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Women's health

Dysmenorrhoea

Last revised in October 2023

Dysmenorrhoea is painful cramping, usually in the lower abdomen, occurring shortly before or during menstruation, or both.

Dysmenorrhoea: Summary

  • Dysmenorrhoea is painful cramping, usually in the lower abdomen, which occurs shortly before and/or during menstruation. 
  • There are two types of dysmenorrhoea: primary and secondary.
    • Primary dysmenorrhoea occurs in the absence of any identifiable underlying pelvic pathology. It is thought to be caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain. 
    • Secondary dysmenorrhoea is caused by an underlying pelvic pathology (such as endometriosis, fibroids, or pelvic inflammatory disease [PID]) or by intrauterine device (IUD) insertion. 
  • Dysmenorrhoea is common. Prevalence rates vary widely in the literature and range from 16–91% in women of reproductive age.
  • Dysmenorrhoea adversely affects a woman's quality of life and well-being and can lead to restriction of daily activities and absence from school or work. 
  • Risk factors for primary dysmenorrhea (or more severe episodes) include earlier age at menarche, heavy menstrual flow, nulliparity, and family history of dysmenorrhoea. 
  • Secondary causes for dysmenorrhoea must be excluded before a diagnosis of primary dysmenorrhoea is considered. 
  • Primary dysmenorrhoea usually starts 6–12 months after the menarche once cycles are regular.
    • The pain starts shortly before the onset of menstruation and may last for up to 72 hours, improving as the menses progresses.
    • The pain is usually lower abdominal but may radiate to the back and inner thigh. It may be accompanied by non-gynaecological symptoms, such as vomiting, nausea, diarrhoea, fatigue, irritability, dizziness, headache, and lower back pain. 
    • Pelvic examination is normal.
  • Secondary dysmenorrhoea often starts after several years of painless periods. 
    • The pain is not consistently related to menstruation and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
    • Other gynaecological symptoms (such as dyspareunia) are often present.
    • Pelvic examination may be abnormal, but normal findings do not exclude secondary dysmenorrhoea.
  • Clinical features indicating a serious secondary cause of dysmenorrhoea include:
    • Positive pregnancy test with vaginal bleeding.
    • Ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids).
    • Abnormal cervix on examination.
    • Persistent intermenstrual or postcoital bleeding without associated features of PID, such as pelvic pain, deep dyspareunia, and abnormal vaginal or cervical discharge.
  • For primary dysmenorrhoea:
    • A nonsteroidal anti-inflammatory drug (such as ibuprofen) and/or paracetamol will usually provide pain relief.
    • For women who do not wish to conceive, hormonal contraception is an alternative first-line treatment and has the additional advantage of providing contraception.
    • Local application of heat (for example, a hot water bottle or heat patch) and transcutaneous electrical nerve stimulation (TENS) may also help to reduce pain.
    • If symptoms are severe and have not responded to initial treatment within 3–6 months or if there is doubt about the diagnosis, referral to a gynaecologist should be arranged. 
  • Women with secondary dysmenorrhoea should be referred appropriately to secondary care for further investigation and management. 

Have I got the right topic?

From age 10 years onwards (Female).

This CKS topic covers the management of dysmenorrhoea in primary care.

This CKS topic does not cover the management of chronic or non-cyclical pelvic pain, or premenstrual syndrome. It also does not cover in detail the management of secondary causes of dysmenorrhoea.

There are separate CKS topics on Contraception - IUS/IUD, Endometriosis, Fibroids, Pelvic inflammatory disease, and Premenstrual syndrome.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2023 — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Previous changes

November 2018 — reviewed. A literature search was conducted in November 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made, but the topic has been restructured.

March to May 2014 — reviewed. Literature searches were conducted in January 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. Only one significant change has been made to this topic:

  • Codeine has been removed as a treatment option. There is no evidence that weak opioids are effective for the treatment of primary dysmenorrhoea. Expert opinion published in guidelines by the European Association of Urology state that as a result of the chronic nature of dysmenorrhoea, potentially addictive analgesics should be avoided [EAU, 2012]. This is in line with recommendations made by the Royal College of Obstetricians and Gynaecologists [RCOG, 2012].

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

October 2010 — minor update. From mid-October 2010, Nexplanon® will replace Implanon®. Nexplanon® is bioequivalent to Implanon®. The main differences are that Nexplanon® is radio-opaque and the insertion technique is different. 

September 2010 — minor update. A prescription for Rigevidon®, a new ethinylestradiol plus levonorgestrel combined oral contraceptive (COC) pill, has been added. 

June 2010 — minor update. A prescription for Levest®, a new ethinylestradiol plus levonorgestrel COC pill, has been added.

March 2010 — minor update. Results of the updated Cochrane systematic review on nonsteroidal anti-inflammatory drugs for dysmenorrhoea have been updated in the Supporting evidence section. 

June 2009 — minor update. Correction to prescription title.

December 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Progestogen-only contraceptives are now recommended as an alternative to COCs.

March 2009 — minor update. The upper age limit on the COC pill prescriptions has been reduced to 50 years. 

October 2006 — minor update. Analgesia prescriptions have been updated to reflect new doses of ibuprofen for children as recommended in the British National Formulary (BNF). 

October to December 2005 — reviewed. Validated in March 2006 and issued in May 2006. The topic was reviewed and updated following a full literature review. There have been no major changes to the recommendations. A more detailed Supporting evidence section has been included.

August 2002 — reviewed. Validated in December 2002 and issued in February 2003.

November 1999 — written. Validated in March 2000 and issued in May 2000.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 November 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 November 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 November 2023.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analyses 1 November 2023.

Primary evidence

No new randomized controlled trials published in major journals since 1 November 2023.

New policies

No new national policies or guidelines since 1 November 2023.

New safety alerts

No new safety alerts since 1 November 2023.

Changes in product availability

No changes in product availability since 1 November 2023.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Distinguish between primary and secondary dysmenorrhoea.
  • Manage primary dysmenorrhoea appropriately in primary care.
  • Assess for a cause of secondary dysmenorrhoea.
  • Refer appropriately to secondary care or other specialist services.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Dysmenorrhoea is painful cramping, usually in the lower abdomen, which occurs shortly before or during menstruation, or both. 
  • There are two types of dysmenorrhoea: primary and secondary.
    • Primary dysmenorrhoea occurs in the absence of any identifiable underlying pelvic pathology. It usually begins 6–12 months after the menarche, once cycles are regular, and is thought to be caused by the production of uterine prostaglandins during menstruation.
      • Before menstruation begins, progesterone levels drop, causing endometrial cells to release prostaglandins. Prostaglandins stimulate uterine myometrial contractions, leading to decreased blood flow, uterine hypoxia, and pain.
      • Further effects of prostaglandins on smooth muscles may manifest as gastrointestinal symptoms (such as vomiting, nausea, and diarrhoea), which frequently coexist with primary dysmenorrhoea.
      • Leukotrienes and vasopressin may also play a role in the aetiology of primary dysmenorrhoea.
    • Secondary dysmenorrhoea often starts after several years of painless periods and is caused by an underlying pelvic pathology (such as endometriosis, adenomyosis, fibroids, endometrial polyps, or pelvic inflammatory disease) or by intrauterine device (IUD) insertion.

[Righarts, 2018; Ferries-Rowe, 2020; McKenna, 2021; BMJ Best Practice, 2023a]

How common is it?

  • Dysmenorrhoea is common.
  • Prevalence rates vary widely in the literature and range from 17–91% in women of reproductive age, with severe pain reported in 2–29% of women.
    • The variation in reported prevalence rates is probably due to different definitions of dysmenorrhoea, variable methods of data collection, and diverse study populations. 
    • Despite the high reported prevalence of dysmenorrhoea and the impact it has on quality of life and general well-being, many women do not seek medical treatment and accept it as a normal part of the menstrual cycle.

[Lacovides, 2015; Subasinghe, 2016; Righarts, 2018; Ferries-Rowe, 2020; BMJ Best Practice, 2023a]

What are the risk factors?

  • Risk factors for primary dysmenorrhoea (or more severe episodes) include earlier menarche, heavy menstrual flow, nulliparity, family history of dysmenorrhoea, and emotional stress.
    • Primary dysmenorrhoea has also been associated with a BMI of less than 20 kg/m2, cigarette smoking, and a history of sexual abuse.
  • Primary dysmenorrhoea tends to improve with increased age, parity, and use of oral contraceptives.
  • There is a lack of data on an association between primary dysmenorrhoea and nutritional deficiency. However, treatment with iron supplements can cure or improve dysmenorrhoea in women with iron deficiency.
  • Risk factors for secondary dysmenorrhoea will depend on the underlying cause.

[Ju, 2014; De Sanctis, 2015; Righarts, 2018; Ferries-Rowe, 2020; BMJ Best Practice, 2023a]

What are the complications of dysmenorrhoea?

Primary dysmenorrhoea is a substantial public health burden because of its high prevalence.

    • It adversely affects the woman's quality of life and well-being and can lead to restriction of daily activities and absence from school or work.
      • Women with dysmenorrhoea have poorer mood and sleep quality during menstruation compared with their pain-free follicular phase and compared with the menstruation phase of pain-free control women.
      • Depression and anxiety are more common in women with dysmenorrhoea.
      • About 30–50% of women with primary dysmenorrhoea are reported to miss school or work at least once per cycle (and more frequently in 5–14% of women).
      • A meta-analysis found that 41% of young women at school or university reported effects on concentration and academic performance due to dysmenorrhoea.
    • It can also lead to enhanced pain sensitivity.
      • Compared with women without dysmenorrhoea, women with dysmenorrhoea have greater sensitivity to pain throughout their cycles, even in phases of the menstrual cycle when women are not experiencing menstrual pain, suggesting that long-term differences in pain perception extend outside of the painful menstruation phase.

[Ju, 2014; De Sanctis, 2015; Lacovides, 2015; Subasinghe, 2016; Armour, 2019; Ferries-Rowe, 2020; McKenna, 2021; BMJ Best Practice, 2023a]

Diagnosis of dysmenorrhoea

How should I assess for the cause of dysmenorrhoea?

Secondary causes of dysmenorrhoea must be excluded before considering a diagnosis of primary dysmenorrhoea.

  • To assess for a secondary cause of dysmenorrhoea:
    • Take a history. Ask about:
      • When the symptoms started in relation to the menarche.
      • Characteristics of the pain, including type of pain, timing and duration, severity, and exacerbating and alleviating factors.
      • Any associated symptoms, including other gynaecological symptoms and non-gynaecological symptoms.  
      • Menstrual history, including length of menstrual cycle, regularity, and duration, and the volume of menstrual flow.Risk factors for primary dysmenorrhoea, such as family history of dysmenorrhoea.
      • Medical history, past and present. Several conditions (for example, irritable bowel syndrome and lactose intolerance) can mimic dysmenorrhoea. See the CKS topic on Irritable bowel syndrome for more information. 
      • Obstetric history, including plans for pregnancy.
      • Drug history, including treatment(s), tried and the effect.
    • Examine the woman. 
      • Perform an abdominal examination in all women — to assess for large fibroids and other masses.
      • Perform a pelvic examination (including a speculum examination of the cervix), except in young women who are not sexually active if the symptoms are suggestive of primary dysmenorrhoea.
    • Consider arranging the following investigations:
      • An ultrasound scan — to rule out fibroids, adnexal pathology, and endometriosis or to assess an intrauterine contraceptive device. 
      • High vaginal and endocervical swabs — if the woman is at risk of a sexually transmitted infection, especially if pain is associated with vaginal discharge and abnormal vaginal bleeding. See the CKS topic on Vaginal discharge for more information.
      • Pregnancy test — to exclude an ectopic pregnancy. See the CKS topic on Ectopic pregnancy for more information.
  • Primary dysmenorrhoea is the most likely diagnosis when:
    • Menstrual pain starts 6–12 months after the menarche, once cycles are regular.
    • Pain, usually cramping in nature, occurs in the lower abdomen but may radiate to the back and inner thigh.
    • Pain starts shortly before the onset of menstruation and lasts for up to 72 hours, improving as the menses progresses.
    • Non-gynaecological symptoms, such as nausea, vomiting, diarrhoea, fatigue, irritability, dizziness, bloating, headache, lower back pain, and emotional symptoms, are present.
    • Other gynaecological symptoms are not present.
    • Pelvic examination is normal.
  • Secondary dysmenorrhoea is the most likely diagnosis when:
    • Pain starts after several years of painless periods. 
    • Pain is not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation.
    • Other symptoms are present, including:
      • Other gynaecological symptoms, such as dyspareunia, vaginal discharge, menorrhagia, intermenstrual bleeding, and postcoital bleeding.
      • Non-gynaecological symptoms, such as rectal pain and bleeding (which may be associated with endometriosis).
    • Pelvic examination is abnormal, although the absence of abnormal findings does not exclude secondary dysmenorrhoea.

Secondary causes of dysmenorrhoea

  • Conditions that can cause secondary dysmenorrhoea include:
    • Endometriosis/adenomyosis — characterized by cyclical or chronic pelvic pain frequently occurring prior to menstruation and accompanied by heavy menstrual bleeding and deep dyspareunia. Rectal pain or bleeding may indicate recto-vaginal endometriosis. See the CKS topic on Endometriosis for more information.
    • Fibroids (myomas) — characterized by lower abdominal pain, frequently accompanied by menorrhagia; a pelvic mass may be identified on examination. See the CKS topic on Fibroids for more information.
    • Pelvic inflammatory disease — characterized by lower abdominal pain and tenderness that may be accompanied by dyspareunia, abnormal vaginal bleeding, and abnormal vaginal discharge. In acute infection, fever may be present. See the CKS topic on Pelvic inflammatory disease for more information.
    • Ectopic pregnancy — characterized by a positive pregnancy test with acute pelvic or abdominal pain and tenderness and vaginal bleeding with or without clots. Symptoms generally appear 6–8 weeks after the last normal menstrual period. See the CKS topic on Ectopic pregnancy for more information.
    • Ovarian cancer —  characterized by pelvic or abdominal pain, abdominal distension, early satiety and/or loss of appetite, and increased urinary urgency and/or frequency. There may be abnormal or postmenopausal bleeding and gastrointestinal symptoms (such as dyspepsia or nausea). See the CKS topic on Ovarian cancer for more information.
    • Cervical cancer — characterized by pelvic pain, dyspareunia, intermenstrual or postcoital bleeding, postmenopausal bleeding, and blood-stained, mucoid, or purulent vaginal discharge. See the CKS topic on Cervical cancer and HPV for more information.
    • Intrauterine device (IUD) insertion — IUD insertion may be a secondary cause of dysmenorrhoea (usually following insertion 3–6 months previously). Pain may be accompanied by longer and heavier periods, often with intermenstrual bleeding or spotting. The IUD may require removal, and an alternative form of contraception considered. See the CKS topic on Contraception - IUS/IUD for more information.

[Osayande, 2014; De Sanctis, 2015; Lacovides, 2015; BMJ Best Practice, 2022; BMJ Best Practice, 2023b; BMJ Best Practice, 2023a; NICE, 2023]

Basis for recommendation

The recommendations on how to assess a woman with dysmenorrhoea are based largely on expert opinion in the BMJ Best Practice guideline Assessment of dysmenorrhoea  [BMJ Best Practice, 2023a] and in review articles Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge [De Sanctis, 2015], What we know about primary dysmenorrhea today: a critical review [Lacovides, 2015], Prevalence and severity of dysmenorrhoea, and management options reported by young Australian women [Subasinghe, 2016], Primary Dysmenorrhea: Diagnosis and Therapy [Ferries-Rowe, 2020], Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents [Sachedina, 2020] and Dysmenorrhoea [McKenna, 2021]. The information on conditions that can cause secondary dysmenorrhoea derives from the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The initial management of chronic pelvic pain [RCOG, 2012], the American College of Obstetrics and Gynecologists Practice Bulletin Chronic Pelvic Pain [ACOG, 2020], and the BMJ Best Practice guideline Assessment of dysmenorrhoea  [BMJ Best Practice, 2023a].

Management

Scenario: Primary dysmenorrhoea

From age 10 years onwards (Female).

How should I manage primary dysmenorrhoea?

To manage primary dysmenorrhoea (that is, menstrual pain in the absence of any identifiable underlying pelvic pathology): 

  • Offer a nonsteroidal anti-inflammatory drug (NSAID) unless contraindicated.
  • Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient.
  • If the woman does not wish to conceive, consider prescribing a 3–6 month trial of a hormonal contraceptive as an alternative first-line treatment.
    • Monophasic combined oral contraceptive (COC) preparations containing 30–35 micrograms of ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually the first choice.
    • Oral (desogestrel 75 micrograms), parenteral (Depo-Provera® or Sayana Press®, and Nexplanon®), and intrauterine progestogen-only (Mirena®) contraceptives may also be considered after a full discussion of the advantages and disadvantages.
    • See the CKS topics on Contraception - combined hormonal methods, Contraception - IUS/IUD, and Contraception - progestogen-only methods for detailed information on prescribing hormonal contraceptives.
  • If the response to individual treatments is insufficient, a combination of an NSAID (or paracetamol) and hormonal contraception may be considered.
  • Consider recommending the following non-drug measures (in addition to drug treatments) to help reduce pain:
    • Local application of heat (for example, a hot water bottle or heat patch).
    • Transcutaneous electrical nerve stimulation (TENS) — set to a high frequency.
  • Provide patient information on dysmenorrhoea. For example:
  • If symptoms are severe and do not respond to initial treatment within 3–6 months, or if there is doubt about the diagnosis, refer to a gynaecologist.

Basis for recommendation

The information on management of primary dysmenorrhoea is largely based on expert opinion within the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The initial management of chronic pelvic pain [RCOG, 2012],  the European Association of Urology guideline Chronic Pelvic Pain [EAU, 2018] the BMJ Best Practice guideline Assessment of dysmenorrhoea  [BMJ Best Practice, 2023a] and review articles What we know about primary dysmenorrhea today: a critical review  [Lacovides, 2015], Prevalence and severity of dysmenorrhoea, and management options reported by young Australian women [Subasinghe, 2016], Primary Dysmenorrhea: Diagnosis and Therapy [Ferries-Rowe, 2020], Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents [Sachedina, 2020], Dysmenorrhea [McKenna, 2021].

Non-steroidal anti-inflammatory drugs (NSAIDs)
  • NSAIDs are widely recommended by experts for the treatment of dysmenorrhea [RCOG, 2012; EAU, 2018].
    • Women with dysmenorrhoea have high levels of prostaglandins (hormones known to cause cramping abdominal pain). NSAIDs act by blocking prostaglandin production by inhibiting the action of cyclooxygenase (COX, an enzyme responsible for the formation of prostaglandins) [Marjoribanks, 2015]. 
      • The COX enzyme exists in two forms: COX‐1 and COX‐2. Standard NSAIDs (such as ibuprofen, naproxen, and mefenamic acid) are considered 'non-selective' because they inhibit both COX‐1 and COX‐2 enzymes. Coxibs (such as celecoxib and etoricoxib) are highly selective for COX-2 but can interact with COX-1 in certain circumstances.
    • A subsequent network meta-analysis compared the efficacy and safety of 13 different NSAIDs in 5723 women with primary dysmenorrhea and found that all NSAIDs except aspirin were significantly more efficacious than placebo [Feng, 2018].
  • Choice of NSAIDs
    • The Cochrane systematic review found little evidence of the superiority of any individual NSAID for either pain relief or safety, but the available evidence had little power to detect such differences as most individual comparisons were based on very few small trials. There was no evidence that COX‐2‐specific inhibitors were more effective or tolerable for the treatment of dysmenorrhoea than standard NSAIDs, although data was scant [Marjoribanks, 2015]. 
    • However, according to the results of the network meta-analysis, which calculated the ranking of each treatment using results from a surface under cumulative ranking curve [Feng, 2018]:
      • Flurbiprofen was considered to be the most efficacious treatment, and aspirin the least.
      • Tiaprofenic acid and mefenamic acid were indicated as the safest treatments, and indomethacin was most likely to cause mild gastrointestinal (GI) discomfort.
      • Naproxen was not significantly efficacious compared with other NSAIDs drugs and showed an average efficacy in ranking.
    • Tiaprofenic acid has been associated with severe cystitis. It is recommended that tiaprofenic acid should not be given to people with urinary-tract disorders and should be stopped if urinary symptoms develop [BNF, 2023].
  • Licensed indications
    • Ibuprofen, naproxen, and flurbiprofen are licensed for the treatment of dysmenorrhoea. Tiaprofenic acid is licensed for the treatment of pain and inflammation in rheumatic disease and other musculoskeletal disorders in adults [BNF, 2023]. 
    • Mefenamic acid is also licensed for the treatment of dysmenorrhoea; however, it can cause seizures in overdose [BNF, 2023]. The National Poisons Information Service considers an ingestion of 40 mg/kg or more to be potentially toxic [Toxbase, 2022]. This means that a woman who weighs 50 kg would only need to ingest one extra dose of 500 mg of mefenamic acid in 24 hours (total of 2000 mg) to be considered to be at risk of toxicity.
Hormonal contraception
  • There is evidence that dysmenorrhea improves with the use of oral contraceptives.
    • Combined oral contraceptives (COCs)
      • A Cochrane systematic review (search date February 2008) found limited evidence that COCs are effective for relieving pain associated with primary dysmenorrhoea. However, the overall quality of the trials was poor, some trials were over 25 years old, and some used COCs with higher doses of oestrogen than is present in currently available products [Wong, 2009].
      • Despite the limited trial evidence, COCs are widely recommended by experts for this indication [Proctor, 2006; Harel, 2012; RCOG, 2012], and the added contraceptive advantage make them a suitable first-line option for some women. 
      • COCs containing 20 micrograms of ethinylestradiol are less preferred because they are more likely to cause unscheduled bleeding. See the section on Combined oral contraceptive in the CKS topic on Contraception - combined hormonal methods for more information.
    • Oral progestogen-only contraceptives
      • An observational study (n = 406) assessed the effects of desogestrel 75 micrograms (Cerazette®) in women with dysmenorrhoea and found that dysmenorrhoea resolved or considerably improved in 93% of the study population [Ahrendt, 2007].
    • Parenteral progestogens
      • A review of open-label, non-comparative and comparative studies (n = 923) assessed the effects of etonogestrel subdermal implant (Implanon®, which is bioequivalent to Nexplanon®) on menstrual bleeding patterns and found that it reduced both the incidence and severity of dysmenorrhoea. Most women (77%) who had baseline dysmenorrhoea experienced complete resolution of symptoms [Mansour, 2008]. 
      • Some experts recommend that parenteral progestogens (such as depot medroxyprogesterone acetate) may be considered in the treatment of dysmenorrhea [Proctor, 2006]. Depot medroxyprogesterone acetate works primarily by suppressing ovulation; it can also induce endometrial atrophy. One of its benefits is amenorrhea with a resultant reduction in the incidence of dysmenorrhea.
    • Intrauterine contraception
      • A longitudinal population study assessed the prevalence and severity of dysmenorrhea in women using an intrauterine contraception and found that the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) was associated with reduced dysmenorrhea severity compared with other methods of contraception (barrier methods, natural family planning, coitus interruptus, and sterilization) or no method of contraception. The copper intrauterine device (Cu-IUD) did not reduce the severity of dysmenorrhea when compared with other methods of contraception [Lindh, 2013].
      • The RCOG guideline states that that non endometriosis-related cyclical pain also appears to be well controlled by the LNG-IUS [RCOG, 2012], and previous expert reviewers of this CKS topic agree that the LNG-IUS is an option for women with dysmenorrhoea who require contraception. It is also an option for those who do not require contraception, particularly older women who have had children and women with heavy menstrual bleeding.
  • The Royal College of Obstetricians and Gynaecologists (RCOG) guideline The initial management of chronic pelvic pain recommends that women with cyclical pain are offered a therapeutic trial using hormonal treatment for a period of 3–6 months [RCOG, 2012].

Scenario: Secondary dysmenorrhoea

From age 10 years onwards (Female).

How should I manage secondary dysmenorrhoea?

Management of secondary dysmenorrhoea will depend on the underlying cause.

  • Suspect a serious secondary cause of dysmenorrhoea and refer urgently if any of the following 'red flags' are present:
  • Consider and manage other secondary causes of dysmenorrhoea (such as endometriosis, fibroids, or pelvic inflammatory disease) if the onset of menstrual pain follows several years of painless periods. See the CKS topics on Endometriosis Fibroids and Pelvic inflammatory disease for more information.

Basis for recommendation

The information on management of secondary dysmenorrhoea is largely based on expert opinion within the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The initial management of chronic pelvic pain [RCOG, 2012],  the BMJ Best Practice guideline Assessment of dysmenorrhoea  [BMJ Best Practice, 2023a] and review articles Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents [Sachedina, 2020] and Dysmenorrhea [McKenna, 2021].

  • The clinical features indicating a serious secondary cause for dysmenorrhoea are largely derived from the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2021].
  • The recommendation to consider and manage secondary causes of dysmenorrhoea if menstrual pain appears after several years of painless periods is pragmatic, based on what CKS considers to be good clinical practice.

Supporting evidence

This CKS topic is based largely on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The initial management of chronic pelvic pain [RCOG, 2012],  the European Association of Urology guideline Chronic Pelvic Pain [EAU, 2018] the BMJ Best Practice guideline Assessment of dysmenorrhoea  [BMJ Best Practice, 2023a] and review articles What we know about primary dysmenorrhea today: a critical review [Lacovides, 2015], Prevalence and severity of dysmenorrhoea, and management options reported by young Australian women [Subasinghe, 2016], Primary Dysmenorrhea: Diagnosis and Therapy [Ferries-Rowe, 2020], Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents [Sachedina, 2020] and Dysmenorrhea [McKenna, 2021]. The rationale for the primary care assessment and management of dysmenorrhoea is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of dysmenorrhoea.

Search dates

November 2018 - October 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 25th October 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S6 S1 OR S2 OR S3 OR S4 OR S5
S5 AB ( ((period*) N2 (cramp* or pain*)) ) OR TI ( ((period*) N2 (cramp* or pain*)) ) 
S4 AB ( ((menstrual or menses or menstruation) N2 (cramp* or pain*)) ) OR TI ( ((menstrual or menses or menstruation) N2 (cramp* or pain*)) )
S3 AB dysmenorrhea OR TI dysmenorrhea 
S2 AB dysmenorrhoea OR TI dysmenorrhoea
S1 (MH "Dysmenorrhea") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • ACoG (2020) Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstetrics & Gynecology 135(3), e98-e109. [Abstract]
  • Ahrendt, H.J., Karckt, U., Pichl, T., et al. (2007) The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: results from two studies on oestrogen-related symptoms and dysmenorrhoea. European Journal of Contraception & Reproductive Health Care 12(4), 354-61. [Abstract]
  • Armour, M., Parry, K., Manohar, N., et al. (2019) The Prevalence and Academic Impact of Dysmenorrhea in 21,573 Young Women: A Systematic Review and Meta-Analysis. Journal of Women's Health 28(8), 1161-1171. [Abstract]
  • BMJ Best Practice (2022) Ovarian Cancer. London: BMJ Publishing Group.
  • BMJ Best Practice (2023a) Assessment of dysmenorrhoea. London: BMJ Publishing Group.
  • BMJ Best Practice (2023b) Cervical cancer. London: BMJ Publishing Group.
  • BNF (2023) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • De Sanctis, V., Soliman, A., Bernasconi, S., et al. (20151) Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge. Pediatric Endocrinology reviews 13(2), 512-520. [Abstract]
  • EAU (2012) Guidelines on chronic pelvic pain. European Association of Urology. http://www.uroweb.org [Free Full-text]
  • EAU (2018) Chronic Pelvic Pain. European Association of Urology. http://www.uroweb.org [Free Full-text]
  • Feng, X. and Wang, X. (2018) Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs for patients with primary dysmenorrhea: A network meta-analysis. Molecular Pain 14(epub). [Abstract]
  • Ferries-Rowe, E., Corey, E. and Archer, J.S. (2020) Primary Dysmenorrhea: Diagnosis and Therapy. Obstetrics and Gynecology 136(5), 1047-1058. [Abstract]
  • Harel, Z. (2012) Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies. Expert Opinion on Pharmacotherapy 13(15), 2157-2170. [Abstract]
  • Ju, H., Jones, M. and Mishra, G. (2014) The prevalence and risk factors of dysmenorrhea. Epidemiologic Reviews 36, 104-113. [Abstract]
  • Lacovides, S., Avidon, I. and Baker, F. (2015) What we know about primary dysmenorrhea today: a critical review. Human reproduction update 21(6), 762-778. [Abstract]
  • Lindh, I. and Milsom, I. (2013) The influence of intrauterine contraception on the prevalence and severity of dysmenorrhea: a longitudinal population study. Human Reproduction 28(7), 1953-60. [Abstract]
  • Mansour, D., Korver, T., Marintcheva-Petrova, M. and Fraser, I.S. (2008) The effects of Implanon on menstrual bleeding patterns. European Journal of Contraception & Reproductive Health Care 13(Suppl 1), 13-28. [Abstract]
  • Marjoribanks, J.,  Ayeleke, R.,  Farquhar, C.,  Proctor, M. (2015) Nonsteroidal anti-inflammatory drugs for dysmenorrhoea (Cochrane Review). Issue 7. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • McKenna, K.A. and Fogleman, C.D. (2021) Dysmenorrhea. American Family Physician 104(2), 164-170. [Abstract]
  • NICE (2021) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2023) Ovarian cancer: recognition and initial management. National Institute of Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Osayande, A. and Mehulic, S. (2014) Diagnosis and initial management of dysmenorrhea. American Family Physician 89(5), 341-346. [Free Full-text]
  • Proctor, M. and Farquhar, C. (2006) Diagnosis and management of dysmenorrhoea. British Medical Journal 332(7550), 1134-1138.
  • RCOG (2012) The initial management of chronic pelvic pain. Royal College of Obstetricians and Gynaecologists. http://www.rcog.org.uk [Free Full-text]
  • Righarts, A., Osborne, L., Connor, J. and Gillet, W. (2018) The prevalence and potential determinants of dysmenorrhoea and other pelvic pain in women: a prospective study. BJOG: An International Journal Of Obstetrics And Gynaecology 125(12), 1532-1539. [Abstract] [Free Full-text]
  • Sachedina A, Todd N. (2020) Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents. Journal of Clinical Research in Pediatriatric Endocrinology 12(Suppl 1), 7-17. [Abstract]
  • Subasinghe, A., Happo, L., Jayasinghe, Y., et al. (2016) Prevalence and severity of dysmenorrhoea, and management options reported by young Australian women. Australian Family Physician 45(11), 829-834. [Abstract] [Free Full-text]
  • Toxbase (2022) Mefenamic acid. National Poisons Information Service (NPIS). http://www.toxbase.org
  • Wong, C.L., Farquhar, C., Roberts, H. and Proctor, M. (2009) Oral contraceptive pill for primary dysmenorrhoea (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
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