By Rebecca Bowers

EXECUTIVE SUMMARY

The American College Of Obstetricians And Gynecologists Has Issued A New Committee Opinion Designed To Help Clinicians Aid Patients In Managing Symptoms Of Dysmenorrhea Effectively So That Women May Continue Everyday Activities With Minimal Disruption.

  • Dysmenorrhea represents the most common menstrual symptom among teen girls and young women, with a prevalence of 50-90%.
  • Primary dysmenorrhea is painful menstruation without other pelvic disease. Dysmenorrhea may involve symptoms such as nausea, vomiting, diarrhea, headaches, and muscle cramps. With secondary dysmenorrhea, painful menstruation is caused by a recognized medical condition or disease.

Dysmenorrhea represents the most common menstrual symptom among teen girls and young women, with a prevalence of 50-90%.1 How can clinicians best diagnose and treat this condition?

The American College of Obstetricians and Gynecologists has issued a new committee opinion designed to help clinicians aid patients in managing their symptoms effectively and continuing everyday activities with minimal disruption.2

Dysmenorrhea is divided into two categories: primary and secondary. Primary dysmenorrhea is painful menstruation without another pelvic disease. With primary dysmenorrhea, excessive levels of prostaglandins cause intense cramping and discomfort, leading to menstrual pain. Most adolescents present with primary dysmenorrhea. Dysmenorrhea may involve symptoms such as nausea, vomiting, diarrhea, headaches, and muscle cramps.

With secondary dysmenorrhea, a recognized medical condition or disease causes the painful menstruation. Endometriosis is the most common cause of secondary dysmenorrhea. However, secondary dysmenorrhea also can occur with adenomyosis, infection, myomas, reproductive tract obstructions, congenital malformations, and ovarian cysts.2

No matter the cause of dysmenorrhea, the condition has a profound effect on patients’ lives, especially adolescents, says Geri Hewitt, MD, a general obstetrician/gynecologist and professor in the Department of Obstetrics and Gynecology at The Ohio State University Wexner Medical Center in Worthington, OH.

“It is the leading cause of recurrent short-term absences from school for adolescent girls, to the detriment of their learning and socializing,” said Hewitt, author of the committee opinion, in a press statement. “By quickly identifying and diagnosing dysmenorrhea, [clinicians] can help relieve patients’ pain and enable them to resume normal order in their lives.”

Evaluating Primary Dysmenorrhea in Teens

How should clinicians approach an initial evaluation of primary dysmenorrhea in teen patients? As with all patients presenting with dysmenorrhea, be prepared to evaluate the patient’s medical, gynecologic, menstrual, family, and psychosocial history to assess whether the patient is experiencing primary dysmenorrhea or whether the symptoms may indicate secondary dysmenorrhea. If a patient exhibits symptoms suggestive only of primary dysmenorrhea, then a pelvic examination is not necessary. If the patient has sexually transmitted infection symptoms, then a pelvic examination is warranted.

Anita Nelson, MD, professor and chair, Obstetrics and Gynecology, Western University of Health Sciences in Pomona, CA, advises that it is important to remember that symptoms of primary dysmenorrhea often do not develop until a young woman’s cycles become ovulatory.

“So, just because she does not have painful cramping from the time of her first period, she may still have primary dysmenorrhea that should respond well to medical therapies,” notes Nelson.

When should clinicians suspect secondary dysmenorrhea? Symptoms include:

  • severe dysmenorrhea that occurs immediately after menarche or dysmenorrhea that worsens over time;
  • uterine bleeding that is abnormal (heavy and/or irregular bleeding);
  • pain that occurs mid-cycle or that is acyclic;
  • lack of response to medical treatment; or
  • family history of endometriosis.2

Clinicians should be cognizant of cultural differences in attitudes regarding menstruation that may affect patients’ comfort with discussing menstruation symptoms. Parental modeling of pain response and discussions may affect young patients’ reports and perceptions of pain and anxiety about experiencing pain.3

Understand Treatment Options

What are the treatment options for primary dysmenorrhea? Consider nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen sodium, and mefenamic acid, as a first-line treatment option. These drugs disrupt cyclooxygenase-mediated prostaglandin production. They have been shown to relieve primary dysmenorrhea pain better than placebo.

Patient education about the use of NSAIDs is essential, since data indicate that many adolescents with dysmenorrhea self-direct their medication use, leading to subtherapeutic treatment.4 Informing school personnel about a student’s need to take medication during school may be necessary, so be prepared to provide authorization to use medication for dysmenorrhea during the school day.

NSAIDs are effective for primary dysmenorrhea when initiated one to two days before menses begin and continuing for the first two to three days of bleeding.5 Advise patients to take the medication with food and increase fluid intake to ease possible adverse gastrointestinal and renal effects. If one NSAID does not provide relief, consider switching to an alternative NSAID.

How about hormonal agents? If NSAIDs do not relieve dysmenorrhea symptoms, clinicians can opt for hormonal agents, which also are considered a first-line option. If needed, NSAIDs may be continued or used in addition to hormonal therapy. Which hormonal agents may work best? Options to consider include a combination oral contraceptive, a contraceptive patch or vaginal ring, a single-rod contraceptive progestin implant, depot medroxyprogesterone acetate (intramuscular or sub-cutaneous), and a levonorgestrel intrauterine device.2

If a patient’s dysmenorrhea does not clinically improve within three to six months of treatment initiation, clinicians should be prepared to perform more a comprehensive evaluation of chronic pelvic pain. A more extensive assessment includes a history and focused physical examination for potential causes of pain that may be gastroenterologic, urologic, musculoskeletal, or psychosocial.

A pelvic examination may detect conditions such as endometriosis, an obstructed reproductive tract, uterine enlargement or irregular shape, friability or discharge of the cervix (indicative of pelvic inflammatory disease), pelvic masses, vaginismus, or other disorders of the pelvic floor. Consider using pelvic imaging with ultrasonography to evaluate for secondary dysmenorrhea. For initial imaging, ultrasonography is the most appropriate option for teasing out possible causes of secondary dysmenorrhea, such as uterine myomas, obstructive reproductive tract anomalies, and adnexal masses with endometriomas.6

Endometriosis Affects Teens

The most common cause of secondary dysmenorrhea in teens is endometriosis.2 Patients who continue to have persistent and significant dysmenorrhea following treatment with hormonal agents and NSAIDs should be evaluated for endometriosis, especially if no other cause for the chronic pelvic pain or secondary dysmenorrhea has been identified. A family history of endometriosis can play a role. Research indicates that patients have a seven-fold to 10-fold increased risk of developing endometriosis if they have a first-degree relative who is affected by it.7

The key goals of endometriosis treatment include relieving symptoms, suppressing disease progression, and protecting future fertility. Because endometriosis can present differently in teen patients than in adults, the new guidance details key differences in symptoms.2

What approaches can clinicians take when treating endometriosis in teens? The new guidance describes diagnosis and treatment with conservative surgical therapy, combined with continued medical therapies to prevent proliferation of the endometrium. Since some patients may have recurrent pain following conservative surgical treatment and hormone therapy, consider GnRH agonists such as leuprolide acetate as an appropriate additional treatment.

“Endometriosis is a chronic condition, and it’s important that we address immediate and long-term treatments and considerations with adolescents,” stated Hewitt. “This includes having education about the disease available to patients and their families, as well as encouraging or assisting in identifying complementary therapies, such as acupuncture, that may help with management of symptoms over time.” 

REFERENCES

  1. Al-Jefout M, Nawaiseh N. Continuous norethisterone acetate versus cyclical drospirenone 3 mg/ethinyl estradiol 20 μg for the management of primary dysmenorrhea in young adult women. J Pediatr Adolesc Gynecol 2016;29:143-147.
  2. ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol 2018;132:1517-1518.
  3. Boerner KE, Chambers CT, McGrath PJ, et al. The effect of parental modeling on child pain responses: The role of parent and child sex.
    J Pain 2017;18:702-715.
  4. Zannoni L, Giorgi M, Spagnolo E, et al. Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents. J Pediatr Adolesc Gynecol 2014;27:258-265.
  5. Harel Z. Dysmenorrhea in adolescents and young adults: An update on pharmacological treatments and management strategies. Expert Opin Pharmacother 2012;13:2157-2170.
  6. Eskenazi B, Warner M, Bonsignore L, et al. Validation study of nonsurgical diagnosis of endometriosis. Fertil Steril 2001;76:929-935.
  7. Malinak LR, Buttram VC Jr, Elias S, Simpson JL. Heritage aspects of endometriosis. II. Clinical characteristics of familial endometriosis. Am J Obstet Gynecol 1980;137:332-337.