Dysmenorrhea, defined as pain with menstruation, affects 50%–90% of menstruating adolescents and is the leading cause of recurrent school absenteeism in this population
One-third of menstruating adolescents miss school or sports because of dysmenorrhea.1 To minimize impact on academic and social development, physicians should proactively counsel patients on options for managing period pain.1–3 First-line treatment can be started before a specific diagnosis is made.2
Up to 90% of dysmenorrhea in adolescents occurs in the absence of pelvic pathology (primary dysmenorrhea) and is mediated by excess prostaglandin production
Features suggestive of secondary dysmenorrhea (Box 1) should prompt pelvic ultrasonography and may warrant referral to a gynecologist.2,3
Features suggestive of secondary dysmenorrhea2,3
Onset immediately with menarche
Progressively worsening dysmenorrhea
Abnormal bleeding (including irregular bleeding) with pain
Family or personal history of renal or other congenital anomalies (including spine, cardiac, or gastrointestinal)
Midcycle or acyclic pain
Dyspareunia
Family history of endometriosis
First-line treatment is short-term use of prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs)
Naproxen, ibuprofen and other NSAIDs are equally effective, with a number needed to treat (NNT) of 3 to achieve pain relief in people with primary dysmenorrhea.4 Full-strength doses should be taken with food, on a regular schedule with no skipped administrations starting 1–2 days before the onset of menses (if predictable) or at the first sign of bleeding or pain, and continued for the first 2–3 days of bleeding.2,3
Combined or progestin-only hormonal medications can be added as adjunct therapy
Combined oral contraceptives have an NNT of 5 for treating primary dysmenorrhea.5 Combined oral contraceptives with doses of ethinylestradiol above 30 μg should be chosen for adolescents, for maintenance of bone health.6 Continuous dosing provides more effective relief than standard cyclic use.2,3 Levonorgestrel-containing intrauterine systems and the etonogestrel implant are also safe and effective first-line options.2,3,7
Endometriosis is the most common cause of secondary dysmenorrhea in adolescents
Endometriosis is found in as many as 70% of adolescents who undergo laparoscopy for dysmenorrhea refractory to treatment with NSAIDs and hormonal therapy.3 If dysmenorrhea persists beyond 3 months despite adequate first-line treatment, referral to a gynecologist is warranted.
Footnotes
CMAJ Podcasts: author interview at www.cmaj.ca/lookup/doi/10.1503/cmaj.201972/tab-related-content
Competing interests: None declared.
This article has been peer reviewed.
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
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- Dysmenorrhea, defined as pain with menstruation, affects 50%–90% of menstruating adolescents and is the leading cause of recurrent school absenteeism in this population
- Up to 90% of dysmenorrhea in adolescents occurs in the absence of pelvic pathology (primary dysmenorrhea) and is mediated by excess prostaglandin production
- First-line treatment is short-term use of prophylactic nonsteroidal anti-inflammatory drugs (NSAIDs)
- Combined or progestin-only hormonal medications can be added as adjunct therapy
- Endometriosis is the most common cause of secondary dysmenorrhea in adolescents
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