Dysmenorrhea

Kathryn A. McKenna, MD, MPH, and Corey D. Fogleman, MD, Penn Medicine Lancaster
General Health Family and Community Medicine Residency Program, Lancaster, Pennsylvania

Dysmenorrhea is common and usually independent of, rather than secondary to, pelvic pathology. Dys-
menorrhea occurs in 50% to 90% of adolescent girls and women of reproductive age and is a leading
cause of absenteeism. Secondary dysmenorrhea as a result of endometriosis, pelvic anatomic abnormal-
ities, or infection may present with progressive worsening of pain, abnormal uterine bleeding, vaginal
discharge, or dyspareunia. Initial workup should include a menstrual history and pregnancy test for
patients who are sexually active. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives
are first-line medical options that may be used independently or in combination. Because most proges-
tin or estrogen-progestin combinations are effective, secondary indications, such as contraception,
should be considered. Good evidence supports the effectiveness of some nonpharmacologic options,
including exercise, transcutaneous electrical nerve stimulation, heat therapy, and self-acupressure. If
secondary dysmenorrhea is suspected, nonsteroidal anti-inflammatory drugs or hormonal therapies
may be effective, but further workup should include pelvic examination and ultrasonography. Referral
to an obstetrician-gynecologist may be warranted for further evaluation and treatment. (Am Fam Phy-
sician. 2021;104(2):​164-170. Copyright © 2021 American Academy of Family Physicians.)

Dysmenorrhea, which is defined as painful inflammation causing uterine contractility and

menstruation, affects up to 50% to 90% of ado- cramping pain.1,10
lescent girls and women of reproductive age.1,2 Secondary dysmenorrhea is due to pelvic
Nearly one-half of patients (45%) with symp- pathology or a recognized medical condition and
toms of dysmenorrhea will present first to their accounts for about 10% of cases of dysmenorrhea.1
primary care physician.3 Dysmenorrhea leads The most common etiology is endometriosis.
to decreased quality of life, absenteeism, and Other etiologies include congenital or acquired
increased risk of depression and anxiety.4,5 Up obstructive and nonobstructive anatomic abnor-
to one-half of patients with dysmenorrhea miss malities (e.g., müllerian malformations, uterine
school or work at least once, and 10% to 15% leiomyomas, adenomyosis), pelvic masses, and
have regular absences during menses.6-8 A pro- infection1 (Table 11,11).
spective longitudinal study of 400 patients with
dysmenorrhea revealed that most have persistent Risk Factors
symptoms throughout their years of menstru- Age younger than 30 years, body mass index less
ation, although some improvement in severity than 20 kg per m2, smoking, earlier menarche
may occur, for example, after childbirth.9 (younger than 12 years), longer menstrual cycles,
Primary dysmenorrhea occurs in the absence heavy menstrual flow, and history of sexual abuse
of pelvic pathology. It is mediated by elevated increase the risk of primary dysmenorrhea. Nul-
prostaglandin and leukotriene levels, with liparity, premenstrual syndrome, and a history
of pelvic inflammatory disease are also associ-
CME This clinical content conforms to AAFP criteria for
ated with the disorder. Protective factors include
CME. See CME Quiz on page 128. increasing age, increasing parity, exercise, and
Author disclosure:​ No relevant financial affiliations. oral contraceptive use.9,12
Patient information:​ A handout on this topic is available at
Secondary dysmenorrhea is associated with
https://​w ww.aafp.org/afp/2021/0800/p164-s1.html. infertility, especially when caused by endome-
triosis.13 However, secondary dysmenorrhea

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 DYSMENORRHEA

associated with increasing gravidity, parity, and with the initiation of ovulatory cycles, and tends
body mass index suggests a cause other than to recur with every menstrual cycle.1
endometriosis.14 Symptoms of secondary dysmenorrhea may
start immediately following menarche or may
Clinical Presentation arise later in life.1 Symptoms more consistent
Dysmenorrhea is typically described as cramp- with secondary dysmenorrhea include changes in
ing pain in the lower abdomen beginning at the or progressive worsening of pelvic pain, abnor-
onset of menstrual flow and lasting eight to 72 mal uterine bleeding, vaginal discharge, and
hours.15 It is often accompanied by nausea, vom- dyspareunia.1,11
iting, diarrhea, headaches, muscle cramps, low
back pain, fatigue, and, in more severe cases, Diagnosis
sleep disturbance.1,6 In a study of more than 400 Evaluation should begin with a complete medi-
patients with dysmenorrhea, 47% reported mod- cal, gynecologic, menstrual, family, and surgical
erate pain, and 17% reported severe pain on a 0 to history.1 The history should characterize whether
10 visual analog scale.16 pain coincides with menstruation and include
Primary dysmenorrhea begins an average of six which nonprescription therapies the patient has
to 12 months following menarche, corresponding tried. A family history of similar symptoms may
suggest endometriosis, and a history
of pelvic surgery may suggest adhe-
TABLE 1 sions.1 Symptoms should be carefully
elicited because many patients assume
Differential Diagnosis of Secondary Dysmenorrhea pain is a normal part of menstrua-
Diagnosis* Characteristic signs and symptoms tion.8,17 In a study of more than 4,300
patients seeking care for symptoms of
Endometriosis Infertility;​pain with intercourse, urination, dysmenorrhea, nearly two-thirds were
or bowel movements
told nothing was wrong;​this was even
Ovarian cysts Sudden onset and resolution;​if twisted, more likely when symptoms began
can cause ovarian torsion during adolescence.3 A substantial
delay from symptom onset to diagno-
Uterine polyps Irregular vaginal bleeding
sis is common, ranging from 5.4 years
Uterine leiomyomas Heavy, prolonged periods;​constipation or in adolescents to 1.9 years in adults.3
difficulty emptying the bladder possible;​ In secondary dysmenorrhea, the time
more common in older people
from onset of symptoms to surgically
Adenomyosis Heavy bleeding, blood clots, pain with confirmed diagnosis may range from
intercourse, abdominal tenderness;​more four to 11 years.18
common in older people A pelvic examination is not necessary
Pelvic inflammatory Abdominal pain, fever, vaginal discharge in patients presenting with symptoms
disease and odor, pain with intercourse, bleeding consistent with primary dysmenorrhea
after intercourse (Figure 1). Pregnancy should be ruled
out in patients who are sexually active.
Congenital obstructive Amenorrhea, infertility, miscarriage
müllerian malformations If symptoms consistent with secondary
dysmenorrhea are reported, a pelvic
Pelvic adhesions History of surgery, infertility, bowel examination should be completed and
obstruction, painful bowel movements,
ultrasonography performed to assess
pain with change in position
for anatomic abnormalities or other
Pelvic masses Bloating, frequent urination, nausea pathology 1 (Table 11,11).
Cervical stenosis Amenorrhea, infertility
Treatment
*—Conditions listed in descending order of approximate incidence. If a patient’s history is consistent
Information from references 1 and 11. with primary dysmenorrhea or with
secondary dysmenorrhea due to

August 2021 ◆ Volume 104, Number 2 www.aafp.org/afp American Family Physician 165
 DYSMENORRHEA
FIGURE 1

History consistent with primary dysmenorrhea

Cyclic, cramping pain in the lower abdomen
beginning with onset of menstrual flow and
lasting 8 to 72 hours; initial onset 6 to 12 months
after menarche; negative pregnancy test results

Yes No

Initiate empiric therapy Evaluate for symptoms of secondary

dysmenorrhea
Onset immediately after menarche
NSAIDs (patient desires fertility and there are or later in life (after 25 years of age),
no contraindications) progressively worsening symptoms,
and/or abnormal uterine bleeding, dyspareu-
nia, midcycle or acyclic pain, vaginal
Hormonal therapy (patient desires contraception
discharge concerning for infection, infer-
or NSAIDs are contraindicated)
tility, family history of endometriosis
and/or
Nonpharmacologic therapies (exercise, high-
frequency transcutaneous electrical nerve stimulation, A Perform pelvic
heat therapy, self-acupressure, acupuncture*) examination
Screen for sexually
transmitted infections
3 months
Obtain pelvic
ultrasonography

Improvement No improvement
Normal Abnormal
Continue therapy Assess for treatment adherence findings findings
as long as tolerated Reconsider initial empiric
and symptoms are therapy options; initiate add-on Refer to an obstetrician- Treat identified
well controlled therapy or an alternative therapy gynecologist for abnormalities
additional diagnostic
evaluation and therapies

3 months Consider A

No improvement or worsening symptoms

Go to A

NSAIDs = nonsteroidal anti-inflammatory drugs.

*—Listed in descending order of effectiveness.

Algorithm for the management of dysmenorrhea.

endometriosis, empiric therapy should be initi- of bleeding, correlating with the highest levels of
ated1,19 (Figure 1). prostaglandins.21 There is no difference between
individual NSAIDs, including cyclooxygenase-2
NSAIDS inhibitors, for pain relief or safety.19,22 Commonly
Nonsteroidal anti-inflammatory drugs (NSAIDs), prescribed NSAIDs include ibuprofen (800 mg
which have been shown to be superior to both initially, followed by 400 to 800 mg every eight
placebo and acetaminophen, are a first-line ther- hours) and naproxen (500 mg initially, followed
apy for primary dysmenorrhea. NSAIDs act by by 250 to 500 mg every 12 hours)21;​both medi-
reducing prostaglandin production.20,21 NSAIDs cations can be purchased over the counter, often
should be initiated one to two days before the for less than $10 per month. NSAIDs can also
onset of menses and continued in regular dos- have a secondary benefit of reducing heavy men-
ing intervals through the first two to three days strual bleeding.20

166 American Family Physician www.aafp.org/afp Volume 104, Number 2 ◆ August 2021
 DYSMENORRHEA

Despite the known effectiveness of NSAIDs medroxyprogesterone depot injection (Depo-

in the treatment of dysmenorrhea, nearly 20% Provera), and the levonorgestrel-releasing intra-
of patients report minimal to no relief.10 This uterine system (Mirena).1,25 A systematic review
is likely multifactorial. Up to 25% to 50% of found that the levonorgestrel-releasing intrauter-
patients do not take the correct dosage to provide ine system is as effective as, if not superior to, oral
adequate relief.10 Variance in menstrual cycles contraceptives in the treatment of primary dys-
may prevent appropriate timing of treatment. menorrhea and secondary dysmenorrhea caused
NSAIDS are also associated with adverse effects, by endometriosis.31 Physicians and patients must
including indigestion, headaches, and drowsi- weigh secondary benefits with contraindica-
ness, which may limit use.22 Taking NSAIDs with tions, U.S. Food and Drug Administration boxed
food reduces gastrointestinal adverse effects. warnings, and adverse effects when considering
hormonal treatment options.
HORMONAL THERAPY
Hormonal therapy is also considered a first-line NONPHARMACOLOGIC THERAPIES
treatment for dysmenorrhea and can be added Nonpharmacologic therapies and integrative
or used as an alternative to NSAID therapy in modalities can complement first-line medical
patients who are not planning to become preg- therapy or be used as alternatives when first-line
nant.1,10 Hormonal therapies improve symptoms interventions are contraindicated or declined.
of dysmenorrhea by thinning the endometrial Physical activity reduces intensity and dura-
lining and reducing cyclooxygenase-2 and pros- tion of pain in primary dysmenorrhea.32 Based
taglandin production.10 Hormonal therapies on a Cochrane review, exercise—regardless
may also have secondary benefits, including of intensity but with the goal of achieving 45
improvement of heavy menstrual bleeding,23 pre- to 60 minute intervals at least three times per
menstrual mood,24 acne or hirsutism, and bone week—may significantly reduce menstrual pain
mineral density, and decreased risk of endome- that is associated with moderate to severe dys-
trial, ovarian, and colorectal cancers.25 menorrhea.33 Exercise may not reduce overall
Combined estrogen-progestin oral contracep- menstrual flow or pain intensity as effectively
tives are effective in adolescents and adults with as NSAIDs, but given its many benefits beyond
primary dysmenorrhea, leading to significant managing dysmenorrhea, it should be reviewed
improvement in pain and decreased frequency with patients as a treatment option.33
and dose of analgesics.26,27 There is no difference High-frequency transcutaneous electrical
in effectiveness between low- and medium-dose nerve stimulation is effective for pain reduction
estrogen preparations.27 Commonly reported in primary dysmenorrhea, with improvement in
adverse effects of combined oral contraceptives reported pain level, duration of pain relief, and
include nausea, headaches, and weight gain.27 decreased use of analgesics compared with sham
Continuous combined oral contraceptive regi- transcutaneous electrical nerve stimulation.34,35
mens with more than 28 days of active hormone A small randomized controlled study found heat
may lead to improved and more rapid pain relief therapy to be effective in improving menstrual
but are associated with more weight gain than pain.36
cyclic regimens.28-30 Progestin-only oral con- Self-acupressure, a safe and low-risk interven-
traceptives are an alternative for those who are tion, can significantly reduce average menstrual
not candidates for estrogen therapy. Continuous pain intensity, number of days with pain, and use
norethindrone (5 mg daily) is as effective as cyclic of analgesics over a three-month period37 but is
combined oral contraceptives for the treatment not superior to NSAIDs.38 Manual acupuncture
of dysmenorrhea,2 although this dosing is not and electroacupuncture are effective at reducing
currently approved by the U.S. Food and Drug menstrual pain compared with no treatment,39
Administration as a contraceptive.1 although they may be no better than sham acu-
Other hormonal contraceptives are also puncture.38,40 No evidence supports the use of
acceptable for the management of dysmenorrhea, spinal manipulation to treat dysmenorrhea.41
including transdermal patches, vaginal rings, pro- Behavioral interventions and pain man-
gestin implants, intramuscular or subcutaneous agement training, such as progressive muscle

August 2021 ◆ Volume 104, Number 2 www.aafp.org/afp American Family Physician 167
 DYSMENORRHEA

SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Empiric therapy should be initiated if the history is consis- C Recommendation from

tent with primary dysmenorrhea.1,19 consensus guidelines

Nonsteroidal anti-inflammatory drugs should be used as A Systematic review of 80 ran-

first-line treatment for primary dysmenorrhea. 22 domized controlled trials

Combined estrogen-progestin oral contraceptives are an B Consistent findings from

alternative first-line treatment or an adjunct to nonsteroidal randomized controlled trials
anti-inflammatory drugs for primary dysmenorrhea. 26-28,30

The levonorgestrel-releasing intrauterine system (Mirena) A Systematic review with con-

is effective for the treatment of primary dysmenorrhea and sistent findings
secondary dysmenorrhea caused by endometriosis. 31

Consider exercise, high-frequency transcutaneous elec- B Limited-quality evidence

trical nerve stimulation, heat therapy, or self-acupressure from randomized controlled
as an alternative or adjunct to first-line therapies for trial and systematic review
dysmenorrhea. 32-37

Pelvic examination and ultrasonography should be com- C Recommendation from

pleted if first-line therapy is ineffective or if symptoms of consensus guidelines
secondary dysmenorrhea are present.1,19

A = consistent, good-quality patient-oriented evidence;​ B = inconsistent or limited-quality patient-oriented evidence;​

C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the
SORT evidence rating system, go to https://​w ww.aafp.org/afpsort.

relaxation, imagery, and biofeedback, that focus more extensive workup should be performed for
on coping strategies may help with spasmodic- secondary causes of dysmenorrhea (Figure 1). A
type pain.42 However, studies were small and of comprehensive history and physical examination
poor methodological quality. should evaluate for causes of chronic pelvic pain,
There is insufficient evidence to support the including gastroenterologic, urologic, musculo-
use of the dietary supplements fenugreek, fish skeletal, or psychosocial etiologies.1 Workup for
oil, ginger, valerian, vitamin B1, Zataria multi- secondary dysmenorrhea should also include
flora, and zinc sulfate for dysmenorrhea43 or the a pelvic examination and ultrasonography.1,19
use of antioxidants for endometriosis-related pel- Normal findings do not rule out endometriosis,
vic pain.44 A small systematic review found that which is a surgical and pathologic diagnosis.
the herbal therapy fennel (Foeniculum vulgare) Referral to an obstetrician-gynecologist may be
may be as effective as NSAID therapy in reduc- indicated for diagnostic evaluation, including
ing menstrual pain in primary dysmenorrhea, advanced imaging or laparoscopy.1,19
although the quality of evidence was considered Gonadotropin-releasing hormone analogues,
low.45 Small studies have found improvement in such as elagolix (Orilissa) or leuprolide (Lupron),
dysmenorrhea pain with the use of Chinese herbal used for at least six months with add-back
medicines, but these studies should be inter- replacement estrogen therapy have been used for
preted with caution given poor methodological treatment of surgically confirmed endometrio-
quality and inconsistencies in formulations.46,47 sis;​studies demonstrate up to a 75% reduction
of dysmenorrhea symptoms.1,10,48 Adverse effects
Treatment Resistance may include hot flashes, headaches, and hyper-
If symptoms persist despite three to six months lipidemia, which improve with discontinuation
of empiric treatment or if at any time the symp- of treatment.48 Aromatase inhibitors also require
tom pattern suggests a secondary etiology, a add-back estrogen therapy, and further research

168 American Family Physician www.aafp.org/afp Volume 104, Number 2 ◆ August 2021
 DYSMENORRHEA

is needed to support their effectiveness.10 Alter- References

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170 American Family Physician www.aafp.org/afp Volume 104, Number 2 ◆ August 2021