Adolescent dysmenorrhea (<18 years) - Curbside
Adolescent dysmenorrhea (<18 years)
Editors: Dan Imler, MD, Paula Hillard
Inclusion Criteria  (Any one criteria present)
  • Recurrent, crampy lower abdominal pain that occurs during menstruation
Exclusion Criteria
  • History of abdominal/pelvic surgery
  • Immunocompromised or oncologic history
  • Other complex medical history

Consider gynecology consult

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Evidence
Total Notes: 4
Evidence

1 Primary dysmenorrhea

Dysmenorrhea is the most common gynecologic complaint among adolescent females with a prevalence from 60-93%. Of this population however only about 15% will seek care. It is likely caused by an excess production of endometrial prostaglandin F2 alpha (PGF2 alpha), or an elevated PGF2 alpha:prostaglandin E2 (PGE2) ratio which leads to dysrhythmic uterine contractions, hypercontractility, and increased uterine muscle tone.

Dysmenorrhea usually does not occur until a women starts ovulatory menstrual cycles are established:

  • 18-45% by 2 years postmenarche
  • 45-70% by 2-4 years postmenarche
  • 80% by 4-5 years postmenarche


References:
  1. Use of medication by adolescents for the management of menstrual discomfort.
    Campbell MA, McGrath PJ,
    Arch Pediatr Adolesc Med 1997 Sep;151(9):905-13.
  2. A survey of adolescent dysmenorrhea and premenstrual symptom frequency. A model program for prevention, detection, and treatment.
    Wilson CA, Keye WR,
    J Adolesc Health Care 1989 Jul;10(4):317-22.
  3. Epidemiology of adolescent dysmenorrhea.
    Klein JR, Litt IF,
    Pediatrics 1981 Nov;68(5):661-4.
  4. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea.
    Johnson J,
    J Adolesc Health Care 1988 Sep;9(5):398-402.
  5. Primary dysmenorrhea in young Western Australian women: prevalence, impact, and knowledge of treatment.
    Hillen TI, Grbavac SL, Johnston PJ, Straton JA, Keogh JM,
    J Adolesc Health 1999 Jul;25(1):40-5.
  6. Dysfunctional uterine bleeding.
    Hertweck SP,
    Obstet. Gynecol. Clin. North Am. 1992 Mar;19(1):129-49.
  7. Studies in the involvement of prostaglandins in uterine symptomatology and pathology.
    Willman EA, Collins WP, Clayton SG,
    Br J Obstet Gynaecol 1976 May;83(5):337-41.
  8. Current status of the etiology and management of dysmenorrhea in adolescence.
    Alvin PE, Litt IF,
    Pediatrics 1982 Oct;70(4):516-25.
  9. Prostaglandins in primary dysmenorrhea. Comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives.
    Chan WY, Dawood MY, Fuchs F,
    Am. J. Med. 1981 Mar;70(3):535-41.
  10. The treatment of dysmenorrhea with naproxen sodium: a report on two independent double-blind trials.
    Henzl MR, Buttram V, Segre EJ, Bessler S,
    Am. J. Obstet. Gynecol. 1977 Apr;127(8):818-23.
  11. Dysmenorrhea: treatment with an antiprostaglandin.
    Larkin RM, Van Orden DE, Poulson AM, Scott JR,
    Obstet Gynecol 1979 Oct;54(4):456-60.

2 NSAIDs

NSAIDs are the first line of therapy in primary dysmenorrhea with 70-90% of patients having effective pain relief. In general, NSIADs have also been shown to be more effective than acetaminophen in this disease context. Some patients respond better to one class of NSAIDs vs. another (mefenamic acid vs propionic acid) so a trial of the other class may be useful if the patient is not initally improving.



References:
  1. Dysmenorrhoea.
    Proctor M, Farquhar C,
    Clin Evid 2003 Jun(9):1994-2013.
  2. Efficacy of minor analgesics in primary dysmenorrhoea: a systematic review.
    Zhang WY, Li Wan Po A,
    Br J Obstet Gynaecol 1998 Jul;105(7):780-9.
  3. Dysmenorrhea.
    French L,
    Am Fam Physician 2005 Jan;71(2):285-91.
  4. Current status of the etiology and management of dysmenorrhea in adolescence.
    Alvin PE, Litt IF,
    Pediatrics 1982 Oct;70(4):516-25.
  5. Prostaglandins in primary dysmenorrhea. Comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives.
    Chan WY, Dawood MY, Fuchs F,
    Am. J. Med. 1981 Mar;70(3):535-41.
  6. The treatment of dysmenorrhea with naproxen sodium: a report on two independent double-blind trials.
    Henzl MR, Buttram V, Segre EJ, Bessler S,
    Am. J. Obstet. Gynecol. 1977 Apr;127(8):818-23.
  7. Dysmenorrhea: treatment with an antiprostaglandin.
    Larkin RM, Van Orden DE, Poulson AM, Scott JR,
    Obstet Gynecol 1979 Oct;54(4):456-60.
  8. Cyclic pelvic pain and dysmenorrhea.
    Smith RP,
    Obstet. Gynecol. Clin. North Am. 1993 Dec;20(4):753-64.
  9. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea.
    Marjoribanks J, Proctor M, Farquhar C, Derks RS,
    Cochrane Database Syst Rev 2010 Jan(1):CD001751.
  10. Use of mefenamic acid in the treatment of primary dysmenorrhea.
    Budoff PW,
    JAMA 1979 Jun;241(25):2713-6.

3 Alternative therapies

Heat packs, exercise, sexual activity, mindfulness training and yoga have all been shown to be effective in releaving pain in dysmenorrhea. In addition, vitamin B1 (100 mg daily) and vitamin E (500 units daily) have been shown to impove symptoms greater than placebo.

It is unclear if acupuncture is useful in patients with primary dysmenorrhea as a meta-analysis was ineffective secondary to the heterogeneity of data.



References:
  1. Continuous low-level topical heat in the treatment of dysmenorrhea.
    Akin MD, Weingand KW, Hengehold DA, Goodale MB, Hinkle RT, Smith RP,
    Obstet Gynecol 2001 Mar;97(3):343-9.
  2. Continuous, low-level, topical heat wrap therapy as compared to acetaminophen for primary dysmenorrhea.
    Akin M, Price W, Rodriguez G, Erasala G, Hurley G, Smith RP,
    J Reprod Med 2004 Sep;49(9):739-45.
  3. Efficacy of the device combining high-frequency transcutaneous electrical nerve stimulation and thermotherapy for relieving primary dysmenorrhea: a randomized, single-blind, placebo-controlled trial.
    Lee B, Hong SH, Kim K, Kang WC, No JH, Lee JR, Jee BC, Yang EJ, Cha EJ, Kim YB,
    Eur. J. Obstet. Gynecol. Reprod. Biol. 2015 Nov;194:58-63.
  4. Effects of aerobic training on primary dysmenorrhea symptomatology in college females.
    Israel RG, Sutton M, O'Brien KF,
    J Am Coll Health 1985 Jun;33(6):241-4.
  5. Exercise for dysmenorrhoea.
    Brown J, Brown S,
    Cochrane Database Syst Rev 2010 Feb(2):CD004142.
  6. Primary dysmenorrhea and physical activity.
    Golomb LM, Solidum AA, Warren MP,
    Med Sci Sports Exerc 1998 Jun;30(6):906-9.
  7. Effect of three yoga poses (cobra, cat and fish poses) in women with primary dysmenorrhea: a randomized clinical trial.
    Rakhshaee Z,
    J Pediatr Adolesc Gynecol 2011 Aug;24(4):192-6.
  8. Effects of a Yoga Program on Menstrual Cramps and Menstrual Distress in Undergraduate Students with Primary Dysmenorrhea: A Single-Blind, Randomized Controlled Trial.
    Yang NY, Kim SD,
    J Altern Complement Med 2016 Sep;22(9):732-8.
  9. Counseling couples about coitus during menstrual flow.
    Hatcher RA,
    Contracept Technol Update 1981 Dec;2(12):167.
  10. Behavioural interventions for primary and secondary dysmenorrhoea.
    Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM,
    Cochrane Database Syst Rev 2007 Jul(3):CD002248.
  11. Dietary supplements for dysmenorrhoea.
    Pattanittum P, Kunyanone N, Brown J, Sangkomkamhang US, Barnes J, Seyfoddin V, Marjoribanks J,
    Cochrane Database Syst Rev 2016 Mar;3:CD002124.
  12. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms.
    Barnard ND, Scialli AR, Hurlock D, Bertron P,
    Obstet Gynecol 2000 Feb;95(2):245-50.
  13. Influence of dietary intake of dairy products on dysmenorrhea.
    Abdul-Razzak KK, Ayoub NM, Abu-Taleb AA, Obeidat BA,
    J. Obstet. Gynaecol. Res. 2010 Apr;36(2):377-83.
  14. A randomised placebo-controlled trial to determine the effect of vitamin E in treatment of primary dysmenorrhoea.
    Ziaei S, Faghihzadeh S, Sohrabvand F, Lamyian M, Emamgholy T,
    BJOG 2001 Nov;108(11):1181-3.
  15. A randomised controlled trial of vitamin E in the treatment of primary dysmenorrhoea.
    Ziaei S, Zakeri M, Kazemnejad A,
    BJOG 2005 Apr;112(4):466-9.
  16. Herbal and dietary therapies for primary and secondary dysmenorrhoea.
    Proctor ML, Murphy PA,
    Cochrane Database Syst Rev 2001(3):CD002124.
  17. Improvement of primary dysmenorrhea caused by a single oral dose of vitamin D: results of a randomized, double-blind, placebo-controlled study.
    Lasco A, Catalano A, Benvenga S,
    Arch. Intern. Med. 2012 Feb;172(4):366-7.
  18. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial.
    Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, Nicholson GC,
    JAMA 2010 May;303(18):1815-22.
  19. Efficacy of Ginger for Alleviating the Symptoms of Primary Dysmenorrhea: A Systematic Review and Meta-analysis of Randomized Clinical Trials.
    Daily JW, Zhang X, Kim DS, Park S,
    Pain Med 2015 12;16(12):2243-55.
  20. Acupuncture for dysmenorrhoea.
    Smith CA, Armour M, Zhu X, Li X, Lu ZY, Song J,
    Cochrane Database Syst Rev 2016 Apr;4:CD007854.
  21. Spinal manipulation for primary and secondary dysmenorrhoea.
    Proctor ML, Hing W, Johnson TC, Murphy PA,
    Cochrane Database Syst Rev 2006 Jul(3):CD002119.

4 Hormonal therapies

OCPs are effective in the treatment of dysmenorrhea often after inital trial of NSAIDs or as the primary method if the patient wishes for contraception at the same time. OCPs are thought to work by suppressing ovulation, thus causing a decrease in uterine prostaglandins. Although not as well tested, other hormonal methods besides pills (patch, ring, injectable/implantable contraceptives, or IUD) may also be effective.



References:
  1. Oral contraceptives for dysmenorrhea in adolescent girls: a randomized trial.
    Davis AR, Westhoff C, O'Connell K, Gallagher N,
    Obstet Gynecol 2005 Jul;106(1):97-104.
  2. Oral contraceptive pill for primary dysmenorrhoea.
    Wong CL, Farquhar C, Roberts H, Proctor M,
    Cochrane Database Syst Rev 2009 Oct(4):CD002120.
  3. Estradiol valerate plus dienogest versus ethinylestradiol plus levonorgestrel for the treatment of primary dysmenorrhea.
    Petraglia F, Parke S, Serrani M, Mellinger U, Römer T,
    Int J Gynaecol Obstet 2014 Jun;125(3):270-4.
  4. Effect of a low-dose oral contraceptive containing 20 microg ethinylestradiol and 150 microg desogestrel on dysmenorrhea.
    Callejo J, Díaz J, Ruiz A, García RM,
    Contraception 2003 Sep;68(3):183-8.
  5. Cycle control, quality of life and acne with two low-dose oral contraceptives containing 20 microg ethinylestradiol.
    Winkler UH, Ferguson H, Mulders JA,
    Contraception 2004 Jun;69(6):469-76.
  6. A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 20 micrograms ethinylestradiol/150 micrograms desogestrel, with respect to efficacy, cycle control and tolerance.
    Endrikat J, Jaques MA, Mayerhofer M, Pelissier C, Müller U, Düsterberg B,
    Contraception 1995 Oct;52(4):229-35.
  7. Primary dysmenorrhea treatment with a desogestrel-containing low-dose oral contraceptive.
    Hendrix SL, Alexander NJ,
    Contraception 2002 Dec;66(6):393-9.
  8. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception.
    Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA,
    Cochrane Database Syst Rev 2005 Jul(3):CD004695.
  9. Bleeding patterns and menstrual-related symptoms with the continuous use of a contraceptive combination of ethinylestradiol and drospirenone: a randomized study.
    Machado RB, de Melo NR, Maia H,
    Contraception 2010 Mar;81(3):215-22.
  10. The contraceptive vaginal ring compared with the combined oral contraceptive pill: a comprehensive review of randomized controlled trials.
    Roumen FJ,
    Contraception 2007 Jun;75(6):420-9.
  11. Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized controlled trial.
    Audet MC, Moreau M, Koltun WD, Waldbaum AS, Shangold G, Fisher AC, Creasy GW, Creasy GW,
    JAMA 2001 May;285(18):2347-54.
  12. Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons.
    Hubacher D, Lopez L, Steiner MJ, Dorflinger L,
    Contraception 2009 Aug;80(2):113-8.
  13. Depo-Provera in adolescents: effects of early second injection or prior oral contraception.
    Harel Z, Biro FM, Kollar LM,
    J Adolesc Health 1995 May;16(5):379-84.
  14. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)--a systematic enquiry and overview.
    Varma R, Sinha D, Gupta JK,
    Eur. J. Obstet. Gynecol. Reprod. Biol. 2006 Mar;125(1):9-28.
  15. Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea.
    Bahamondes L, Petta CA, Fernandes A, Monteiro I,
    Contraception 2007 Jun;75(6 Suppl):S134-9.
  16. The influence of intrauterine contraception on the prevalence and severity of dysmenorrhea: a longitudinal population study.
    Lindh I, Milsom I,
    Hum. Reprod. 2013 Jul;28(7):1953-60.
  17. Clinical profile of Implanon: a single-rod etonogestrel contraceptive implant.
    Croxatto HB,
    Eur J Contracept Reprod Health Care 2000 Sep;5 Suppl 2:21-8.
  18. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis--a pilot study.
    Walch K, Unfried G, Huber J, Kurz C, van Trotsenburg M, Pernicka E, Wenzl R,
    Contraception 2009 Jan;79(1):29-34.