••• Chapter 27^ Dysmenorrhea and Premenstrual Syndrome^271
❍ What other nonpharmacologic approaches may improve dysmenorrhea?
Rest, heating pad to lower abdomen and back, regular nutritious diet, exercise, relaxation such as meditation or
yoga, sexual activity with orgasm, transcutaneous electrical nerve stimulation (TENS), acupuncture/acupressure,
and uterosacral nerve ablation/resection.
❍ How can severity of dysmenorrhea be classified?
According to a verbal multidimensional scoring system, classification includes Grade 0 (unaffected), Grade 1
(rarely affected, with few needing treatment), Grade 2 (moderately affected, requiring therapy but without
functional limitation), and Grade 3 (clearly inhibited, with poor treatment response).
❍ Define secondary dysmenorrhea.
Menstrual pain with underlying pelvic pathology.
❍ Which patients should have a diagnostic evaluation of secondary dysmenorrhea?
Those with onset after age 25, abnormal uterine bleeding, nonmidline pelvic pain, dyspareunia, dyschezia,
progression of symptoms, or absence of other symptoms such as nausea, diarrhea, back pain, headache, or dizziness
during menses.
❍ In relation to the menstrual cycle, when does the pain of secondary dysmenorrhea begin?
1 to 2 weeks prior to menses. It will generally continue until a few days after the cessation of bleeding.
❍ What exam findings may be associated with secondary dysmenorrhea?
Purulent cervical discharge, cervical motion or adnexal tenderness, uterosacral ligament nodularity, thickening
or focal tenderness, lateral cervical displacement, cervical stenosis, adnexal masses, enlarged or irregularly shaped
uterus, cervical or vaginal anomalies, and vulvar varicosity.
❍ Name the most common cause of secondary dysmenorrhea.
Endometriosis, affecting approximately 5% of patients. This is followed by adenomyosis, infection (ie, intrauterine
device or pelvic inflammatory disease) adhesions, and anatomic abnormalities.
❍ When should endometriosis be suspected?
Patients who report pelvic pain related to menses and occurring without menses, dyspareunia, dyschezia, poor
response to NSAID therapy, progressively worsening symptoms, or functional incapacitation.
❍ Name three causes of secondary dysmenorrhea that are a result of blockage of the outflow tract.
Imperforate hymen, transverse vaginal septum, and cervical stenosis.
❍ Name five causes of secondary dysmenorrhea that are due to uterine causes.
Endometrial polyps, uterine leiomyoma, adenomyosis, Asherman syndrome, pelvic congestion, and uterine
anomalies.
❍ What is pelvic congestion syndrome?
It is one of the etiologies of secondary dysmenorrhea and results from congestion of the uterus and engorgement of
varicosities of broad ligaments.