Benefits, Harms, and Costs
- 1.Dysmenorrhea is highly prevalent and commonly undertreated (III).
- 2.Non-steroidal anti-inflammatory drugs are more effective than placebo but have more gastrointestinal side effects. All currently available non-steroidal anti-inflammatory drugs are of comparable efficacy and safety (I).
- 3.Suppression of ovulation is associated with decreased menstrual pain (II-1).
- 4.Amenorrhea induced by any means is beneficial for the treatment of dysmenorrhea (II-2).
- 5.Hysterectomy is effective treatment (II-2).
- 6.There is some evidence to support laparoscopic nerve ablation in selected cases (II-1).
- 7.Endometrial ablation is likely to reduce symptoms of dysmenorrhea when it occurs in the presence of menorrhagia (I).
- 1.Both primary and secondary dysmenorrhea are likely to respond to the same medical therapy. Therefore, initiation of treatment should not depend on establishing a precise diagnosis (II-1A).
- 2.Health care providers should include specific questions regarding menstrual pain when obtaining a woman's medical history (III-B).
- 3.A pelvic examination is not necessary prior to initiating therapy (III-D).
- 4.A pelvic examination is indicated in patients not responding to conventional therapy and when organic pathology is suspected (III-B).
- 5.Non-steroidal anti-inflammatory drugs, administered with regular dosing regimens, should be considered first-line treatment for most women (I-A).
- 6.Hormonal therapies should be offered to women and girls who are not currently planning pregnancy unless contraindications exist (I-A).
- 7.Continuous or extended use combined hormonal contraceptives are recommended (I-A).
- 8.Regular exercise is likely to improve symptoms of dysmenorrhea and should be recommended (II-1A).
- 9.Local heat in the form of heated pads or patches should be recommended as a complementary treatment for dysmenorrhea (I-A).
- 10.High-frequency transcutaneous electrical nerve stimulation should be considered as a complementary treatment or in women unable or unwilling to use conventional therapy (II-1B).
- 11.Acupoint stimulation should be considered for women wishing to use complementary or alternative therapies (II-1B).
- 12.Ginger is recommended for women wishing to use complementary or alternative therapies (I-A).
- 13.Preoperative investigations should include a detailed history and physical examination, ultrasound, and possibly magnetic resonance imaging to discover secondary causes for dysmenorrhea and to direct appropriate therapy (III-A).
- 14.Surgical intervention should only be considered if a concerted trial of medical therapy has not been successful (III-A).
Abbreviations:CANPAGO (Canadian Pediatric and Adolescent Gynecology and Obstetrics Committee), CHC (combined hormonal contraceptive), COC (combined oral contraceptive), hfTENS (high-frequency transcutaneous electrical nerve stimulation), LN-IUS (levonorgestrel intrauterine system), LUNA (laparoscopic uterosacral nerve ablation), NSAID (non-steroidal anti-inflammatory drug), PSN (pre-sacral neurectomy), TENS (transcutaneous electrical nerve stimulation)
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- Pathophysiology of dysmenorrhea.Acta Obstet Gynecol. 1979; 87: 27-32
- Menstrual pain: its origin and pathogenesis.J Reprod Med. 1980; 25: 207-212
- Markers of adult endometriosis detectable in adolescence.J Pediatr Adolesc Gynecol. 2011; 24: S7-S12
- The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices.Obstet Gynecol. 1996; 87: 55-58
- A prevalence study of dysmenorrhoea in female residents aged 15-54 years in Clementi Town, Singapore.Ann Acad Med Singapore. 1992; 21: 323-327
- Anthropological and clinical characteristics in adolescent women with dysmenorrhea.Coll Antropol. 2003; 27: 707-711
- An epidemiologic study of young women with dysmenorrhea.Am J Obstet Gynecol. 1982; 144: 655-660
- [Relationship between the frequency of menstrual pain and bodyweight in female adolescents].Nihon Koshu Eisei Zasshi. 2002; 49: 516-524
- Prevalence of menstrual pain in relation to the reproductive life history of women from the Mayan rural community.Ann Hum Biol. 2004; 31: 1-8
- Prevalence of dysmenorrhoea in Wellington women.N Z Med J. 1988; 101: 52-54
- The prevalence of chronic pelvic pain in women in the United Kingdom: a systematic review.Br J Obstet Gynaecol. 1998; 105: 93-99
- Primary dysmenorrhea in young Western Australian women: prevalence, impact, and knowledge of treatment.J Adolesc Health. 1999; 25: 40-45
- Prevalence of primary dysmenorrhea in Canada.J Obstet Gynaecol Can. 2005; 27: 765-770
- The natural history of primary dysmenorrhoea: a longitudinal study.BJOG. 2004; 111: 345-352
- Factors influencing the prevalence and severity of dysmenorrhoea in young women.Br J Obstet Gynaecol. 1990; 97: 588-594
- Cigarette smoking, alcohol consumption, and risk of primary dysmenorrhea.Epidemiology. 1994; 5: 469-472
- The prevalence and risk factors of dysmenorrhea.Epidemiol Rev. 2014; 36: 104-113
- A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women.Br J Obstet Gynaecol. 1996; 103: 1134-1142
- The association of behavior and lifestyle factors with menstrual symptoms.J Womens Health Gend Based Med. 1999; 8: 1185-1193
- Prospective study of exposure to environmental tobacco smoke and dysmenorrhea.Environ Health Perspect. 2000; 108: 1019-1022
- Disruptions of social relationships accentuate the association between emotional distress and menstrual pain in young women.Health Psychol. 2001; 20: 411-416
- What we know about primary dysmenorrhea today: a critical review.Hum Reprod Update. 2015; 21: 762-778
- Is there a relationship between mood disorders and dysmenorrhea?.J Pediatr Adolesc Gynecol. 2014; 27: 371-374
- Primary dysmenorrhea.Am Fam Physician. 1999; 60: 489-496
- Menstrual cycle abnormalities: diagnosis and management.Adolesc Med. 1999; 10: 255-273
- Prevalence and impact of dysmenorrhea on Hispanic female adolescents.Arch Pediatr Adolesc Med. 2000; 154: 1226-1229
- Pediatric and adolescent gynecology.ed 5. Lippincott, Williams & Wilkins, Philadelphia2005
- Dysmenorrhoea.Curr Obstet Gynaecol. 2002; 12: 341-345
- Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review.Hum Reprod Update. 2013; 19: 570-582
- Use of medication by adolescents for the management of menstrual discomfort.Arch Pediatr Adolesc Med. 1997; 151: 905-913
- Consensus guidelines for the management of chronic pelvic pain.J Obstet Gynaecol Can. 2005; 27: 869-910
- Adenomyosis: epidemiology, risk factors, clinical phenotype and surgical and interventional alternatives to hysterectomy.Geburtshilfe Frauenheilkd. 2013; 73: 924-931
- Effects of noninvasive electroacupuncture at Hegu (LI4) and Sanyinjiao (SP6) acupoints on dysmenorrhea: a randomized controlled trial.J Altern Complement Med. 2012; 18: 137-142
Laufer MR. Helping “adult gynecologists” diagnose and treat adolescent endometriosis: reflections on my 20 years of personal experience. J Pediatr Adolesc Gynecol 2011 Oct:24(5 Suppl):S13-7. http://dx.doi.org/10.1016/j.jpag.2011.07.005.
- Chronic pelvic pain: medical and surgical approaches.in: Sanfilippo J.S. Muram D. Dewhurst J. Le P.A. Pediatric and adolescent gynecology. ed 2. W.B. Saunders Company, Philadelphia2001
- Identification of clear vesicular lesions of atypical endometriosis: a new technique.Fertil Steril. 1997; 68: 739-740
- Efficacy of a paracetamol and caffeine combination in the treatment of the key symptoms of primary dysmenorrhoea.Curr Med Res Opin. 2007; 23: 841-851
- Is acetaminophen, and its combination with pamabrom, an effective therapeutic option in primary dysmenorrhoea?.Expert Opin Pharmacother. 2004; 5: 561-570
- Nonsteroidal anti-inflammatory drugs for dysmenorrhoea.Cochrane Database Syst Rev. 2015; : CD001751
- Stimulation of vasopressin release in women with primary dysmenorrhoea and after oral contraceptive treatment—effect on uterine contractility.Br J Obstet Gynaecol. 1992; 99: 680-684
- Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy.Adv Prostaglandin Thromboxane Res. 1980; 8: 1443-1447
- Prostaglandins: PGF2 alpha, PGE2, 6-keto-PGF1 alpha and TXB2 serum levels in dysmenorrheic adolescents before, during and after treatment with oral contraceptives.Eur J Obstet Gynecol Reprod Biol. 1990; 36: 292-298
- Effect of an oral contraceptive in primary dysmenorrhea—changes in uterine activity and reactivity to agonists.Contraception. 1989; 40: 39-47
- The influence of different combined oral contraceptives on the prevalence and severity of dysmenorrhea.Contraception. 1990; 42: 497-506
- Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic.Am J Obstet Gynecol. 1992; 166: 578-583
- The influence of a low-dose combined oral contraceptive on menstrual blood loss and iron status.Contraception. 1992; 46: 327-334
- Clinical experience with a triphasic oral contraceptive.Acta Obstet Gynecol Scand. 1984; 63: 233-236
- Triphasic combination of ethinyl estradiol and gestodene. Long-term clinical trial.Contraception. 1992; 46: 19-27
- Clinical evaluation of a new triphasic oral contraceptive: norgestimate and ethinyl estradiol.Acta Obstet Gynecol Scand Suppl. 1992; 156: 27-32
- Clinical experience with a modern low-dose oral contraceptive in almost 100,000 users.Contraception. 1991; 43: 101-110
- Effect of a low-dose oral contraceptive containing 20 microg ethinylestradiol and 150 microg desogestrel on dysmenorrhea.Contraception. 2003; 68: 183-188
- Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhea.Cochrane Database Syst Rev. 2001; : CD002120
- Primary dysmenorrhea treatment with a desogestrel-containing low-dose oral contraceptive.Contraception. 2002; 66: 393-399
- Evaluation of a low-dose oral contraceptive pill for primary dysmenorrhea: a placebo-controlled, double-blind, randomized trial.Fertil Steril. 2011; 95: 1928-1931
- Acceptance of altering the standard 21-day/7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms.Am J Obstet Gynecol. 2002; 186: 1142-1149
- Cyproterone acetate versus a continuous monophasic oral contraceptive in the treatment of recurrent pelvic pain after conservative surgery for symptomatic endometriosis.Fertil Steril. 2002; 77: 52-61
- Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen.Fertil Steril. 2003; 80: 560-563
- Continuous compared with cyclic oral contraceptives for the treatment of primary dysmenorrhea: a randomized controlled trial.Obstet Gynecol. 2012; 119: 1143-1150
- Continuous or extended cycle vs. cyclic use of combined hormonal contraceptives for contraception.Cochrane Database Syst Rev. 2014; : CD004695
- Does the presence of coexisting diseases modulate the effectiveness of a low-dose estrogen/progestin, ethinylestradiol/drospirenone combination tablet in dysmenorrhea? Reanalysis of two randomized studies in Japanese women.Int J Womens Health. 2014; 6: 989-998
- The effect of depo-medroxyprogesterone acetate on pituitary and ovarian function, and the return of fertility following its discontinuation: a review.Contraception. 1974; 10: 181-202
- Hatcher R.A. Trussell J. Stewart F. Contraceptive technology. ed 17. Arden Media Inc., New York1998
- Contraceptive use—efficacy study utilizing medroxyprogesterone acetate administered as an intramuscular injection once every 90 days.Fertil Steril. 1973; 24: 331-339
- Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population.Fam Plann Perspect. 1996; 28: 174-178
- Menstrual bleeding patterns in untreated women and with long-acting methods of contraception. Task Force on Long-Acting Systemic Agents for Fertility Regulation.Adv Contracept. 1991; 7: 257-270
- A multicentered phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1. Contraceptive efficacy and side effects. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Special Programme of Research, Development and Research Training in Human Reproduction.Contraception. 1986; 34: 223-235
- Continuous norethisterone acetate versus cyclical drospirenone 3 mg/ethinyl estradiol 20 μg for the management of primary dysmenorrhea in young adult women.J Pediatr Adolesc Gynecol. 2016; 29: 143-147
- Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial.Hum Reprod. 2010; 25: 633-641
- Postoperative levonorgestrel-releasing intrauterine system for pelvic endometriosis-related pain: a randomized controlled trial.Obstet Gynecol. 2012; 119: 519-526
- The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis.Contraception. 2009; 79: 189-193
- Levonorgestrel-releasing intrauterine device used for dysmenorrhea: five-year literature review.Clin Exp Obstet Gynecol. 2014; 41: 495-498
- The influence of intrauterine contraception on the prevalence and severity of dysmenorrhea: a longitudinal population study.Hum Reprod. 2013; 28: 1953-1960
- Emerging indications for the levonorgestrel-releasing intrauterine system (LNG-IUS).Acta Obstet Gynecol Scand. 2012; 91: 3-9
- Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding.Cochrane Database Syst Rev. 2015; : CD002126
- Non-pharmacologic strategies used by adolescents for the management of menstrual discomfort.Clin J Pain. 1999; 15: 313-320
- Primary dysmenorrhea and physical activity.Med Sci Sports Exerc. 1998; 30: 906-909
- Exercise for dysmenorrhoea.Cochrane Database Syst Rev. 2010; : CD004142
- The effect of aquatic exercises on primary dysmenorrhoea in nonathlete girls.Iran J Nurs Midwifery Res. 2013; 18: 378-383
- Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea.Cochrane Database Syst Rev. 2002; : CD002123
- Efficacy of the device combining high-frequency transcutaneous electrical nerve stimulation and thermotherapy for relieving primary dysmenorrhea: a randomized, single-blind, placebo-controlled trial.Eur J Obstet Gynecol Reprod Biol. 2015; 194: 58-63
- Transcutaneous electrical nerve stimulation (TENS) for the treatment of primary dysmenorrhea: a randomized crossover comparison with placebo TENS and ibuprofen.Obstet Gynecol. 1990; 75: 656-660
- Relief of primary dysmenorrhea by transcutaneous electrical nerve stimulation.Acta Obstet Gynecol Scand. 1985; 64: 491-497
- The efficacy of transcutanesous electrical nerve stimulation in dysmenorrhea.Clin J Pain. 1985; 1: 75-83
- Primary spasmodic dysmenorrhea: the use of TENS on acupuncture points.Am J Acupunct. 1985; 13: 35-42
- Transcutaneous electrical nerve stimulation in the relief of primary dysmenorrhea.Phys Ther. 1989; 69: 3-9
- Transcutaneous electrical nerve stimulation for pain relief in primary dysmenorrhea.Clin J Pain. 1987; 3: 17-22
- Acupuncture for primary dysmenorrhoea.Cochrane Database Syst Rev. 2011; : CD007854
- Acupuncture for dysmenorrhoea.Cochrane Database Syst Rev. 2016; : CD007854
- Acupoint stimulation intervention for people with primary dysmenorrhea: systematic review and meta-analysis of randomized trials.Complement Ther Med. 2012; 20: 353-363
- Efficacy of acupuncture versus combined oral contraceptive pill in treatment of moderate-to-severe dysmenorrhea: a randomized controlled trial.Evid Based Complement Alternat Med. 2015; 2015: 735690
- Behavioural treatments for primary dysmenorrhea: a review.Behav Res Ther. 1981; 19: 303-312
- Behavioural interventions for primary and secondary dysmenorrhoea.Cochrane Database Syst Rev. 2007; : CD002248
- Continuous low-level topical heat in the treatment of dysmenorrhea.Obstet Gynecol. 2001; 97: 343-349
- Comparing the analgesic effect of heat patch containing iron chip and ibuprofen for primary dysmenorrhea: a randomized controlled trial.BMC Womens Health. 2012; 12: 25
- Continuous, low-level, topical heat wrap therapy as compared to acetaminophen for primary dysmenorrhea.J Reprod Med. 2004; 49: 739-745
- A randomised controlled trial of exercise and hot water bottle in the management of dysmenorrhoea in school girls of Chandigarh, India.Indian J Physiol Pharmacol. 2013; 57: 114-122
- The effect of mefenamic acid and ginger on pain relief in primary dysmenorrhea: a randomized clinical trial.Arch Gynecol Obstet. 2015; 291: 1277-1281
- Comparison of effects of ginger, mefenamic acid, and ibuprofen on pain in women with primary dysmenorrhea.J Altern Complement Med. 2009; 15: 129-132
- The effect of ginger for relieving of primary dysmenorrhoea.J Pak Med Assoc. 2013; 63: 8-10
- Efficacy of ginger for alleviating the symptoms of primary dysmenorrhea: a systematic review and meta-analysis of randomized clinical trials.Pain Med. 2015; 16: 2243-2255
- Effect of Zingiber officinale R. rhizomes (ginger) on pain relief in primary dysmenorrhea: a placebo randomized trial.BMC Complement Altern Med. 2012; 12: 92
- Dietary supplements for dysmenorrhoea.Cochrane Database Syst Rev. 2016; : CD002124
- SOGC. Endometriosis: diagnosis and management.J Obstet Gynaecol Can. 2010; 32: S1-S32
- Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis.N Engl J Med. 1997; 337: 217-222
- Combined surgical and hormone therapy for endometriosis is the most effective treatment: prospective, randomized, controlled trial.J Minim Invasive Gynecol. 2013; 20: 473-481
- A double-blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain.BJOG. 2004; 111: 950-959
- Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea.Cochrane Database Syst Rev. 2005; : CD001896
- Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial.Am J Obstet Gynecol. 2003; 189: 5-10
- Long-term effectiveness of presacral neurectomy for the treatment of severe dysmenorrhea due to endometriosis.J Am Assoc Gynecol Laparosc. 2004; 11: 23-28
- Pain reduction after total laparoscopic hysterectomy and laparoscopic supracervical hysterectomy among women with dysmenorrhoea: a randomised controlled trial.BJOG. 2015; 122: 1102-1111
- Outcomes and postoperative complications after hysterectomies performed for benign compared with malignant indications.Obstet Gynecol. 2016; 128: 467-475
- Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness.Acta Obstet Gynecol Scand. 2007; 86: 4-15
- Hysteroscopic rollerball endometrial ablation as an alternative treatment for adenomyosis with menorrhagia and/or dysmenorrhea.J Obstet Gynaecol Res. 2010; 36: 1031-1036
This Clinical Practice Guideline has been prepared and reviewed by the Society of Obstetricians and Gynaecologists of Canada Clinical Practice-Gynaecology and CANPAGO Committees and approved by the Board of the SOGC.
Disclosure statements have been received from all members of the committees.