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Gynecology

Dysmenorrhoea

Abdominal pain occurring just before or during menstruation, typically starting 12 hours before menses and lasting 1-3 days. Can be primary (common in adolescents, unknown cause) or secondary (due to underlying pathology like PID or fibroids, common >30 years).

Also known as: Menstrual Pain, Period Pain

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Referral and warning signs

When to refer

Refer to HC4/Specialist if no response to initial treatment after 5 days or if symptoms are recurrent/severe, or if secondary cause suspected.

Red flags

  • Severe pain unresponsive to simple analgesics.
  • Symptoms suggestive of secondary cause (e.g., heavy bleeding, infertility, fever).

Signs and symptoms

  • Lower abdominal cramping
  • Backache
  • Headache
  • Nausea
  • Vomiting
  • Diarrhoea
  • Fainting
  • Fever
  • Fatigue
  • Dizziness

Risk factors

  • For Secondary Dysmenorrhoea:
  • - Pelvic inflammatory disease (PID)
  • - Endometriosis
  • - Uterine fibroids
  • - Older age (>30 years)

Diagnosis

Clinical assessment

Diagnosis based on characteristic history of cyclical lower abdominal pain related to menstruation. Differentiate primary (occurs 6-12 months after menarche, decreases with age/childbirth) from secondary (older onset, underlying cause suspected). Rule out other causes of lower abdominal pain.

Differential diagnosis

  • Endometriosis
  • Pelvic Inflammatory Disease
  • Uterine Fibroids
  • Other causes of lower abdominal pain

Investigations

  • Clinical history and examination are primary.
  • Investigations focus on ruling out secondary causes if suspected (e.g., pelvic exam, ultrasound, STI screening).

Diagnostic criteria

Clinical diagnosis based on cyclical pain related to menstruation.

Management

Non-pharmacological management

  • Rest or sleep.
  • Exercise.
  • Warm compress application to abdomen.
  • Wear loose fitting clothes.
  • Dietary advice: Low fat diet; supplements like magnesium, vitamin B1, vitamin E, zinc.
  • (LOC: HC2)

Pharmacological treatment

  • NSAIDs: Ibuprofen 200–400 mg PO Q8H PRN. (LOC: HC2)
  • Alternative NSAID: Diclofenac 50 mg PO Q8H PRN for severe forms. (LOC: HC2)
  • Alternative (Mild pain): Paracetamol 1 g PO Q6H. (LOC: HC2)
  • Treat underlying cause if secondary dysmenorrhoea (e.g., treat PID). (LOC: HC3/HC4)

Monitoring

Review patient after 5 days. If no response or recurrent, refer for specialist management.

Complications

  • Impact on quality of life, school/work attendance.
  • Complications related to underlying cause if secondary dysmenorrhoea.

Prevention

  • Addressing underlying causes for secondary dysmenorrhoea.

Patient education

  • Reassurance about nature of primary dysmenorrhoea.
  • Explanation of non-pharmacological measures (rest, heat, exercise, diet).
  • How to use analgesics effectively.
  • When to seek further medical attention.

Uganda-specific notes

Common complaint, especially among adolescents. Need to consider PID as a cause of secondary dysmenorrhoea.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 14, Section 14.1.1

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