Dysmenorrhea is the medical term for painful
cramping associated with menstruation. It is classified as “primary” if not associated
with pelvic pathology, or “secondary” if associated with pelvic disease. Primary
dysmenorrhea can be attributed to endogenous prostaglandins and most commonly presents
in younger women. There are no abnormal physical exam findings, laboratory values, or imaging
studies. It is effectively treated with NSAIDs. Secondary dysmenorrhea is usually due one
of these three pelvic diseases: Endometriosis, which is the growth of endometrial
tissue outside of the uterine cavity. Depending on its location it can be associated with
such things as dyspareunia, bowel or bladder symptoms or infertility.Pelvic exam findings
might reveal nodularity of the uterosacral ligaments or enlarged ovaries suggestive of
endometriomas (ovarian endometriosis). Definitive diagnosis is made via laparoscopy at which
time endometrial implants are visualized or biopsied. Treatment can include surgical resection,
NSAIDs or hormonal therapy. Adenomyosis, which is the growth of endometrial
tissue into the uterine myometrium. In addition to dysmenorrhea it can also cause menorrhagia.An
enlarged (up to the equivalent of a 12 week gestation) or tender uterus may be found on
physical examination. Diagnosis is definitively made by surgical pathology. In some cases,
adenomyosis is responsive to NSAIDs and hormonal therapy but the definitive treatment is total
hysterectomy. Fibroids are benign tumors of the uterine
myometrium. They are associated with menorrhagia, infertility, and bowel and bladder symptoms.
Fibroids can frequently be palpated on pelvic exam as an enlarged, irregular shaped, pelvic
mass. Ultrasound or MRI confirm diagnosis, and treatment is directed by fertility desires.
Pelvic pain is not always limited to gynecological origin. Remember to keep bowel and bladder
pathology in your differential diagnosis.