MB helped to carry out the research and to prepare the first draft of the manuscript. LL designed the study, helped to carry out the research, and helped to prepare the first draft of the manuscript. F Perelli helped to carry out the research and contributed to the preparation of the manuscript. FMR contributed to the research, provided expertise in the literature review, and contributed to the preparation of the manuscript.
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MB helped to carry out the research and to prepare the first draft of the manuscript. LL designed the study, helped to carry out the research, and helped to prepare the first draft of the manuscript. F Perelli helped to carry out the research and contributed to the preparation of the manuscript. FMR contributed to the research, provided expertise in the literature review, and contributed to the preparation of the manuscript. F Petraglia conceived the study and contributed to the preparation of the manuscript.
All authors were involved in the revision of the draft manuscript and have agreed to the final content. Dysmenorrhea is a common symptom secondary to various gynecological disorders, but it is also represented in most women as a primary form of disease. Pain associated with dysmenorrhea is caused by hypersecretion of prostaglandins and an increased uterine contractility. The primary dysmenorrhea is quite frequent in young women and remains with a good prognosis, even though it is associated with low quality of life.
The secondary forms of dysmenorrhea are associated with endometriosis and adenomyosis and may represent the key symptom. The diagnosis is suspected on the basis of the clinical history and the physical examination and can be confirmed by ultrasound, which is very useful to exclude some secondary causes of dysmenorrhea, such as endometriosis and adenomyosis. The treatment options include non-steroidal anti-inflammatory drugs alone or combined with oral contraceptives or progestins.
Dysmenorrhea is defined as the presence of painful cramps of uterine origin that occur during menstruation and represents one of the most common causes of pelvic pain and menstrual disorder. In particular, chronic pelvic pain is located in the pelvic area and lasts for 6 months or longer 2. The burden of dysmenorrhea is greater than any other gynecological complaint 3 : dysmenorrhea is the leading cause of gynecological morbidity in women of reproductive age regardless of age, nationality, and economic status 4 — 7.
The effects extend beyond individual women to society, resulting annually in an important loss of productivity 8 , 9. Thus, the World Health Organization estimated that dysmenorrhea is the most important cause of chronic pelvic pain Because it is accepted as a normal aspect of the menstrual cycle and therefore is tolerated, women do not report it 13 and do not seek medical care 13 , On the basis of pathophysiology, dysmenorrhea is classified as primary dysmenorrhea menstrual pain without organic disease or secondary dysmenorrhea menstrual pain associated with underlying pelvic pathology The cause of primary dysmenorrhea is not well established.
However, the responsible cause has been identified on the hyper-production of uterine prostaglandins, particularly of PGF 2a and PGF 2 , thus resulting in increased uterine tone and high-amplitude contractions Women with dysmenorrhea have higher levels of prostaglandins, which are highest during the first two days of menses Prostaglandin production is controlled by progesterone: when progesterone levels drop, immediately prior to menstruation, prostaglandin levels increase 13 , If the exposure of endometrium to luteal phase is crucial for the increased production of progesterone, dysmenorrhea occurs only with ovulatory cycles.
This could explain why primary dysmenorrhea onset is shortly after menarche and why dysmenorrhea responds well to ovulatory inhibition. However, multiple other factors may play a role in the perception and the severity of pain, which does not depend only on endocrine factors The recurrent menstrual pain is associated with central sensitization, which is associated with structural and functional modification of the central nervous system 24 , The most common causes of secondary dysmenorrhea in young women are endometriosis and adenomyosis.
Endometriosis is characterized by the presence of endometrial tissue glands and stroma outside the uterine cavity and is the most common cause of secondary dysmenorrhea 27 , Pain symptoms negatively influence physical and psychological well-being of women with endometriosis.
All forms of pain induce elevated sympathetic nervous system activity and this is considered a stressor, inducing changes in neuromediators, neuroendocrine, and hormonal secretions 27 , Given that women with endometriosis wait before getting the right diagnosis 30 , a great deal of effort has been made in recent years to try to find signs and symptoms that would help in making an earlier diagnosis.
The early identification of these symptoms could help reduce the delay necessary for diagnosis 15 and enable the use of less invasive procedures An early age onset of dysmenorrhea is considered a risk factor for endometriosis 32 ; other menstrual characteristics such as cycle length and menstrual bleeding duration and quantity are not related to the development of endometriosis.
Parameters that may predict a later finding of deep infiltrating endometriosis are prolonged use of oral contraceptives OCs for treating primary dysmenorrhea, absenteeism from school during menstruation, and a positive family history of dysmenorrhea The endometriosis prevalence is higher in adolescents with chronic pelvic pain resistant to treatment with OC pills and non-steroidal anti-inflammatory drugs NSAIDs and in girls with dysmenorrhea Therefore, severe dysmenorrhea that does not respond to medical therapy warrants further investigation such as by laparoscopy Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium and is associated with dysmenorrhea and abnormal uterine bleeding AUB.
Adenomyosis is one of the most common causes of AUB The diagnosis is usually confirmed through transvaginal ultrasonography and magnetic resonance imaging.
Via specific ultrasonographic criteria by bidimensional and tridimensional transvaginal ultrasound morphological uterus sonographic assessment 37 , the detection of adenomyosis features by imaging is accepted and the association with menstrual pain, heavy menstrual bleeding, and infertility may facilitate the diagnosis of adenomyosis Heavy menstrual bleeding and longer menstrual bleeding duration are often associated with dysmenorrhea 3 , Childbearing is a very influential factor for the decrease of dysmenorrhea 5.
Increasing age is also associated with less severe dysmenorrhea 12 , although a longitudinal study found that the proportion of women with moderate to severe dysmenorrhea remained constant with increasing age 5. The early onset of pain is associated with more severe pain 3 , and a family history of dysmenorrhea is associated with a significantly higher prevalence of dysmenorrhea Since anxiety and depression are often associated, dysmenorrhea may be part of a somatoform syndrome 3.
A focused history and physical examination are usually sufficient for making a diagnosis of primary dysmenorrhea 23 , The onset of primary dysmenorrhea is usually 6 to 12 months after menarche.
The typical pain is sharp and intermittent, is located in the suprapubic area, and develops within hours of the start of menstruation and peaks with maximum blood flow The physical examination is completely normal, and the menstrual pain may be associated with systemic symptoms, such as nausea, vomiting, diarrhea, fatigue, fever, headache, and insomnia 11 , 16 , There is no evidence for routine use of ultrasound in the evaluation of primary dysmenorrhea, although ultrasound is very useful in excluding the secondary causes of dysmenorrhea, such as endometriosis and adenomyosis 26 Figure 1.
Dysmenorrhea that occurs any time after menarche, that is associated with other gynecological symptoms such as dyspareunia, heavy menstrual bleeding, AUB, and infertility, and that does not respond to treatment with NSAIDs or OCs might be suspicious for secondary dysmenorrhea 23 , In particular, the analysis of menstrual bleeding abnormalities associated with dysmenorrhea might be helpful for the diagnosis of adenomyosis Figure 1. NSAIDs are usually the first-line therapy for dysmenorrhea and should be tried for at least three menstrual periods 41 , NSAIDs are drugs that act by blocking prostaglandin production through the inhibition of cyclooxygenase, an enzyme responsible for formation of prostaglandins.
They make the menstrual cramps less severe and can prevent other symptoms such as nausea and diarrhea NSAIDs reduce moderate to severe pain in women with primary dysmenorrhea With the widespread availability of NSAIDs, the management of dysmenorrhea is mainly self-care 13 , Contraceptive hormones act by suppressing ovulation and causing no endometrial proliferation OCs bring almost immediate relief from symptoms associated with menstruation: heavy periods, painful periods, and irregular bleeding.
In addition, OCs often are used as therapeutic drugs for women with symptomatic menorrhagia or endometriosis 45 , The effectiveness of OC therapy for treating dysmenorrhea, regardless of the administration route oral, transdermal, intravaginal, or intrauterine , has been shown 12 , 46 — However, limited evidence supports the use of OCs as a standard treatment Hormonal progestins-only treatment produces a benefit on menstrual pain, causing endometrial atrophy and inhibiting ovulation.
Several long-acting reversible progestin contraceptives have been found to be effective treatments for primary dysmenorrhea. F Faculty Reviews are commissioned from members of the prestigious F Faculty and are edited as a service to readers. In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published.
The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions any comments will already have been addressed in the published version. National Center for Biotechnology Information , U. Journal List FRes v. Version 1. Published online Sep 5.
Reis , 3 and Felice Petraglia a, 2. Fernando M. Author information Article notes Copyright and License information Disclaimer. Competing interests: The authors declare that they have no competing interests. Accepted Sep 6. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract Dysmenorrhea is a common symptom secondary to various gynecological disorders, but it is also represented in most women as a primary form of disease. Keywords: Dysmenorrhea, endometriosis, adenomyosis, menstrual disorders. Introduction Dysmenorrhea is defined as the presence of painful cramps of uterine origin that occur during menstruation and represents one of the most common causes of pelvic pain and menstrual disorder.
Definition and pathogenesis On the basis of pathophysiology, dysmenorrhea is classified as primary dysmenorrhea menstrual pain without organic disease or secondary dysmenorrhea menstrual pain associated with underlying pelvic pathology Endometriosis Endometriosis is characterized by the presence of endometrial tissue glands and stroma outside the uterine cavity and is the most common cause of secondary dysmenorrhea 27 , Adenomyosis Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium and is associated with dysmenorrhea and abnormal uterine bleeding AUB.
Risk factors Heavy menstrual bleeding and longer menstrual bleeding duration are often associated with dysmenorrhea 3 , Diagnosis A focused history and physical examination are usually sufficient for making a diagnosis of primary dysmenorrhea 23 , Open in a separate window. Figure 1. Flowchart for the management of patients with dysmenorrhea. Treatment The aim of the treatment for primary dysmenorrhea is pain relief. Non-steroidal anti-inflammatory drugs NSAIDs are usually the first-line therapy for dysmenorrhea and should be tried for at least three menstrual periods 41 , Oral contraceptives Contraceptive hormones act by suppressing ovulation and causing no endometrial proliferation Progestins Hormonal progestins-only treatment produces a benefit on menstrual pain, causing endometrial atrophy and inhibiting ovulation.
Notes [version 1; referees: 3 approved]. Funding Statement The author s declared that no grants were involved in supporting this work.
References 1. Chronic pelvic pain. Obstet Gynecol.
Dysmenorrhea and related disorders
Menstruation , or period, is normal vaginal bleeding that happens as part of a woman's monthly cycle. Many women have painful periods, also called dysmenorrhea. The pain is most often menstrual cramps, which are a throbbing, cramping pain in your lower abdomen. You may also have other symptoms, such as lower back pain, nausea, diarrhea, and headaches. Period pain is not the same as premenstrual syndrome PMS. PMS causes many different symptoms, including weight gain, bloating, irritability, and fatigue.
Menstrual cramps dysmenorrhea are throbbing or cramping pains in the lower abdomen. Many women have menstrual cramps just before and during their menstrual periods. For some women, the discomfort is merely annoying. For others, menstrual cramps can be severe enough to interfere with everyday activities for a few days every month.