. While the crampy pain may occur with menses, these patients typically have more pronounced gastrointestinal symptoms such as diffuse abdominal pain or diarrhea; additional symptoms suggesting a gastrointestinal cause of pain including fever, nausea, or vomiting; and persistence of symptoms beyond the duration of menses.

(See "Causes of abdominal pain in adults".)

(See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

(See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults".)

(See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)

(See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults".)

(See "Clinical presentation and diagnosis of inflammatory bowel disease in children".)

RESOURCES FOR PATIENTS AND CLINICIANS

American College of Obstetricians and Gynecologists (ACOG) Frequently Asked Questions on Dysmenorrhea

Society of Obstetricians and Gynaecologists of Canada (SOGC) YourPeriod

North American Society for Pediatric and Adolescent Gynecology (NASPAG) patient handout on painful periods

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dysmenorrhea".)

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 education: Painful periods (The Basics)")

Beyond the Basics topics (see "Patient education: Painful menstrual periods (dysmenorrhea) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – For clinical purposes, dysmenorrhea is divided into two broad categories, primary and secondary:

Primary – Primary dysmenorrhea is characterized by recurrent, crampy, midline lower abdominal pain that occurs during menses in the absence of other etiology. The pain is a result intense uterine contractions that causes uterine ischemia. Prostaglandins release from the endometrium at the beginning of menses and are a major cause of these contractions. (See 'Terminology' above and 'Pathogenesis' above.)

Secondary – Secondary dysmenorrhea is the occurrence of painful menses in the presence of a disease that could account for the pain (table 2). (See 'Terminology' above.)

Clinical features – Pain begins with the onset of menses and gradually diminishes over 12 to 72 hours. Additional symptoms that may be present include nausea, diarrhea, fatigue, headache, and a general sense of malaise. Primary dysmenorrhea tends to improve with advancing age, while secondary dysmenorrhea tends to begin later in life, worsens over time, and improves with treatment or resolution of the underlying etiology. (See 'Clinical features' above.)

Diagnostic evaluation – Evaluation includes a detailed history and physical examination to look for signs and symptoms suggestive of pelvic pathologies, such as pelvic inflammatory disease, endometriosis, adenomyosis, or fibroids. Laboratory tests, imaging studies, and laparoscopy are performed as indicated. (See 'Diagnostic evaluation' above.)

Diagnosis

Primary – Primary dysmenorrhea is a clinical diagnosis made in females who experience recurrent, crampy, midline, pelvic pain that starts just before or with the onset of menstrual bleeding and then gradually diminishes over 12 to 72 hours and who have no evidence of other disorders that could account for the pain. (See 'Primary dysmenorrhea' above.)

Secondary – Secondary dysmenorrhea is the presence of the same symptoms but in response to an underlying causative disorder. (See 'Secondary dysmenorrhea' above.)

Differential diagnosis – The differential diagnosis includes any process or abnormality that can create pain with menses. Identifying features that suggest dysmenorrhea include the recurrent nature of the pain and timing relative to menses in addition to the pain itself. The diagnosis of primary dysmenorrhea is made when other potential etiologies have been excluded. Thus, if an underlying etiology for dysmenorrhea is identified, then the diagnosis becomes secondary dysmenorrhea. (See 'Differential diagnosis' above.)

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Topic 5483 Version 35.0

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