Menstruation: Severe Cramps (Dysmenorrhea)

Description

Alternative Names

Diagnosis

A physician will perform a pelvic examination to check for pregnancy-related conditions or any abnormalities, such as ovarian cysts or fibroids.

Medical and Personal History

The physician needs to have a complete history of any medical or personal conditions that might be causing dysmenorrhea. He or she may need the following information:

• Any family history of menstrual problems.
• The presence or history of any medical conditions that might be causing pelvic pain.
• The pattern of the pelvic pain.
• Regular use of any medications (including vitamins and over-the-counter agents).
• Diet history, including caffeine and alcohol intake.
• Past or present contraceptive use.
• Any recent stressful events.
• Sexual history. (It is very important that the patient trust the physician enough to describe any sexual activity that might be risky.)

Ruling Out Causes of Pelvic Pain

Many conditions cause secondary dysmenorrhea. Also, abdominal pain caused by other conditions may mimic dysmenorrhea or may be associated with menstrual-like cramps and should be ruled out. Some causes of pelvic pain can be serious and should be ruled out during a work-up for dysmenorrhea. Resolving or treating these problems can often resolve the dysmenorrhea.

Conditions that cause secondary dysmenorrhea include the following:

• Endometriosis. This is an important cause of secondary dysmenorrhea and is difficult to diagnosis. Endometriosis should be highly suspected in women with severe menstrual cramps who also have infertility. Laparoscopy, an invasive diagnostic procedure, is the only definitive method for diagnosing endometriosis. However, a trial using one of several hormonal therapies is usually sufficient to confirm or rule out endometriosis. Such agents include danazol, GnRH agonists, and progestins.
• Uterine fibroids.
• Pelvic inflammatory disease (PID) (which is a result of infections in the pelvic area).
• Miscarriage.
• Ectopic pregnancy.
• Pelvic cancer (rare).
• Uterine polyps.
• Varices (enlarged or twisted veins) in the pelvic or genital area.

Fibroid tumors may not need to be removed if they are not causing pain, bleeding excessively, or growing rapidly.

Click the icon to see an image of an ectopic pregnancy.

Conditions that cause abdominal pain that may mimic dysmenorrhea include the following:

• Severe kidney or urinary tract infections.
• Celiac disease.
• Appendicitis.
• Interstitial cystitis.
• Inflammatory bowel disease.
• Diverticulitis.
• Irritable bowel syndrome.

Imaging Techniques

Imaging techniques using ultrasound or magnetic resonance imaging (MRI) may sometimes be used to detect certain conditions that may be causing menstrual disorders, such as fibroids or other structural abnormalities of the reproductive organs.

Click the icon to see an image of a CT scan.

Pelvic Examination

A physician will perform a pelvic examination to check for pregnancy-related conditions or any abnormalities, such as ovarian cysts or fibroids.

Diagnostic Procedures

Laparoscopy. Diagnostic laparoscopy, an invasive surgical procedure, is currently the only definitive method for diagnosing endometriosis. Laparoscopy normally requires a general anesthetic, although the patient can go home the same day. The procedure is as follows:

Click the icon to see an image of laparoscopy.

• The surgeon makes tiny abdominal incisions through which a fiber optic tube, equipped with small camera lenses, is inserted. The physician uses these devices to view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis) on a video monitor.
• Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away so that the physician has a wider view.
• A blue dye may be flushed through the fallopian tubes to determine blockage; if there is an obstruction, the dye will not flow through the tube.
• If the surgeon needs to remove small endometrial cysts or other lesions during the procedure (operative laparoscopy), tiny surgical instruments are passed through a tube.

The procedure is used for detecting and staging endometriosis to determine its severity. In some cases, the procedure itself will restore fertility in women with endometriosis.

Transvaginal Hydrolaparoscopy. Transvaginal hydrolaparoscopy is a new and less invasive approach than laparoscopy, since the instruments are inserted through the vagina, not through incisions in the abdomen. It requires only sedation, does not use CO2 to distend the abdomen, and has a much shorter and easier recovery than with standard laparoscopy. When used by a skilled professional, it is as accurate as laparoscopy, but is not yet widely available.

Hysteroscopy. Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. (It may miss cases of uterine cancer, however, and is not a substitute for more invasive procedures, such as D&C or endometrial biopsy, if cancer is suspected.)

It is done in the office setting and requires no incisions. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the physician to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.

Hysteroscopy is non-invasive, but 30% of women report severe pain with the procedure. The use of an anesthetic spray such as lidocaine may be highly effective in preventing pain from this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation. Hysteroscopy is also employed as part of surgical procedures.

Ultrasound

Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, endometriosis, ovarian cysts and tumors, and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort.