Approach to dysmenorrhea: Clinical sciences

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Introduction0:00–0:42

Dysmenorrhea is pain with menstruation. It can be primary in nature, meaning pain without pelvic pathology or secondary, indicating pain from pelvic pathology or a recognized medical condition.
Causes of secondary dysmenorrhea include endometriosis, adenomyosis, uterine leomyomas, adnexal masses, pelvic inflammatory disease, vaginal obstructive anomalies, and cervical stenosis.
Dysmenorrhea is one of the most common gynecologic conditions and can have a significant impact on your patient's physical and mental well-being.
Let's begin with primary dysmenorrhea. When evaluating a patient, your first step is to obtain a focused history.

Primary dysmenorrhea0:42–1:37

Pain typically begins with the onset of ovulatory cycles, which usually occurs within 6 to 12 months following monarchy.
The pain is typically located in the lower back, pelvis, and or the upper thighs. It can be associated with other symptoms like nausea, vomiting, diarrhea, headaches, muscle cramps, and poor sleep.
If your patient's history meets these criteria, you can diagnose primary dysmenorrhea, which is more common in adolescents.
Here's a clinical pearl. Keep secondary dysmenorrhea in mind for patients whose symptoms do not improve within 3 to 6 months of treatment, whose symptoms are progressively worsening, or if pelvic pathology is suspected.

Secondary dysmenorrhea1:37–2:23

OK, let's move on to secondary dysmenorrhea. On history, common symptoms might include severe dysmenorrhea, which may have begun immediately after monarchy or may have developed some time after monarchy.
Progressively worsening dysmenorrhea, abnormal uterine bleeding, mid-cycle or acyclic pain, infertility, lack of response to empiric medical treatment.
Other symptoms can be dysperunia or pain with intercourse, pelvic pain associated with vaginal discharge, and family history of pelvic pathology, such as endometriosis or congenital anomalies.
Any of these symptoms should raise your suspicion for underlying pelvic pathology and secondary dysmenorrhea. Now, let's assess for causes of secondary dysmenorrhea.

Endometriosis 2:23–4:32

Let's start with the most common one, endometriosis. This is characterized by endometrial stroma or glandular tissue outside of the endometrial cavity.
A focused history may reveal the four Ds of endometriosis dysmenorrhea, dysperunia, dyschesia, or painful defecation, and in some patients, nonbacterial dysuria.
These symptoms, as well as generalized pelvic pain, are often exacerbated by menses and can be cyclic in nature. On a physical exam, you might find lower abdominal or pelvic tenderness, a pelvic mass, reduced uterine mobility, a tender posterior vaginal fornix, and rectal vaginal nodularity.
If this is the case, consider endometriosis. The next step is to obtain a pelvic ultrasound and consider performing a diagnostic laparoscopy to confirm your diagnosis.
Characteristic findings include a pelvic or adnexal mass, such as an ovarian endometrioma or deep infiltrating endometriosis.
Endometriomas appear as cysts that contain low-level homogeneous internal echoes consistent with old blood. If you see an endometrioma on ultrasound, or if the laparoscopy reveals an endometrioma or endometriotic implants and scarring, you can diagnose endometriosis.
Here's a clinical pearl. The definitive diagnosis of endometriosis can only be made by pathologic confirmation of lesions removed via laparoscopic surgery.
However, given surgical risks and costs, many clinicians make a presumptive diagnosis of endometriosis based on clinical history, physical exam, and ultrasound.
And now a high yield fact, an endometrioma can also be referred to as a chocolate cyst, because it contains old blood that, when expressed, looks like chocolate syrup.

Adenomyosis4:32–5:13

Next up is adenomyosis. Here the glandular endometrial tissue extends into the uterine myometrium.
The patient might report heavy vaginal bleeding and intermenstrual spotting. Physical exam findings may include lower abdominal or pelvic tenderness and an enlarged globular uterus.
In this case, consider adenomyosis and obtain a pelvic ultrasound. Signs of adenomyosis on ultrasound include a heterogeneous myometrium, myometrial cysts, and asymmetrical myometrial thickness.
If you see these findings, diagnose adenomyosis. Moving on to liomyomas or uterine fibroids.

Uterine leiomyoma 5:13–6:17

These are common benign solid neoplasms made up of smooth muscle cells and fibroblasts. History might reveal heavy vaginal bleeding as well as the symptoms of uterine enlargement such as pelvic pressure or low back pain, urinary frequency, and constipation.
On physical exam, you may note abdominal or pelvic tenderness and an enlarged uterus or an irregular uterine contour. With these findings, consider a uterine liomyoma and obtain a pelvic ultrasound.
If the ultrasound reveals an enlarged uterus with at least one myometrial mass, the diagnosis is liomyoma. Here's another high yield fact.
Uterine leomyomas are the most common gynecologic pelvic neoplasm. Without surgical removal and histologic analysis, they're difficult to distinguish from the rare but aggressive leomyosarcoma.

Benign or malignant adnexal mass 6:17–7:32

OK, let's move on to adnexal pathology. Your patient may describe intermittent unilateral pain that's indolent or progressive in nature.
They may also report abdominal distention or bloating along with pelvic pressure. A physical exam might reveal abdominal or pelvic tenderness and a pelvic mass.
In these patients, consider an adnexal mass and obtain a pelvic ultrasound. If the ultrasound demonstrates a cystic or solid adnexal mass, your diagnosis is either a benign or malignant adnexal mass.
As a quick reminder, adnexal masses can be cystic or solid, simple or complex, as well as unilateral or bilateral. Time for another clinical pearl.
The diagnosis and management of eggnexal masses is complicated and is determined by multiple factors, including patient age, history, risk factors for malignancy, and ultrasound findings.
The differential includes a simple ovarian cyst, endometrioma, cystadenoma, teratoma, hydrosalpinx, tubo ovarian abscess, an adnexolomyoma, and ovarian or tubal malignancy.

Pelvic inflammatory disease7:32–8:53

Next up is pelvic inflammatory disease or PID, which is an infection of the uterus, fallopian tubes, ovaries, and or peritoneum.
Gonorrhea or chlamydia, two sexually transmitted infections, are often the cause of PID, but it can also be due to normally existing microorganisms in the vaginal flora.
Generally, patients are sexually active. They usually present with intermenstrual bleeding, but might also report pelvic or abdominal pain, abnormal vaginal discharge, fever, nausea and vomiting, and dysuria.
On physical exam you will often note mucopurulent cervical discharge or a friable cervix and one or more of the following pelvic tenderness, abdominal tenderness, and or cervical motion tenderness.
With these findings, you can diagnose pelvic inflammatory disease. Here's a clinical pearl.
PID typically presents as either acute pelvic pain or as chronic pelvic pain. Chronic pelvic pain is defined as pain symptoms perceived to originate from pelvic structures, typically lasting more than 6 months.
Nonetheless, PID may also present in some patients as secondary dysmenorrhea. OK, let's switch gears and talk about congenital anomalies that can cause secondary dysmenorrhea.

Congenital anomalies8:53–11:23

These patients may present after puberty with amenorrhea, pelvic pain, which may be cyclic in nature, lower abdominal or back pain, chronic constipation, urinary symptoms like increased frequency, dysuria, hematuria, or retention, pain or difficulty using tampons, recurrent vaginal discharge, and infertility.
If these symptoms are present, consider an obstructive congenital anomaly. Now, an abdominal exam may reveal tenderness or an abdominal mass from an enlarged obstructed uterus.
If on genital exam you visualize a shortened vagina without a palpable cervix, your most likely diagnosis is a transverse vaginal septum.
On the flip side, visualization of hematoculpus, or trapped blood in the vagina, which appears as a dark colored or blue tinged bulge at the vaginal introitis along with membranous tissue covering the introus, indicates an imperforate hymen azure diagnosis.
Both of these obstructive congenital anomalies can exist as partial or complete obstructions. Here's another clinical pearl.
Physical exam should be guided by patient comfort. Start with gentle downward labial traction to open and separate the labia and adequately visualize the distal introus.
If a speculum exam is not possible or tolerated, you can insert a cotton swab through the introitis to assess vaginal length.
Use a smaller speculum or even consider a nasal speculum. Also, a digital rectal exam may be less uncomfortable and help assess vaginal length and the presence of a cervix.
And now a high yield fact. Imaging is not always required if the diagnosis is straightforward, as with an imperforate hymen.
However, when needed, ultrasound is the preferred, and transabdominal pelvic assessment should be completed first. Conditions like a transverse vaginal septum, distal vaginal atresia, cervical atresia, or an obstructed uterine horn require further imaging with an MRI.
Keep in mind that congenital obstructions may be associated with other Mullerian and renal abnormalities. All right, let's discuss cervical stenosis, which is a non-congenital obstruction.

Cervical stenosis11:23–12:33

Your patient will often present with amenorrhea, abnormal uterine bleeding, infertility, history of cervical surgery, such as prior cold knife cone or LEEP, or history of endometrial ablation.
On physical exam, the cervix may appear normal or scarring may be present. The defining feature of a stenotic cervix is difficulty or the inability to access the uterine cavity through the cervix.
This is typically diagnosed with attempts to collect endocervical cells or an endometrial sample. When this is encountered, obtain a pelvic ultrasound.
The ultrasound can be helpful to look for a hemanometra or pyometra, meaning when the uterus is filled with blood or pus, respectively.
With these findings, you can diagnose cervical stenosis. Lastly, if you've ruled out all these causes of secondary dysmenorrhea, consider other possible or alternative diagnoses, such as endometrial polyps and pelvic adhesions.

Review12:33–13:10

All right, as a quick recap, dysmenorrhea is pain with menstruation, a common gynecological condition that can have a significant impact on your patient's physical and mental well-being.
Primary dysmenorrhea is pain without pelvic pathology and typically occurs in adolescence. Secondary dysmenorrhea is due to pelvic pathology or a recognized medical condition.
These include endometriosis, adenomyosis, uterine liomyomas, adnexal masses, pelvic inflammatory disease, obstructive congenital anomalies, and cervical stenosis.
Approach to dysmenorrhea: Video, Steps, and Uses | Osmosis