Dysmenorrhea (Menstrual Cramps)

8.01 Dysmenorrhea (Menstrual Cramps)

Presentation
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.