Dysmenorrhoea, or menstrual pain, is the most common menstrual sympto.m among adolescent girls and young women. This is a common cause of teenagers missing school and young adolescents being absent from work.
Dysmenorrhoea in adolescents
Some pain, cramping, and discomfort during menstrual periods is normal, but when the pain is very severe, and lasts several months, this is a cause for concern. Dysmenorrhoea refers to intense pain and cramping during menstruation. It is very common among adolescents girls. Dysmenorrhoea is the most common gynaecologic complaint among adolescent females. Prevalence rates vary but range from 50% to 90%. Most adolescents experiencing dysmenorrhoea have primary dysmenorrhoea defined as painful menstruation in the absence of pelvic pathology. Primary dysmenorrhea characteristically begins when adolescents attain ovulatory cycles, usually within 6–12 months of menarche (age of first menstrual period). Secondary dysmenorrhea refers to painful menses due to pelvic pathology or a recognized medical condition. The most common cause of secondary dysmenorrhea is endometriosis. Other causes of secondary dysmenorrhea include adenomyosis, infection, myomas, müllerian anomalies, obstructive reproductive tract anomalies or ovarian cysts.
Other symptoms associated with dysmenorrhea
Several medical disorders significantly affect adolescents with dysmenorrhea. Symptoms associated with dysmenorrhea in adolescents may include nausea, vomiting, diarrhoea, headaches and muscle cramps. Poor sleep quality, including disturbances in sleep onset, latency, and sleep efficiency, has been self-reported by patients with severe dysmenorrhoea. As a result of these related symptoms, dysmenorrhea is the leading cause of recurrent short-term school absenteeism for adolescent girls.
Diagnosis and evaluation
Many adolescents are reluctant to see their gynaecologist when they have symptoms. It is important that parents encourage their adolescents to seek medical advice if they suffer from dysmenorrhoea.
The initial evaluation for all patients presenting with dysmenorrhoea includes a medical, gynaecologic, menstrual, family, and psychosocial history to determine whether the patient has primary dysmenorrhoea or symptoms suggestive of secondary dysmenorrhoea. When a patient presents with symptoms only of primary dysmenorrhoea, a pelvic examination is not necessary. However, a pelvic examination should be conducted if symptoms of a sexually transmitted infection are present.
Treatment of primary dysmenorrhoea
When the patient’s history suggests primary dysmenorrhoea, empiric treatment should be initiated. Various therapies are available for treating primary dysmenorrhea in adolescents. Nonsteroidal anti-inflammatory agents (NSAIDS) are considered a first-line treatment option. If a trial of NSAIDs does not provide adequate relief of dysmenorrhoea symptoms, consideration should be given to the use of hormonal agents.
There are promising, although limited, data on the benefits of exercise and heat treatment for symptoms of dysmenorrhoea. Given the low risk of harm and low cost of heat therapy and exercise, as well as the additional general health benefits of exercise, both options should be encouraged.
Follow-up for primary dysmenorrhoea
Regardless of chosen therapy, patients with a presumed diagnosis of primary dysmenorrhoea should be monitored for response to treatment. Response to treatment of primary dysmenorrhoea supports the diagnosis.
When a patient does not experience clinical improvement for her dysmenorrhoea within 3–6 months of therapy initiation, her obstetrician–gynaecologist should investigate her for possible secondary causes and for treatment adherence. Adolescents may be less adherent to medication schedules and may face conflict with parents about medication use. Other barriers may include forgetfulness, disorganization, financial costs and pharmacy access.
Secondary dysmenorrhea in the adolescent
Most adolescents who present with dysmenorrhea have primary dysmenorrhea and will respond well to empiric treatment with NSAIDs, or hormonal suppression, or both. However, some patients either present initially with symptoms suggesting secondary dysmenorrhea or they fail empiric treatment for primary dysmenorrhea, require further evaluation. Additionally, if a patient has pain for 3–6 months a more comprehensive evaluation of chronic pelvic pain should be performed with a history and focused physical examination to assess potential disorders for such pain. Ultrasonography is the most appropriate initial imaging modality to identify potential etiologies of secondary dysmenorrhea. If a particular disorder is found then this disorder should be managed appropriately.
Primary dysmenorrhoea and pregnancy
Primary dysmenorrhoea usually does not affect fertility. In a few cases the symptoms of dysmenorrhoea improve after childbirth, but this does not occur in the majority of patients with primary dysmenorrhoea. The use of hormonal contraception to prevent pregnancy tends to improve symptoms associated with primary dysmenorrhoea.
Conclusion
Dysmenorrhoea is the most common gynaecologic complaint among adolescent females. Dysmenorrhea in adolescents is usually primary, and is associated with normal ovulatory cycles and with no pelvic pathology. In approximately 10% of adolescents with severe dysmenorrhoeic symptoms, pelvic abnormalities such as endometriosis or uterine anomalies may be found. There are many options for therapy, but many adolescents are reluctant to seek medical advice despite severe symptoms. Severe menstrual cramps usually do not cause other medical complications, but they can interfere with school, work and social activities, therefore it is important to seek medical attention for correct management.
Ask Your Dr is a health education column and is not a substitute for medical advice from your physician. The reader should consult his or her physician for specific information concerning specific medical conditions. While all reasonable efforts have been made to ensure that all information presented is accurate, as research and development in the medical field are ongoing, it is possible that new findings may supersede some data presented.
Dr Brett Hodge MB BS DGO MRCOG is an obstetrician/Gynaecologist and Family Doctor with over thirty-five years in clinical practice. Dr Brett Hodge has a medical practice in The Johnson Building in The Valley (Tel: 264 497 5928).
