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Cathleen Morrow, MDa,*, Elizabeth H. Naumburg, MDb
KEYWORDS  Cramping  Menstrual pain  Menstrual flow  Pelvic pain  Treatment of dysmenorrhea

Dysmenorrhea is the most common gynecologic condition experienced by menstruating women. The term dysmenorrhea is derived from the Greek words dys (difficult, painful, or abnormal), meno (month), and rrhea (flow). It is characterizedby crampy lower abdominal pain that can range widely in severity and associated symptoms, yet its overall impact often has significant medical and psychosocial implications. Dysmenorrhea is potentially the most underdiagnosed gynecologic condition because of common societal beliefs regarding a lack of effective treatments and expectations about the burden of menstruation. The hallmark of primary(spasmodic) dysmenorrhea is painful menses in the absence of any associated macroscopic pathologic process, whereas secondary (congestive) dysmenorrhea implies painful menses with associated organic pelvic pathology.1 The focus of this article is on primary dysmenorrhea.

The prevalence of primary dysmenorrhea peaks in the second and third decades of life and decreases in frequencywith advancing age as the prevalence of secondary dysmenorrhea increases. A recent systematic review of worldwide literature on chronic pelvic pain reports a prevalence of dysmenorrhea at 17% to 80%.2 The most recent studies conducted on adolescent women report a prevalence range from 20% to 90%.3,4 The precise prevalence of dysmenorrhea is difficult to discern because of variations in definitionsand survey methodology. A population-based survey conducted in Sweden nearly 2 decades ago found that 10% to 24% of women who had dysmenorrhea admitted that symptoms interfered with their daily function, 51% missed work or school because of their symptoms, and only 31% had reported their symptoms to their physician.5 Women often do not seek medical evaluation for their symptoms of dysmenorrhea,despite a common negative impact on their quality of life.

Department of Community and Family Medicine, Dartmouth Medical School, DHMC HB #7015, 1 Medical Center Drive, Lebanon, NH 03756, USA b Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Highland Family Medicine Center, 777 South Clinton Avenue, Rochester, New York 14620, USA * Corresponding author.E-mail address: (C. Morrow). Prim Care Clin Office Pract 36 (2009) 19–32 doi:10.1016/j.pop.2008.10.004 0095-4543/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.



Morrow & Naumburg


Most sources agree that primary dysmenorrhea is associated with ovulatory cycles, so symptoms typically do notbegin with the first menstrual cycles. As menses due to ovulation ensues, associated with the maturation of the hypothalamic-pituitarygonadal axis, the symptoms of dysmenorrhea are more likely to present. Generally, it is believed that ovulation becomes associated with menstrual cycles 2 to 4 years after menarche in most women, but there is some evidence to suggest that ovulatory cycles may startwithin months or even with the onset of menses.6 The diagnosis of primary dysmenorrhea is thus suggested by the onset of symptoms coinciding with the natural history of ovulation. For any given menstrual cycle, there may be a wide variation in the degree of symptomatology from woman to woman. Adverse symptoms generally begin within hours after the onset of menstrual flow and can last for up to 72hours, typically peaking in the first 24 to 48 hours of the menstrual cycle. The experienced pain is commonly in the lower abdominal or suprapubic region, is described as crampy or waxing and waning in intensity, and may radiate to the lower back or inner thighs. Associated symptoms are common and may include nausea, vomiting, diarrhea, headache, malaise, or fatigue. The specific pattern of...