Circumstances That May Indicate Secondary Dysmenorrhea
(see also chapter on Approach to abdominal pain in a woman)

Dysmenorrhea occurring during the first one or two cycles after menarche (congenital outflow obstruction).
Dysmenorrhea beginning after 25 years of age. Late onset of dysmenorrhea after a history without previous pain with menstruation (consider complications of pregnancy: ectopic or threatened spontaneous abortion).

Pelvic abnormality on physical examination Infertility (consider endometriosis, pelvic inflammatory disease or other causes of scarring) Heavy menstrual flow or irregular cycles (consider adenomyosis, fibroids, polyps) dyspareunia.

Little or no response to therapy with nonsteroidal anti-inflammatory drugs, oral contraceptives, or both.
Some secondary causes may be differentiated by inquiring about age of menarche, length of cycle, and the regularity and timing of the pain.

It is usually possible to differentiate dysmenorrhea from premenstrual syndrome PMS) based on the patient’s history. The pain associated with PMS is generally related to breast tenderness and abdominal bloating, rather than a lower abdominal cramping pain. PMS symptoms begin before the menstrual cycle and resolve shortly after menstrual flow begins.
Endometriosis may present as progressive dysmenorrhea but is often accompanied by pain

during intercourse and may affect fertility. In addition to the history of the timing of pain, the patient’s family history may be helpful in differentiating endometriosis from primary dysmenorrhea. Endometriosis has been found in up to 7 percent of first-degree relatives of women with confirmed endometriosis compared with an approximate overall incidence of 1 percent in the general population. An early diagnosis of endometriosis during adolescence can be an important step in minimizing the long-term sequelae, including pain and infertility.

A detailed sexual history is essential to assess for the risk of pelvic inflammatory disease (PID). Women with a previous history of PID, sexually transmitted diseases, multiple sexual partners or unprotected sex are at increased risk.

The physical examination centers on the bimanual pelvic examination. Findings during the nonmenstrual phase of the cycle are typically negative. If the pain is reproducible, it should be nonspecific and limited to the midline.

The primary intent of the examination is to rule out secondary causes of pain such as tumors or ovarian cysts.

With a typical history and a lack of abnormal findings on routine pelvic examination, further diagnostic evaluation is not needed. In fact, in many instances, it is preferable to confirm the diagnosis through a therapeutic trial of NSAIDs. At least partial relief of pain with NSAID therapy is so predictable in women with primary dysmenorrhea that failure to respond should raise doubts about the diagnosis.

Important to exclude endometriosis as early recognition is vital Family history may be suggestive in endometriosis Sexual history to exclude PID Trial of NSAIDs may be helpful in making the distinction