Painful menstruation affects over half of menstruating women and is the leading cause of lost time from school and work among women of childbearing age. This pain may precede menstruation by several days or may accompany it, and usually subsides as bleeding tapers off.

Some pain during menstruation is normal; excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities or require medication.

There are several types of dysmenorrhea:
Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women. This type of pain is not related to any specific problems with the uterus or other pelvic organs. Prostaglandin (a substance that circulates in the body) activity is thought to be a causative factor because prostaglandin levels have been found to be much higher in women with dysmenorrhea than in women who experience only mild or no menstrual pain.

Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus (for example, pelvic inflammatory disease, fibroids, endometriosis, adhesions, or uterine displacement). Endometriosis is the most common cause of dysmenorrhea associated with a disease process and is frequently misdiagnosed.

Psychogenic dysmenorrhea may be attributed to emotional stress or anxiety. It can also be caused by wrong information regarding menstruation or negative attitudes about the menstrual cycle.

The presence of an IUD (intrauterine device for contraception) may be a potential cause of menstrual pain, however the currently used IUDs usually lead to pelvic pain only around the time of insertion.

The incidence of menstrual pain is greatest in women in the late teens and twenties, then declines with age. It does not appear to be affected by childbearing. An estimated 10 to 15% of women experience menstrual pain each month severe enough to prevent normal daily function at school, work, or home. The majority of women will suffer this degree of disability at least once during their reproductive years. Increased risk is associated with younger age, multiple sexual partners, and past medical history of any of the conditions associated with secondary dysmenorrhea.

• premenstrual syndrome (PMS)
• stress and anxiety
• pelvic inflammatory disease
• multiple sexual partners
• history of sexual or physical abuse
• fibroids
• ovarian cysts
• endometriosis

• the pain is severe.
• menstrual periods always hurt, or if other unexplained symptoms accompany the pain.

• menstrual history
  • Are you a woman presently in a menstruating age?
  • Are you sexually active?
  • Do you use birth control? What type?
• quality
  • Was the previous menstrual period a normal amount?
  • Do you use tampons with menstruation?
  • Do you normally have regular periods?
  • Do you have heavy menstrual bleeding (menorrhagia)?
    • With passage of blood clots?
  • Do you have prolonged menstrual bleeding (more than five days per menstrual period)?
  • Describe the pain (sharp, dull, intermittent, constant, aching, cramping).
• time pattern
  • When was the last menstrual period?
  • What was the age at which you had your first menstrual period?
  • How long have you had the same menses pattern?
  • When did you begin to have painful menstruation?
  • Is it getting worse or better?
  • When in your menstrual cycle do you experience the pain?
• relieving factors
  • What have you done to try to relieve the discomfort?
    • How effective was it?
  • What has been effective in the past for you?
• other
  • What other symptoms are also present?

• dilation of the cervix (see D&C procedure)
• laparoscopy
• cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or Chlamydia infections)
• CBC
• sed rate
• RPR

• Oral contraceptives may be prescribed as an attempt to alleviate menstrual pain. If not needed for contraception, they may be discontinued after 6 to 12 months. Many women note continued freedom from symptoms despite stopping the medication.
• Surgery may be indicated for those women unable to obtain adequate pain relief or control. Procedures may range from removal of cysts, polyps, adhesions, or fibroids to complete hysterectomy in cases of extreme endometriosis.
• Prescription medications may be used for endometriosis.
• For pain caused by IUD, removal of the IUD and alternative birth control methods may be needed.
• Antibiotics may be indicated for pelvic inflammatory disease.