Treatment Guideline Chart
Primary dysmenorrhea is a painful menstruation without demonstrable pelvic pathology.
Symptoms include intermittent painful spasms, crampy labor-like pain localized over the lower abdomen and the suprapubic area which may radiate to the lower back or inner thighs occurring during and occasionally starting prior to menstruation.
The pain may also be described as a dull ache or as a stabbing pain.
Accompanying symptoms include nausea, vomiting, diarrhea, constipation, abdominal bloating, changes in appetite, headaches, lightheadedness, fatigue, fever, muscle cramps, body and joint pains, tender breasts, nervousness, anxiety, irritability, depression, lethargy, fainting, increased urination and poor sleep quality.

Dysmenorrhea%20-%20primary Diagnosis


  • Diagnosis is based on clinical presentation, history and physical exam
  • Further evaluation is required when history is inconsistent with primary dysmenorrhea and indicated also in cases of severe dysmenorrhea or if patient is unresponsive to initial empiric therapy


Important Points in the History

Menstrual History

  • Age at menarche
  • Time interval between menarche and the start of dysmenorrhea
  • Length and regularity of cycles
  • Dates of last 2 menses
  • Duration and amount of bleeding

Characteristics of Pain

  • Type, location, radiation, associated symptoms
  • Severity and duration
  • Relation of onset of pain to menstrual bleeding
  • Progression over time
  • Degree of patient’s disability resulting from pain
  • Presence of gastrointestinal or urinary symptoms that may suggest other causes of pelvic pain
  • Inquire about self-treatment with over-the-counter analgesics including NSAIDs


  • Dyspareunia
  • Contraceptive use, eg hormonal contraceptives, intrauterine device (IUD)
  • History of sexually transmitted infections (STIs), multiple sexual partners, unprotected sex, sexual abuse, pelvic inflammatory disease (PID), pelvic surgery, infertility, psychiatric disorders
  • Abnormal vaginal discharge 
  • Family history of endometriosis 

Physical Examination

Physical and Pelvic Exam

  • General physical exam and routine pelvic exam during non-menstrual phase of cycle reveal no abnormalities
    • Virginal girl with mild cramps and a normal physical exam: Inspection of genitalia to exclude abnormality of hymen is all that is typically required
    • A careful pelvic exam is warranted if STI symptoms are present and in moderate or severe dysmenorrhea especially if it interferes with daily living
  • Intend to rule out secondary causes of dysmenorrhea (eg ovarian cysts or tumors, STIs)
    • Careful bimanual pelvic exam and rectal exam may reveal abnormality associated with cause of secondary dysmenorrhea
      • Bimanual pelvic exam may show a pelvic mass, an enlarged, irregular or retroflexed uterus, a tender uterus or adnexa or uterosacral nodularity

If history is typical of primary dysmenorrhea and there are normal findings on routine physical and pelvic exam, further diagnostic evaluation is not usually warranted 

Laboratory Tests

  • No lab tests are diagnostic or specific for primary dysmenorrhea
  • Some lab tests may be helpful
    • Complete blood count (elevated white blood cells [WBC] may be an indication of infection, or use blood count to evaluate if excessive bleeding has occurred)
    • Erythrocyte sedimentation rate to identify chronic inflammatory process
    • Human chorionic gonadotropin (hCG) to rule out ectopic pregnancy
    • Urinalysis to evaluate urinary symptoms
    • Vaginal and endocervical swabs may be done to screen for the presence of STIs, eg chlamydia and gonorrhea testing


  • Pelvic ultrasonography, magnetic resonance imaging (MRI) and diagnostic laparoscopy may be considered
    • Ultrasound is the initial imaging modality and can differentiate endometriomas from other adnexal masses
    • MRI can evaluate deep infiltrating or rectovaginal disease  
    • Ultrasonography and MRI are useful in evaluating genital tract abnormalities or obstruction
    • Diagnostic laparoscopy can confirm peritoneal endometriosis and adhesions in patients with persistent symptoms despite NSAID and/or hormonal contraceptive treatment
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