History

Fact Explanation
Crampy pelvic pain maximally occuring just before or at onset of menstruation, lasting one to three days. [1][4][5] This is typical of primary dysmenorrhea, begins in adolescence. These do not have an underlying organic cause.[1] [4]
Crampy abdominal pain, outlasting menstruation (starts before menstruation and lasts for days after it has subsided, pain gets worse with menstruation and reaches a peak) with other associated symptoms pointing towards organic pathology.[1] [4][5] This is known as secondary dysmenorrhea and onset of this could be at any age. [1][4]
Affected activities of daily living. [1] Dysmenorrhea is a leading cause of absenteeism. [1]
Dyspareunia. [2] Endometriosis, pelvic inflammatory disease are associated with both dyspareunia and dysmenorrhea. [2]
Subfertility. [2] Endometriosis, due to adhesions, has reduced fertilization, implantation, and oocyte production resulting in subfertility as well as dysmenorrhea. [2]
Abnormal vaginal discharge [3] May indicate pelvic inflammatory disease(PID). But dysmenorrhea associated with PID is usually mild. [3]
Fever with or without chills [3] May indicate PID. [3]
Dysuria [3] May indicate PID. [3]
Postcoital bleeding [3] May indicate PID. [3]
Abnormal uterine bleeding. These can be seen in endometriosis and pelvic inflammatory disease.[2][3] Excessive bleeding itself is a risk factor for dysmennorhea due to clot colic (crampy uterine contraction to propel the clot out of the uterine cavity.) [4]
Smoking [1] This is a known risk factor for dysmenorrhea. [1]
Early menarche [1] This is a known risk factor for dysmenorrhea. [1]
Parity [6][7] Nulliparity is a known risk factor for endometriosis whereas women who have given birth to at least one child are at higher risk of developing adenomyosis than in nulliparous women. [6][7]
References
  1. LATTHE Pallavi, CHAMPANERIA Rita, KHAN Khalid Dysmenorrhea [online] Clinical Evidence Handbook BMJ, Am Fam Physician. 2012 Feb 15;85(4):386-387 Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0215/p386.html
  2. MOUNSEY L Anne, WILGUS Alex, SLAWSON C David Diagnosis and Management of Endometriosis [online] Am Fam Physician. 2006 Aug 15;74(4):594-600. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2006/0815/p594.html
  3. GRADISON Margaret, Pelvic Inflammatory Disease [online] Am Fam Physician. 2012 Apr 15;85(8):791-796. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0415/p791.html
  4. FRENCH Linda Dysmenorrhea [online] Am Fam Physician. 2005 Jan 15;71(2):285-291. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2005/0115/p285.html
  5. American Congress Obstetricians and Gynecologists. Frequently asked questions. Gynecological problem Dysmenorrhea [online] FAQ046, July 2012 Viewed on: 19/08/2014 Available from: http://www.acog.org/Patients/FAQs/Dysmenorrhea
  6. PARAZZINI F, FERRARONI M, FEDELE L, BOCCIOLONE L, RUBESSA S, RICCARDI A Pelvic endometriosis: reproductive and menstrual risk factors at different stages in Lombardy, northern Italy. [online] J Epidemiol Community Health. Feb 1995; 49(1): 61–64. Viewed on: 19/08/2014 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060076/
  7. TRABERT Britton, WIESS S Noel, RUDRA B Carole, SCHOLES Delia, HOLT L Victoria. A case-control investigation of adenomyosis: impact of control group selection on risk factor strength [online] Womens Health Issues. 2011 Mar–Apr; 21(2): 160–164. Published online Jan 26, 2011. doi: 10.1016/j.whi.2010.09.005 Viewed on: 19/08/2014 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052973/#!po=86.3636

Examination

Fact Explanation
Abdominal distension [2] May indicate large fibroid
Palpable abdominal lump arising from pelvis [2] Confined mass indicate fibroid [2]
Bimanual pelvic examination showing a fixed and retroverted uterus with tender adnexal/ posterior fornix masses and tenderness on moving the uterus [1] These are common findings of endometriosis. [1]
Bimanual pelvic examination exhibiting cervical motion tenderness along with uterine and adenexial tenderness without nodules [2] These symptoms indicate pelvic inflammatory disease. [2]
Bimanual pelvic examination showing uniformly enlarged uterus Indicative of adenomyosis.
Speculum examination revealing distorted cervix in a patient with history of past surgery [4] Indicate cervical stenosis [4]
Speculum examination revealing double cervix/ vagina [3] Indicates uterus didelphys [3]
References
  1. MOUNSEY L Anne, WILGUS Alex, SLAWSON C David Diagnosis and Management of Endometriosis [online] Am Fam Physician. 2006 Aug 15;74(4):594-600. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2006/0815/p594.html
  2. GRADISON Margaret, Pelvic Inflammatory Disease [online] Am Fam Physician. 2012 Apr 15;85(8):791-796. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0415/p791.html
  3. ALI Khairy Mohammed, ABDELBADEE Yehia Ahmed, El-KARMIN Abd Sherif, SHAZLY Mohammed, ABBASAhmed Mohammed Uterus didelphys with multiple fibroids: A case report [online] Proceedings in Obstetrics and Gynecology, 2013; 3(2):3 Viewed on: 19/08/2014 Available from: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1190&context=pog
  4. THOMAS Santosh, ROY Priyankur, BISWAS Bivas, JOSE Ruby. Complete Cervical Stenosis Following Cesarean Section & VVF Repair [online] J Obstet Gynaecol India. Dec 2012; 62(Suppl 1): 49–51. Published online Mar 12, 2013. doi: 10.1007/s13224-013-0380-8 Viewed on: 19/08/2014 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3632691/

Differential Diagnoses

Fact Explanation
Primary dysmenorrhea [1] This is not associated with underlying organic causes and usually begins at adolescence. The crampy abdominal pain starts with menstruation and last 8 to 72 hours. [1]
Secondary dysmenorrhea: Endometriosis, Adenomyosis, Chronic pelvic inflammatory disease, Fibroids, Ovarian cyst, Cervical stenosis, Uterus didelphys [1][2] Secondary dysmenorrhea is dysmenorrhea with underlying organic causes, it can begin at any age of woman. [1] Uterus didelphys is presence of double uterus due to non fusion of mullerian ducts [2]
References
  1. LATTHE Pallavi, CHAMPANERIA Rita, KHAN Khalid Dysmenorrhea [online] Clinical Evidence Handbook BMJ, Am Fam Physician. 2012 Feb 15;85(4):386-387 Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0215/p386.html
  2. ALI Khairy Mohammed, ABDELBADEE Yehia Ahmed, El-KARMIN Abd Sherif, SHAZLY Mohammed, ABBASAhmed Mohammed Uterus didelphys with multiple fibroids: A case report [online] Proceedings in Obstetrics and Gynecology, 2013; 3(2):3 Viewed on: 19/08/2014 Available from: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1190&context=pog

Investigations - for Diagnosis

Fact Explanation
Transvaginal ultrasonography(TVS) [1] Endometriomas in retroperitoneal or uterosacral regions can be diagnosed with TVS but peritoneal and small endometriomas maybe missed. [1] Changes of pelvic inflammatory disease maybe seen. [2]
Pelvic MRI (Magnetic Resonance Imaging) [1] May show changes of endometriosis, but not entirely reliable for this; ovarian cysts, fibroid masses will be visualised. [1] Thick, fluid-filled fallopian tubes maybe visualised in cases of pelvic inflammatory disease. [2]
Laparoscopy [1] This is the preferred method of diagnosis for endometriosis and pelvic inflammatory disease. [1][2]
Serum cancer antigen 125 (CA 125) [1] CA 125 will be elevated in endometriosis, though this is non specific, it is used in patients with subfertility to identify patients with severe endometriosis who will benefit from early surgical intervention. [1]
Endometrial biopsy [2] Histopathological establishment of endometritis may indicate pelvic inflammatory disease. [2]
Infection screening with vaginal or endocervical swab [2] Saline microscopy or nucleic acid amplification tests can be done to identify pelvic inflammatory disease [2]
References
  1. MOUNSEY L Anne, WILGUS Alex, SLAWSON C David Diagnosis and Management of Endometriosis [online] Am Fam Physician. 2006 Aug 15;74(4):594-600. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2006/0815/p594.html
  2. GRADISON Margaret, Pelvic Inflammatory Disease [online] Am Fam Physician. 2012 Apr 15;85(8):791-796. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0415/p791.html

Investigations - Followup

Fact Explanation
Serum cancer antigen 125 (CA 125) [1] In cases of endometriosis, this marker is used to monitor treatment response [1]
References
  1. MOUNSEY L Anne, WILGUS Alex, SLAWSON C David Diagnosis and Management of Endometriosis [online] Am Fam Physician. 2006 Aug 15;74(4):594-600. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2006/0815/p594.html

Management - General Measures

Fact Explanation
If pelvic inflammatory disease is suspected the male partner should be treated. [1] This helps to reduce chances of reinfection, also the partners should abstain from having intercourse till the treatment course is completed. [1]
References
  1. GRADISON Margaret, Pelvic Inflammatory Disease [online] Am Fam Physician. 2012 Apr 15;85(8):791-796. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0415/p791.html

Management - Specific Treatments

Fact Explanation
Simple analgesics [1] Paracetamol reduces pain in short term [1]
Nonsteroidal anti-inflammatory drugs (NSAIDs) [1] Responds better than placebo in patients with moderate to severe primary dysmenorrhea [1] Valdecoxib is a COX-2 specific inhibitor, thus alleviates dysmenorrhea without the side effect of reduced platelet function displayed in non specific NSAIDs. [2]
Combined oral contraceptives [1] Effective in women with primary dysmenorrhea but also used first line in endometriosis. [1][3]
Thiamine and Vitamine E [1] Its been shown that this has higher outcome than placebo in young women with primary dysmenorrhea. [1]
Behavioural intervention [1] Such as teaching relaxation technique is known to be more effective than no treatment at all. [1]
Topical heat (about 102°F [39°C]) [1] This is shown to be of equal efficacy as ibuprofen and of higher effecacy than paracetamol. [1]
High-frequency transcutaneous electrical nerve stimulation (TENS) [1] TENS is also used in treatment of dysmenorrhea but its efficacy is less than that of ibuprofen. [1]
Danazol [3] This is an androgenic agent, this can be used for endometriosis [3]
Progestogens [3] Medroxyprogesterone acetate is also used in endometiosis. [3]
Gonadotropin-releasing hormone (GnRH) analogues [3] Leuprolide, goserelin, triptorelin, nafarelin are some of the GnRH analogues used in treatment of endometriosis. [3]
Antiprogestogens [3] Gestrinone is an antiprogestogen used intreatment of endometriosis. [3]
Levonorgestrel-releasing intrauterine system [3] This is used as post surgical treatment for dysmenorrhea. [3]
Laparoscopic uterine nerve ablation/ Presacral neurectomy [3] Alleviates dysmenorrhea, presacral neurectomy is division of sympathetic nerves from uterus resulting in reduced midlin abdominal pain [3]
Laparoscopy [3] Ablation of endometrial deposits in endometriosis increase the chances of fertility [3]
Hysterectomy and bilateral salpingooophorectomy [3] This is the definitive treatment of endometriosis [3]
Specific antibiotic regimen should be used in cases of pelvic inflammatory disease [4] Oral or parenteral regimes are used according to the severity. Cephalosporin, doxycycline and metronidazole are used in treatment. [4]
Serial cervical dilatation for cervical stenosis [5] If does not respond to this hysterectomy may have to be considered [5]
References
  1. LATTHE Pallavi, CHAMPANERIA Rita, KHAN Khalid Dysmenorrhea [online] Clinical Evidence Handbook BMJ, Am Fam Physician. 2012 Feb 15;85(4):386-387 Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0215/p386.html
  2. DANIELS E Stephen, TORRI Sarah, DESJARDINS J Paul Valdecoxib for Treatment of Primary Dysmenorrhea A Randomized, Double-blind Comparison with Placebo and Naproxen [online] J Gen Intern Med. Jan 2005; 20(1): 62–67. doi: 10.1111/j.1525-1497.2004.30052.x Viewed on: 19/08/2014 Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490036/
  3. MOUNSEY L Anne, WILGUS Alex, SLAWSON C David Diagnosis and Management of Endometriosis [online] Am Fam Physician. 2006 Aug 15;74(4):594-600. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2006/0815/p594.html
  4. GRADISON Margaret, Pelvic Inflammatory Disease [online] Am Fam Physician. 2012 Apr 15;85(8):791-796. Viewed on: 19/08/2014 Available from: http://www.aafp.org/afp/2012/0415/p791.html
  5. ALI Khairy Mohammed, ABDELBADEE Yehia Ahmed, El-KARMIN Abd Sherif, SHAZLY Mohammed, ABBASAhmed Mohammed Uterus didelphys with multiple fibroids: A case report [online] Proceedings in Obstetrics and Gynecology, 2013; 3(2):3 Viewed on: 19/08/2014 Available from: http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1190&context=pog