MENSTRUAL PAIN OF NEW ONSET AND WORSENING MENSTRUAL PAIN; WHY AND WHAT CAN I DO ABOUT THIS?

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Secondary dysmenorrhea refers to menstrual pain of new onset in a woman previously void of menstrual pain or the presence of worsening menstrual pain over a period of time.It is secondary to an underlying pelvic disease.

Causes

These include diverse set of diseases or disorders affecting the uterus (womb), adnexea and the pelvic cavity. They are:

Pelvic inflammatory disease (PID)

Intra uterine devices

Uterine fibroids

Endometriosis

Pelvic adhesions

Adenomyosis

Cervical stenosis

Gynaetresia

Presentation

The presentation varies and depends on the underlying disease condition. It typically presents as any other pattern of menstrual pain different from that described for primary dysmenorrhea. It has no singular pattern of presentation and may occur at any phase of the menstrual cycle as well as during menstruation and unlike primary dysmenorrhea that typically appears few months after menarche, it may appear at anytime during the reproductive years. It may also present as worsening primary dysmenorrhea or as a new onset of cyclical lower abdominal pain felt in a woman who never experienced primary dysmenorrhea. With multiple possible causes, its severity varies with its cause and resolution of symptoms usually occurs following the treatment of the underlying cause.

It may also present with other symptoms typical of the underlying cause of the dysmenorrhea. For example, secondary dysmenorrhea may be associated with heavy menstrual bleeding in uterine fibroids, adenomyosis and in women with IUCD. Similarly, women with uterine fibroid and adenomyosis may present with a lower abdominal swelling and an abdominal mass on physical examination while those with PID may present with an offensive vaginal discharge associated with fever. Endometriosis another common cause of secondary dysmenorrhea often present with severe symptoms associated with painful intercourse on deep penetration (dyspareunia).

Diagnosis

This involves taking a detailed history, performing a thorough examination and employing the use of necessary investigations. Usually from the clinical history, it is easy to differentiate primary dysmenorrhea from secondary dysmenorrhea, but not always so from the different causes of secondary dysmenorrhea. Specific presentation, investigations and treatment of the various causes of secondary dysmenorrhea will be discussed in detailed in respective articles written about them. In the main time, basic investigations necessary for the diagnosis of secondary dysmenorrhea are discussed below.

Differential diagnosis

This includes primary dysmenorrhea as well as any of the above listed causes of secondary dysmenorrhea.  

Investigations

Investigations commonly done are;

Abdominal ultrasound: This is important in making a diagnosis of uterine fibroids, adenomyosis as well as to diagnose the presence of ovarian masses in suspected cases of endometriosis.

Laparoscopy: This is the gold standard of diagnosis of PID, endometriosis and pelvic adhesions. It can also be used to view first hand, the presence of any other pelvic diseases such as the uterine fibroids and ovarian cysts.  It has the advantage in expert hands to be used for the treatment of many of the causes of secondary dysmenorrhea.

Chlamydia and Gonorrhea screening tests: Patients with vaginal discharge and those with symptoms suggestive of pelvic inflammatory disease (PID) should be screened for Gonorrhea and Chlamydia infection. These include antibody tests for Chlamydia and endo-cervical swab M/C/S for Gonorrhea. If present other STDs should be investigated and all contacts traced to disrupt the chain of transmission.

Treatment

The definitive treatment of secondary dysmenorrhea is by the treating its cause. However, many of the above listed approach for the treatment of primary dysmenorrhea may help to reduce the symptoms till a definitive approach of treatment is available or desirable. For example, patients with uterine fibroids, endometriosis and adenomyosis presenting with secondary dysmenorrhea may benefit from the use of NSAIDs, OCPs or the insertion of Mirena for the relief of their menstrual pains pending their definitive management with surgery. For treatment of specific causes of secondary dysmenorrhea, kindly please see a gynaecologist.

Previous Article:  Primary dysmenorrhea

Reference

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. British Medical Journal 2006; 332: 1134–8.

Source: Ewomen Clinic