Presentation and assessment

In general primary dysmenorrhoea appears 6-12 months after the menarche when ovulatory cycles begin to become established. The early cycles after the menarche are usually anovular and tend to be painless. The pain usually consists of lower abdominal cramps and backache and there may be associated gastrointestinal disturbances such as diarrhoea and vomiting. Symptoms occur predominantly during the first 2 days of menstruation.

The diagnosis of primary dysmenorrhoea is one of exclusion (Table 40.6). If symptoms are typical of primary dysmenorrhoea, a therapeutic trial may be embarked on before considering any examination and investigation especially in adolescents. If clinical evaluation raises suspicion of secondary dysmenorrhoea transvaginal sonog-raphy (TVS) or magnetic resonance imaging (MRI) or laparoscopy should be considered. Similarly, if symptoms of primary dysmenorrhoea are not alleviated with either

Table 40.6 Assessment

How long have periods been painful Has there been any change When does the pain occur

Is there pelvic pain at other times or dyspareunia

Is there flooding or passage of clots

How long do periods last and how often do they occur

Is there any intermenstrual bleeding or post-coital bleeding

Is there a history of infertility or pelvic inflammatory disease

What contraception is being used

Are cervical smears up to date ( according to local screening programmes)

NSAIDs or the combined oral contraceptive pill or the combination of the two, secondary causes of dysmenorrhoea need to be considered. Secondary dysmenorrhoea should also be suspected if symptoms initially typical of primary dysmenorrhoea worsen in duration (starting premenstrually) and intensity.

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