Guideline No. 345: Primary Dysmenorrhea

Objective

This guideline reviews the investigation and treatment of primary dysmenorrhea.

Target Population

Individuals experiencing menstrual pain for which no underlying cause has been identified.

Benefits, Harms, and Costs

Primary dysmenorrhea is common and frequently undertreated, despite effective therapy being widely available at a minimal cost. Treatment of primary dysmenorrhea has the potential to improve quality of life and decrease time away from school or work.

Evidence

Published clinical trials, randomized controlled trials, observational studies, population studies, and systematic review articles indexed in PubMed and the Cochrane database were identified using search the terms “dysmenorrhea” and “menstrual pain.” This search builds on the previous review (January 2005 to March 2016), including new literature between March 2016 and December 2024.

Validation Methods

The author rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

Intended Audience

Primary care providers, pediatricians, and obstetrician/gynaecologists.

Social Media Abstract

Although menstrual pain is commonly experienced by women and adolescents, it is often undertreated or unfairly dismissed. If left untreated, persistent menstrual pain may develop into a chronic pain syndrome. Treatment includes non-steroidal anti-inflammatory drugs and hormonal contraceptives and can be provided without the need for pelvic examinations; treatment should not be delayed pending a definitive diagnosis. Effective treatments are available and do not require a pelvic examination or invasive procedures.

SUMMARY STATEMENTS

• 1.
  Dysmenorrhea is highly prevalent and commonly undertreated (low).
• 2.
  Risk factors associated with primary dysmenorrhea include age, smoking, alcohol use, diet, level of physical activity, family history, parity and psychosocial factors (high).
• 3.
  Primary dysmenorrhea is crampy, suprapubic pain that begins around menstruation, peaks with maximum blood flow, and lasts 2 to 3 days; common symptoms include nausea, vomiting, diarrhea, headache, dizziness, and fatigue (high).
• 4.
  MRI is valuable in diagnosing deep endometriosis and adenomyosis but is less effective in detecting superficial endometriosis, which is commonly found during laparoscopy; laparoscopy remains the gold standard for diagnosing endometriosis, particularly when superficial peritoneal lesions are suspected (good practice point).
• 5.
  Non-steroidal anti-inflammatory drugs are more effective than placebo but have more gastrointestinal side effects. All currently available non-steroidal anti-inflammatory drugs are of comparable efficacy and safety (high).
• 6.
  Most women experience symptom relief with medical therapy, particularly with amenorrhea-inducing treatments (strong).
• 7.
  Endometrial ablation is likely to reduce the symptoms of primary dysmenorrhea when it occurs in the presence of heavy menstrual bleeding (high).

RECOMMENDATIONS

• 1.
  A thorough menstrual, pain, and gynaecologic history should be obtained, including symptom onset, severity, and response to prior treatments. (good practice point).
• 2.
  Health care providers should consider a pelvic examination in patients who are not responding to conventional therapy and when organic pathology is suspected (good practice point).
• 3.
  Health care providers may initiate therapy without first performing a pelvic examination (good practice point).
• 4.
  Ultrasound is indicated when symptoms persist despite appropriate therapy or a clinical abnormality is detected on physical examination (good practice point).
• 5.
  Magnetic Resonance Imaging (MRI) may be considered when transvaginal ultrasound is inconclusive, or when deep infiltrating endometriosis or adenomyosis is strongly suspected based on clinical presentation (good practice point).
• 6.
  Advanced transvaginal ultrasound by an experienced sonographer is preferred over MRI for evaluating deep infiltrative endometriosis (conditional, low).
• 7.
  Given significant wait times for MRI in many jurisdictions, laparoscopy should be considered if transvaginal ultrasound is normal but clinical suspicion for endometriosis remains high (conditional, low).
• 8.
  Health care providers should offer non-steroidal anti-inflammatory drugs or acetaminophen, administered with regular dosing regimens, as a as first-line treatment for most women unless contraindicated (strong, high).
• 9.
  Continuous or extended use combined hormonal contraceptives are recommended for the treatment of dysmenorrhea (strong, high).
• 10.
  Both primary and secondary dysmenorrhea are likely to respond to the same hormonal suppression therapy. Therefore, the practitioner should institute symptomatic treatment even though a precise diagnosis has not been made (good practice point).
• 11.
  Regular exercise should be recommended to improve the symptoms of dysmenorrhea (conditional, low).
• 12.
  High-frequency transcutaneous electrical nerve stimulation (TENS), local heat therapy (heated pads/patches), acupoint stimulation and ginger supplementation may be considered as complementary treatments for dysmenorrhea, especially for women who cannot or choose not to use conventional therapy, though evidence varies in strength and certainty (conditional, low).
• 13.
  Surgical intervention should only be considered when dysmenorrhea persists despite optimized medical therapy or when secondary causes are strongly suspected (strong, moderate).
• 14.
  A thorough clinical evaluation, including pelvic examination, rectovaginal assessment, and abdominal wall muscle evaluation, should be performed before considering surgical options (strong, moderate).