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Dysmenorrhea
What's new
The Society of Obstetricians and Gynaecologists of Canada (SOGC) has published a new guideline on primary dysmenorrhea. Diagnosis is based on clinical history, and treatment can be initiated without an initial pelvic exam. A pelvic exam and ultrasound are recommended for patients who do not respond to conventional therapy or when organic pathology is suspected. MRI may be considered if ultrasound is inconclusive or if there is a strong suspicion of deep infiltrating endometriosis or adenomyosis. First-line therapy includes NSAIDs, acetaminophen, regular exercise, and continuous or extended-use combined hormonal contraceptives. Complementary interventions include high-frequency transcutaneous electrical nerve stimulation, local heat therapy, acupoint stimulation, and ginger supplementation. .
Background
Overview
Definition
Dysmenorrhea refers to painful menstruation, characterized by cramping lower abdominal pain that occurs before or during menstruation, and is classified as either primary or secondary based on underlying etiology.
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Pathophysiology
Primary dysmenorrhea occurs in the absence of identifiable pelvic pathology and is associated with increased endometrial production of prostaglandins, particularly prostaglandin F2α, and leukotrienes, which induce intense uterine contractions, ischemia, and pain. In contrast, secondary dysmenorrhea results from structural or inflammatory pelvic disorders that contribute to pain through mechanisms such as nerve infiltration, chronic inflammation, or distortion of pelvic anatomy. Symptom severity in both forms often correlates with prostaglandin levels and other local inflammatory mediators.
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Epidemiology
Dysmenorrhea is highly prevalent and commonly undertreated, affecting 50-90% of adolescent girls and women of reproductive age. It is a leading cause of school and work absenteeism and significantly impacts QoL.
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Risk factors
Risk factors for primary dysmenorrhea include early menarche, long or heavy menstrual cycles, smoking, alcohol use, high stress levels, nulliparity, premenstrual syndrome, a history of pelvic inflammatory disease, and a family history of dysmenorrhea. Increasing age and increasing parity are protective factors. Secondary dysmenorrhea is associated with identifiable pelvic pathology such as endometriosis, adenomyosis, fibroids, ovarian cysts, Müllerian anomalies, pelvic adhesions, or pelvic inflammatory disease.
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Disease course
Symptoms of primary dysmenorrhea typically begin within a few years of menarche, presenting as cramping suprapubic pain that peaks during the first 1-2 days of menstruation and is often accompanied by nausea, diarrhea, fatigue, dizziness, and headache. Severe cases may also cause sleep disturbances. Secondary dysmenorrhea tends to present later in reproductive life with progressive or atypical pain patterns and is generally less responsive to first-line therapies. Both forms can become chronic and significantly impact QoL, academic performance, and work productivity.
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Prognosis and risk of recurrence
Primary dysmenorrhea often improves with age, childbirth, or hormonal therapy and generally responds well to NSAIDs or hormonal contraceptives. Secondary dysmenorrhea may persist or worsen without appropriate treatment, especially in conditions like endometriosis or adenomyosis. Unless adequately treated and followed, dysmenorrhea may progress to a chronic pain syndrome with significant long-term consequences.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of dysmenorrhea are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2025,2024), the American Academy of Family Physicians (AAFP 2021), and the American College of Obstetricians and Gynecologists (ACOG 2018).
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Diagnostic investigations
History and physical examination
As per SOGC 2025 guidelines:
Elicit a thorough menstrual, pain, and gynecologic history, including symptom onset, severity, and response to prior treatments.
E
Consider performing a pelvic examination in patients not responding to conventional therapy and when organic pathology is suspected. Consider initiating therapy without first performing a pelvic examination.
E
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Diagnostic imaging
Diagnostic procedures
Medical management
General principles
As per AAFP 2021 guidelines:
Consider initiating empiric therapy if the history is consistent with primary dysmenorrhea.
C
Consider initiating therapy without first performing a pelvic examination.
E
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NSAIDs
Hormonal contraceptives
Nonpharmacologic interventions
Exercise: as per SOGC 2025 guidelines, advise regular exercise to improve the symptoms of dysmenorrhea.
B
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Alternative and complementary therapies
Surgical interventions
Indications for surgery
As per SOGC 2025 guidelines:
Consider offering surgical intervention only when dysmenorrhea persists despite optimized medical therapy or when secondary causes are strongly suspected.
B
Obtain a thorough clinical evaluation, including pelvic examination, rectovaginal assessment, and abdominal wall muscle evaluation, before considering surgical options.
B