Dysmenorrhea

Dysmenorrhea is defined as pain and cramping during menstruation that interferes with normal activities and requires over-the-counter or prescription medication. Mild pain during menses is normal. Discomfor during menstruation ranges from mild discomfort to severe pain that causes some patients to be bedridden. Fifty percent of menstruating women suffer from dysmenorrhea and 10% of these are incapacitated for 1 to 3 days each month.

Dysmenorrhea is clssified as primary or secondary. Primary dysmenorrhea is idiopathic menstrual pain without identifiable pathology; secondary dysmenorrhea is painful menses due to underlying pathology ( endometriosis, fibroids, adenomyosis, PID, cervical stenosis).

Primary Dysmenorrhea

Primary dysmenorrhea usually occurs before age 20. Because primary dysmenorrhea is almost always associated with ovulatory cycles, it is usually diagnosed in late teens rather than at menarche when cycles are often anovulatory. although there is no obvious organic cause, primary dysmenorrhea is thought to result from increased levels of endometrial prostaglandin production derived from the arachidonic acid pathway. Additionally, there may be a psychological component involved for some patients that depends onn attitudes toward menstruation learned from mothers, sisters, and friends.

Secondary Dysmenorrhea

Secondary dysmenorrhea implies that the symptoms are secondary to an identifiable cause such as endometriosis and adenomyosis, uterine fibroids, cervical stenosis, or pelvic adhesions. 

Cervical Stenosis

Cervical stenosis causes dysmenorrhea by obstructing blood flow during menstruation. The stenosis can be congenital or secondary to scarring from infection, trauma, or surgery. Patients often complain of scant menses associated with severe cramping pain that is relieved with increased menstrual flow. On physical examination there may be obvious scarring of the external os; often the clinician is unable to pass a uterine sound through the cervical canal.

Pelvic adhesions

Patients with a history of pelvic infections including cervicitis, pelvic inflammatory disease, or tubo-ovarian abscess may have symptoms of dysmenorrhea secondary to adhesion formation. Patients with other local inflammatory disease or prior pelvic surgery may also have adhesions leading to dysmenorrhea. If a patient has a history of any of htese problems and reports pain associated with movement or activity, pelvic adhesions should be suspected. In some patients, pelvic adhesions can be so extensive as to "cement" the uterus into a fixed position, which may be noted on pelvic examination. Adhesions are not visible using traditional imaging modalities such as pelvic ultrasound, MRI, or CT.