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Primary Dysmenorrhea - a major cause of chronic pelvic pain and the easiest to diagnose. Dysmenorrhea
(painful menstruation) is classified as primary when there is no underlying organic cause other than
prostaglandin release from the uterus itself during the time of menstruation.
Symptoms: Once a woman’s cycles become ovulatory, anywhere from 6 months to 2 years after the start of
her periods, she can experience dysmenorrhea and most do. Age of onset is therefore 6-24 months after the
start of menstruation. The pain ranges from very mild to quite severe. It is described as cramping in nature
and is felt in the sacral area, low pelvis and inner thigh area. It usually starts and ends with menstruation. The
patient feels well throughout the remainder of her cycle. Some will have a day or two of premenstrual pain.
Many young women will “grow out of” their primary dysmenorrhea. Women may have associated nausea,
vomiting and diarrhea (due to excessive prostaglandin release from the uterus). Some may be severely
fatigued, pale and ill appearing. Occasionally vasovagal loss of consciousness may occur -usually with the
early years of menstruation only. Fever is not present; anorexia is rare other than with the first day of a
severe menstrual cycle.
Diagnosis: Based on history. Physical examination including pelvic should be normal. If the patient is
examined during her menstrual cycle, her bimanual examination may be notable for a tender uterus that is
of normal shape and size.
Treatment: Involves prostaglandin release suppression with NSAIDs and/or hormonal suppression of
ovulation with birth control pills. Any available NSAID is appropriate; it is important to prescribe at the maximal
level and to have the patient take them regularly either once the pain starts or 1-3 days prior to the onset of her
periods. Birth control pills are very effective at decreasing menstrual pain and should be prescribed to all who
fail NSAIDs. Regular exercise also decreases menstrual pain and premenstrual tension. Patients who do not
respond to the above treatments should be referred to a gynecologist. They may have endometriosis.
Endometriosis - very common cause (60-70%) of chronic pelvic pain in premenopausal women. Caused by
the presence of functional ectopic endometrial glands, which may be located in the ovaries, uterus, uterosacral
ligaments or any area within the pelvis. Essentially small bits of the uterine lining are growing in areas where
they should not be - the body reacts to these implants causing tissue damage. The usual age of onset is
in between age 30 and 40.
Symptoms: Dysmenorrhea (pain with menstruation) will occur in most women with endometriosis. This is
usually a change for them with worsening from the normal minor menstrual discomfort; it will often start at
least a week prior to the onset of menstruation and may last a few days after blood flow stops. This pain
often radiates to the rectum and inner thighs. Pain with intercourse (dyspareunia) is common and sometimes
the only complaint; it becomes worse during menses. Patients are often reluctant to engage in sexual
activity because of this pain. It is not uncommon for women with endometriosis to have daily pelvic pain -
these women will often have more severe disease. At least 30-40% of women with infertility problems have
endometriosis. There also appears to be a certain genetic component with 5-10% having a family history
positive for the disease.
Focused History for Endometriosis: Does the pain worsen with menstruation? Does the pain occur at
times other than during menses? Have you had problems getting pregnant (infertility)? Do you have pain with
intercourse? (Painful intercourse [dyspareunia] caused by endometriosis is described as “deep inside” or high
in the vagina. Pain with initial penetration that occurs at the entrance to the vagina is of other origin.
Pelvic Examination: Palpating the uterus and ovaries often reproduces the pain. The pain may be
reproduced with deep abdominal palpation but this is not a reliable finding. As endometriosis can cause
scarring in the pelvis, one can find that the uterus and ovaries are immobile due to adhesions. Endometriosis
can also cause ovarian cysts. Often the examination is unremarkable other than in the fact that you can
reproduce the patient’s pain. This is because very small areas of endometriosis can cause great pain.
Treatment: As endometriosis is a common cause of pelvic pain it is best keep this disease high in the
differential diagnosis. Many women are not diagnosed for years and so treatment is delayed. In a patient
with any history consistent with the above review it is best to start NSAIDs, birth control pills and refer to
Gynecology as surgery (laparoscopy) gives the definitive diagnosis and often alleviates symptoms. Ibuprofen
800 mg po tid or Naprosyn 500 mg po bid should be helpful. Birth control pills suppress ovulation, which will
decrease the activity of the endometriosis implants.