Painful Periods (Dysmenorrhea) — Full Text

Here we’re talking about painful periods that occur time after time.  We’re not talking about a new symptom that never happened before.  If that occurs & the pain is bad enough for a woman to seek medical care, we address it as pain with bleeding, not “painful period” (see Low Abdominal Pain).

Painful periods (dysmenorrhea) may be heavy or not, regular or not.  It’s common for teenagers to have painful periods, which can usually be managed with medications such as NSAIDs or acetaminophen.  But if the pain is too great, or lasts into their 20’s, or is something new that’s developed, we seek a diagnosis.

Causes of Painful Menstrual Periods

Mainly <25 y.o.Mainly > 25 y.o.Any Age
โ€ข Congenital Obstructions xxxx(occurring from birth)

x
x
โ€ข Uterine Fibroids (aka xxxxleiomyomas)
โ€ข Adenomyosis
โ€ข Rare Tumors
โ€ข Chronic Pelvic Inflammatory xxxxDisease (PID)
โ€ข Endometriosis
โ€ข Intra-Uterine Devices (IUD’s)
โ€ข Cervical Stenosis (tight)

The first step to diagnose dysmenorrhea is a pelvic exam.  Unusual tenderness would lead us to consider P.I.D. and do tests for STDs.  A large uterus would suggest Fibroids or Adenomyosis.  Lumps felt in the space between the vagina and rectum would suggest Endometriosis.  In Teenagers, we may rarely see Congenital Abnormalities that obstruct blood flow; in anyone, we might find cervical stenosis while trying to do a Pap smear, & not being able to insert the brush or spatula into the cervix.  But most of the time, the pelvic exam is completely normal.

So we order a transvaginal ultrasound (a regular ultrasound that includes a probe through the vagina).ย ย  This will easily diagnose Fibroids.ย  It might also show Adenomyosis, which can be hard to distinguish from Fibroids.ย  An MRI can help tell the difference, but that would only be obtained if a woman desired surgery (often a hysterectomy).ย  Surgery for either condition would be for comfort, not life-saving (unless bleeding was so great).ย  The ultrasound can also find ovarian cysts.

The hardest diagnosis to make for a woman with painful (& often heavy) periods is Endometriosis,  a disease caused by uterine tissue that gets implanted in various possible places outside the uterus.  It can have a wide variety of pain patterns.  In terms of menstrual pain, it often begins 1-2 days before the period and may last 2-3 more days afterwards.  The pain may be described by many different possible terms (pressure, burning, throbbing, sharp, and more).  Sexual intercourse may be painful.

Sometimes an ultrasound can suggest the diagnosis, but surgical laparoscopy is often necessary.ย  However, this entails certain risks, and its accuracy depends on skills of the surgeon.ย  So oftentimes, we’ll try treatment with birth control pills.ย  If that’s successful, we can’t be sure of the diagnosis, but at least our patient feels much better.ย  If that doesn’t work, we’d refer for laparoscopy before trying stronger medication that may be riskier.

Chronic P.I.D. thatโ€™s due to STDโ€™s might be diagnosed by routine urine tests, or by testing vaginal discharge (especially if there are white blood cells in it).  But since Chronic P.I.D. is a low-grade infection, it may require laparoscopy to identify.  Diagnosis is important, because the condition commonly causes infertility if untreated.

Teenagers with unusually painful menstrual periods may have Congenital Obstructions; abnormalities from birth which arenโ€™t recognized until they obstruct menstrual blood flow.ย  These often require special imaging techniques beyond an ultrasound.ย  Gynecologists often need to discuss this personally with Radiologists.

See also Painful Menstrual Periods for the clinicianโ€™s condensed thought-process when face-to-face with a patient.

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