THEME

Dysmenorrhoea
Pelvic pain

BACKGROUND
Menstruation has dual significance for women. From one perspective it defines the start and end of reproductive
potential, an affirmation of womanhood. On the other, just as the ancients observed taboos of menstruation, many
women (and men) today are still influenced by outdated negative messages.
OBJECTIVE
This article discusses an approach to assessment and management of dysmenorrhoea that considers the cultural, social
Sue Reddish and personal significance of symptoms and management choices.
MBBS, is a general practitioner
and Medical Director, The DISCUSSION
Jean Hailes Medical Centre for Cultural influences, such as a womans status within society, her life stage, religion, education and employment,
Womens Health, Victoria. sue. determine whether a woman seeks medical help for menstrual problems, and the personal significance of
[email protected] dysmenorrhoea. Assessment involves consideration of pain, associated symptoms, effect on lifestyle and activities
of daily living, and a psychosocial and cultural assessment. Management involves specific treatment of underlying
pathology, psychosocial support and individualising treatment according to impact of the pain, associated symptoms,
reproductive stage, cost, and the womans personal values and attitudes.

If one is born a woman, one must put up with pain. dysmenorrhoea was labelled a purely psychosomatic
Throughout history, menstruation has been viewed disorder. Benjamin Spock stated that: a worried attitude
as an inescapable burden that women must endure. about health and menstruation causes cramps 2 and,
Ancient cultures observed taboos of menstruation as recently as 1980, a gynaecology text stated the
derived from mans fear of the mysterious flow as a appropriate treatment is psychotherapy, but there is
powerful force that must be repressed for the safety little that can be done for the patient who prefers to
of the menstruating woman and all with whom she use her menstrual symptoms as a monthly refuge from
comes in contact. The ability to bleed and not die responsibility and participation.3
equalled control of life powers in some religions. A Today, menstruation has dual significance for women.
menstruating woman was isolated and confined, in From one perspective it defines the start and end of
often cruel ways, so that her deadly contagion would reproductive potential, an affirmation of womanhood,
not poison the earth, herself, and mankind. In several maturing, a time for celebration. In the television comedy
Asian and African cultures, women are still placed in We can be heroes a character celebrates her first
seclusion in menstrual huts. menstrual period with a party and a cake with red icing
and tampons around the edge. Having oral sex with a
It was not until the 1800s that medicine began to menstruating woman is an accepted practice to some
acknowledge the study of diseases peculiar to women. and described as a rainbow kiss or a dolmio grin. Many
In the Victorian era, menstruating women were advised women are reassured monthly that they are cleansing
to stay at home, rest, avoid exertion and bathing. 1 their bodies of old blood and toxins that would otherwise
The 1900s saw the use of narcotic drugs rendering build up inside their bodies and cause illness. In some
women nonfunctional at work, school and home for cultures menstruation positively defines a womans status
23 days per month. Young women were victims of and position in society.
radical surgery such as hysterectomy, oophorectomy On the other hand, just as the ancients observed
and presacral neurectomy. Then followed 50 years where taboos of menstruation, many women (and men) today

842 Reprinted from Australian Family Physician Vol. 35, No. 11, November 2006
are still influenced by outdated negative messages.
Table 1. Taking a history
Menstruation is still regarded by many women as an
unclean state and beliefs persist that encourage girls Pain assessment
to abstain from normal life activities such as bathing, severity
swimming and exercise. Tampons and sanitary pads cyclic versus noncyclic
are advertised as feminine hygiene products, implying chronic versus acute
that hygiene is the issue. Many women, their partners, relationship to menstruation
and their doctors still believe that period pain is all Associated symptoms
in the head. premenstrual syndrome
Belief systems also vary from culture to culture and menorrhagia
ignorance of culturally divergent beliefs may lead to failure migraine
in health care delivery. Under Islamic law, a menstruating dyspareunia
woman is not allowed to pray, fast during Ramadan, have nongynaecological symptoms urinary, bowel, musculoskeletal
sex or divorce. She is not allowed to touch the Koran Medication use medications trialled and with what success
unless it is a translation. A Hindu woman abstains from Family history endometriosis, gynaecological cancers
worship and cooking and stays away from her family, as Sexual history current/past relationships, sexual abuse, sexual partners,
her touch is considered impure when she is menstruating. exposure to STIs
The expression, tolerance and communication about pain Gynaecological history menarche, parity, contraception, IUD use, surgery
in general, varies across cultures and failure to vocalise Psychological assessment depression/anxiety symptoms, psychosomatic
pain does not mean a woman has a higher threshold disorders
For example, some Mediterranean cultures are outwardly Social assessment effect of symptoms on daily activities/work/sport/
social activities/relationships
expressive of pain; whereas the Chinese believe it is
Cultural assessment attitudes to menstruation
important to save face. In some religions, pain is valued as a
Significance of pain to the woman at this time in her life
pathway to heaven; in others it is viewed as a karmic return
for past misdeeds. Different belief systems also influence
attitudes to drugs and other methods of pain relief. There are of sympathy either by family members, employers, school
also clearly defined cultural influences which will determine or college authorities, or by the medical profession. Many
whether or not a woman will seek medical help for menstrual women, particularly teenagers, are embarrassed to discuss
problems, including her status within a particular society, her anything related to menstruation. Others dont believe there
religion, education and her employment. is any treatment and dont want to pay a doctors fee to be
told to rest, have a hot bath, use a hot water bottle or drink
Dysmenorrhoea herbal tea. They may not trust that their doctor or employer
Dysmenorrhoea is chronic, cyclic pelvic pain associated will consider menstrual pain a genuine problem and dont
with menstruation. Typically, it is cramping, lower want to bother the busy doctor with an irrelevant problem
abdominal pain occurring just before and/or during and be told that its all in your head.
menstruation, usually commencing soon after menarche Many women are unaware of the implications of
once regular ovulation is established. secondary dysmenorrhoea, the causes of which may
While our early ancestors may have experienced impact on fertility and propensity for invasive surgical
only 3040 menstrual cycles in their lifetime, the procedures in the future. The delay in diagnosis of
average western woman now experiences 400 menses endometriosis averages 47 years due to women and
during her reproductive life. As dysmenorrhoea doctors not recognising the possible significance of
affects approximately 90% of menstruating women, menstrual pain.4
this has the potential to create a significant health and
socioeconomic issue. However, the majority of women
Assessment
with dysmenorrhoea do not seek medical advice. When a woman presents for assessment of
Some deny the pain, and do not seek help even when dysmenorrhoea we must consider not just the womans
symptoms are severe and incapacitating. They may think presenting symptoms and possible underlying medical
it is normal and therefore their destiny to grin and bear causes, but also the effect the pain is having on her
it or that menstruation is a feminine function and should life, her life stage, and her cultural influences (Table 1).
not be medicalised. These factors will all impact on the significance that the
Sadly, dysmenorrhoea is seldom treated with any degree experience of dysmenorrhoea will have for her.

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 THEME Dysmenorrhoea

Table 2. Differentiating between primary and secondary dysmenorrhoea

Primary Secondary
Age Onset soon after menarche Onset at any age, sometimes after years of pain free menses
Increasing pain with increasing age
Cycle Before/during menstruation Not necessarily limited to menstruation
Usually worse day 1, seldom lasts more May increase in severity over the period and persist for days
than 4872 hours
Pattern Similar with each period Worsens with time
May be unilateral
May be worse with defecation, urination
May radiate to lower back and rectum
Associated symptoms PMS physical and emotional symptoms, Menorrhagia, irregular cycles, infertility, urinary retention,
nausea, vomiting, migraine, bloating cyclic haematuria, dysuria, diarrhoea, dyspareunia, vaginal
discharge
Pelvic exam Normal Tenderness
Adnexal mass
Fixed retroverted uterus
Cervical tenderness
May be normal
History Nil relevant Exposure to STIs
Intrauterine device (IUD)
Tampon use
Previous surgery
Sexual dysfunction
COCP Usually alleviates the pain Minimal improvement, if any
NSAIDs Usually alleviates the pain Minimal improvement, if any

Differential diagnosis and underlying causes undiagnosed endometriosis causing dysmenorrhoea and a
Secondary dysmenorrhoea, with demonstrable pelvic ruptured endometrioma.
pathology the most common being endometriosis Pain may be referred from other pelvic organs that
must be excluded before a diagnosis of primary share their innervation with the uterus, cervix, vagina
dysmenorrhoea (no pelvic pathology) is assumed. Often and ovaries from T1012, L1 and S24. The distribution
pelvic pathology can be confidently excluded on the of referred pain from the lower renal tract and the lower
basis of the history, examination and response to initial uterus/cervix is the same to the lower back, buttocks and
simple therapies alone without the need for invasive posterior thigh. Therefore, low back pain may be attributed
investigations (Table 2, 3). to a urinary tract or gynaecological problem. The presence
Other wise investigations including transvaginal of bowel symptoms may lead to a diagnosis of irritable
ultrasound and laparoscopy +/- hysteroscopy are bowel syndrome, chronic constipation, inflammatory bowel
warranted to confirm the diagnosis. Other laboratory and disease or diverticulitis.
X-ray investigations will only be necessary based on the
Associated symptoms
assessment of individual needs (Table 4).
Although the clinical picture of dysmenorrhoea is Dysmenorrhoea is often associated with other debilitating
often clear cut, differential diagnoses need to be actively symptoms that require specific management. These
considered. Sometimes disorders causing cyclic pain symptoms may be the womans prime reason for
may cause noncyclic pain and vice-versa. For example, presenting, and her most important concerns. Common
endometriosis may cause pain unrelated to menses. On associated symptoms include nausea, vomiting, diarrhoea
the other hand, the pain from pelvic inflammatory disease and fatigue. Dysmenorrhoea is more common in women
(PID) may be exacerbated during menstruation. A woman with premenstrual syndrome (PMS) and PMS symptoms
may first present with acute pain, having disregarded her may occur 114 days before a period. Physical and
chronic menstrual pain for many years. She may have psychological symptoms may in turn exacerbate the pain

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 THEME Dysmenorrhoea

Table 3. Possible causes of secondary dysmenorrhoea

Intrauterine Extrauterine Nongynaecological
Adenomyosis Endometriosis Psychosomatic disorders
Menorrhagia passing clots Pelvic inflammatory disease Depression
Endometrial carcinoma Ovarian carcinoma Irritable bowel syndrome
Fibroids Adhesions Chronic constipation
IUD Ectopic pregnancy Inflammatory bowel disease/diverticulitis
Miscarriage Retained tampon Musculoskeletal referred pain
Haematometra from congenital anomalies Renal calculi/urinary tract infection
Cervical stenosis

of dysmenorrhoea making it the straw that breaks the common presentation of somatisation disorder.5 Clues
camels back. Premenstrual dysphoric disorder (PMDD) from the history hinting at a psychosomatic component to
is a severe form of PMS where women may become dysmenorrhoea may include:
psychotic or homicidal. symptoms are described dramatically and emotionally,
Menstrual migraine may occur in the week before referred to as unbearable, beyond description, or
the period and can be debilitating, with some woman the worst imaginable
confined to bed for 23 days each month. Menorrhagia insistence for investigations, treatments and referral
may also cause significant social disability and may result to specialists
in iron deficiency anaemia with tiredness and lethargy. dissatisfaction with medical care, attending multiple
Dyspareunia will impact on libido, sexual function and may health practitioners
create relationship issues. multiple operations/procedures for pain without
significant findings
Effect on lifestyle
severity of the pain does not correlate with the
Beside the obvious physical concerns about underlying degree of pelvic tenderness
pelvic pathology, dysmenorrhoea can disrupt daily multiple other recurring persistent complaints for
activities, causing significant social disability. Pain may which no organic cause can be found
inconvenience a woman during holidays, social activities dependant, manipulative
or at times when high performance is required (eg. exams, frustration and anger with any suggestion that
sporting competitions, job interviews). Chronic recurrent symptoms are psychological.
pain causes absences from school or work and significant
Is there a history of sexual abuse?
cost to the health care system in medical consultations,
investigations and therapies prescribed. Victims of physical or sexual abuse may present with
chronic pelvic pain, including dysmenorrhoea. While many
Associated mood disorders
doctors do not routinely screen for sexual abuse, women
In addition to excluding underlying pelvic pathology as a with chronic pelvic pain must be asked whether they
cause of dysmenorrhoea, psychosocial issues must be have ever been touched by anyone against their will, as a
defined and assessed important from two aspects: child or as an adult. Obviously this type of inquiry requires
the effect of chronic pain on mood, and extreme sensitivity and compassion and relies on a strong
the effect of mood disorders and other psychiatric rapport and trusting doctor-patient relationship. Rarely
problems on pain. will disclosure come during initial consultations, but will
Coexisting mood disorders such as anxiety and depression require ongoing patience and time.
may exacerbate an individuals pain experience and/or Not only are women with a history of abuse more
chronic pain may cause or exacerbate an underlying mood likely to experience dysmenorrhoea, their pain causes
disorder. Anticipation of the pain of the next period creates significantly more psychological distress often with
additional stress and anxiety. associated depression, sexual dysfunction and
Psychosocial problems such as anxiety, depression, somatisation. It must also be remembered that victims
family and marital disharmony, drug and alcohol abuse, of sexual abuse may be re-traumatised during pelvic
physical and sexual abuse and sexual dysfunction may examinations and vaginal ultrasounds and these invasions
manifest as physical pain. Dysmenorrhoea is also a should be avoided until the woman is ready.

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Life stage Table 4. Investigation of pelvic pain

The significance of dysmenorrhoea and the management
of pain will vary according to a womans reproductive Transvaginal ultrasound Pelvic masses, ovarian cysts, uterine fibroids
and polyps, pelvic abscess, adenomyosis
stage. Teenagers may be embarrassed about discussing
Will not exclude a diagnosis of endometriosis
menstrual difficulties and may have concerns about body
image and modesty. The significance of dysmenorrhoea Laparoscopy Both diagnostic and therapeutic, particularly in
the management of endometriosis and where
to a teenager is likely to be related to the disruption
pain is of uncertain origin
of their studies, sport and social life. A consultation for
And where indicated
dysmenorrhoea may also provide a welcome opportunity
Hysteroscopy Defines intrauterine pathology and provides an
for the young person to discuss issues such as
endometrial tissue sample for histology
contraception and sexually transmitted infections (STIs)
Can be performed as an office procedure at
with or without parental blessing. The appropriateness
centres such as The Jean Hailes Medical Centre
of gynaecological examinations and procedures will for Women, eliminating the need for hospital
vary according to age and previous sexual activity. admission and anaesthesia
Investigation options may be restricted to abdominal Full blood examination To assess anaemia related to chronic
ultrasounds rather than the more accurate transvaginal menorrhagia, infection (PID)
scans. Parents may not be prepared to consider CA-125 Increased in endometriosis and other
management options such as the combined oral gynaecological conditions (ie. ovarian cancer)
contraceptive pill (COCP) for fear that their daughter may Cervical/vaginal swabs PID, choice of antibiotic
become complacent about sexually activity.
Mid stream urine To exclude urinary tract pathology
In the reproductive age group, dysmenorrhoea is more
Quantitative B-HCG To exclude pregnancy with miscarriage/ectopic
likely to be associated with abnormal vaginal bleeding
pregnancy
such as menorrhagia. Assessment and management will
Plain abdominal X-ray, To exclude bowel obstruction, renal calculi,
depend on the womans family planning. Fertility may be
IVP, abdo/pelvic CT scan pelvic masses
a priority. Lifestyle issues may be particularly relevant
to women at this age and they may be more conscious
of preventive health care and present for regular well and hormone therapy. Management options must
womans check,' an opportunity to discuss issues such as be individualised and discussed so that a woman can
pain. On the other hand, many women in this age group make informed decisions regarding her own health
tend to put their own personal health last as they are busy management (Table 5).
caring for children (and partners) while also working and/or Management of any underlying pelvic pathology such
managing the household. as endometriosis and PID may require a combination of
In the menopausal transition, cycles may be medical and surgical therapies.
unpredictable and variable, creating significant social
disability, particularly if cycles are shortened. Fluctuating
Management of associated symptoms
menopausal symptoms physical and psychological may By improving quality of life in general, tolerance to pain
impact on the tolerance of pain. Many women may be may be increased. This may include:
starting to consider their mortality and have a genuine alleviating symptoms of PMS
fear of cancer, particularly if any of their peers have been management of stress/anxiety/mood disorders
afflicted. Carcinoma must always be excluded. Fertility treatment of menorrhagia and accompanying iron
issues change in that, rather than wanting a pregnancy, deficiency anaemia
women dread the prospect of an accidental, unplanned relief of menstrual migraine.
pregnancy, which may affect management options.
Reassurance
Management It is important to reassure the woman that the pain she
Management options for dysmenorrhoea will depend on is experiencing is real and not in her head and that,
whether there is a pelvic disorder requiring treatment and although period pain is common and is experienced in
will vary considerably depending on the life stage, beliefs variable degrees of severity by the majority of healthy
and culture of the woman. Some management options menstruating women, this does not mean that it has
may resolve a number of issues, ie. the COCP may treat to be simply accepted and endured, particularly if it is
dysmenorrhoea, menorrhagia, provide contraception impacting on lifestyle and daily activities. She also needs

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 THEME Dysmenorrhoea

Table 5. Management considerations before the period commences. This may be impossible in a
perimenopausal woman whose cycles may be erratic and
Specific management of underlying pelvic pathology she is unable to predict the onset of menses. Nevertheless
Psychosocial support they are safe, effective, inexpensive, and only require
reassurance of normality intermittent use.
social, financial, emotional support
counselling relationship and sexual, assisted fertility, pre-hysterectomy Combined oral contraceptive pill
Individualise according to reproductive stage As dysmenorrhoea is mainly seen in ovulating women,
maintain fertility or family complete by rendering a woman anovulatory with the COCP,
requires reversible contraception dysmenorrhoea may be resolved. The COCP may have
requires cycle control for menorrhagia or erratic periods other benefits for women also managing issues such
prefers bleed free cycles or a monthly bleed as PMS, contraception, cycle control, menorrhagia and
Specific management of associated symptoms PMS, migraine, hormone therapy (albeit high dose).
menorrhagia, dyspareunia, menopausal symptoms
Even if this does not resolve the issue of pain, a
Compliance, cost and contraindications to medications
significant benefit of a monophasic pill is cycle control.
Attitude toward invasive options IUD, surgery Therefore a womans cycle can be manipulated
so that she can avoid menstruating at times that are
to be reassured that there are many effective management inconvenient to her (eg. holidays). An extension of this
options available to her. Once secondary causes have concept is the use of the COCP long cycle where women
been eliminated or adequately treated, this reassurance have the choice to have bleed free cycles. Occasional
may be all that is required if the degree of social disability breakthrough bleeding may be a nuisance but is
is minimal. easily manageable.
Rest, heat packs, massage, yoga, physical exercise and
Mirena intrauterine device
sexual intercourse may minimise menstrual pain.4 Pelvic
floor physiotherapy may be effective in the management Unfortunately many women abhor intrauterine devices
of chronic pelvic pain.6,7 Alcohol is also a uterine relaxant, (IUDs) due to the negative publicity surrounding the older
supporting my grandmothers remedy a glass of pure nonprogestagenic IUDs that often caused menorrhagia
gin for dysmenorrhoea in the 1940s. At the very least and increased dysmenorrhoea. Therefore, it is important
Mum enjoyed her pain! to dispel these misconceptions when differentiating
Lifestyle changes in general, where necessary, may between the modern progestagenic IUDs. By releasing
improve tolerance to pain by improving quality of life and progesterone locally and directly into the uterus, the
overall happiness. Mirena IUD has the following benefits:
provides effective and reversible contraception if
Psychosocial support
needed
Women may need assistance with the social, financial minimises, and in most cases eliminates, menstrual
and emotional consequences of missing school or bleeding (there may be unpredictable bleeding in the
exams, or sick leave (particularly with an unsympathetic first few months)
employer). Sexual and relationship counselling may be side effects are rare as the progesterone is acting
required if issues such as chronic pain and dyspareunia locally with minimal systemic absorption
impact on a womans relationship and libido. Some natural ovarian function is maintained (attractive
women may need counselling if conditions such as to many older women who do not want to disrupt
endometriosis or chronic PID have compromised their their hormones unnaturally with the OCP or resort
fertility. Other women find it difficult to cope with the to surgery)
concept of hysterectomy due to issues such as loss of is an economically attractive option now that it is
femininity and youth. available on the PBS and is effective for approximately
5 years
NSAIDs
for women in the menopausal transition who require
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as hormone therapy for relief of oestrogen deficiency
mefenamic acid and naproxen can be very effective alone symptoms, Mirena IUD eliminates the need for
in relieving dysmenorrhoea.8,9 However, for maximal benefit progestins (a common cause of side effects) and
it is necessary to commence them at least 48 hours provides effective contraception.1012

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 Dysmenorrhoea THEME

Surgery own health management. The pain of dysmenorrhoea

If medical forms of management are unsuccessful or is a function of complex interactions between various
unacceptable to the patient, then surgery is the only systems from the level of neurotransmitters to the level
other alternative. Invasive surgery would be an extreme of cultural values regarding pain experiences and the
management option for primary dysmenorrhoea alone, expression of pain.14 The significance of dysmenorrhoea
but is a valid option in many women for the management to an individual woman will vary according to her stage in
of secondary dysmenorrhoea due to underlying pelvic life or reproductive phase and the degree of socioeconomic
pathology or in those with associated debilitating disability she is experiencing at that time. Beliefs,
symptoms such as menorrhagia. The aim of surgery is to personality, emotions and circumstances affect both the
either remove a potential cause of pain or ablate or remove perception of pain and the response to treatment. While
the endometrium itself. Minimally invasive techniques have it is important not to medicalise menstruation, it is also
obvious advantages over conventional surgery in reducing important to exclude secondary causes of dysmenorrhoea
the length of hospital stay and postoperative recovery that may impair fertility and cause morbidity and mortality.
period and avoid the trauma and risks of major surgery and Equally important to a woman is the reassurance that
reducing health care costs. her menstrual distress is not being disregarded as
psychosomatic but that psychological elements may be
Endometrial ablation
components of the pain, rather than the cause. Isolation,
Endometrial ablation is a minimally invasive procedure suffering and incapacitation resulting in economic, social or
which significantly reduces or eliminates menstruation and personal disability are no longer necessary. Management
therefore dysmenorrhoea. In many cases the Mirena IUD involves empowering women to take an active role in
will provide the same effect without the need for surgery. their own health care and assisting them to make healthy
choices to best manage individual needs and concerns.
Hysterectomy
Conflict of interest: none declared.
Hysterectomy may be a welcome relief for a long time
sufferer of severe dysmenorrhoea who may prefer a References
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ine devices: a systematic review. Obstet Gynecol Sur 2002;57:1208.
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understood to enable health practitioners to challenge

myths and provide advice for a woman with dysmenorrhoea
CORRESPONDENCE email: [email protected]
thereby enabling her to make informed choices about her

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