GPAtlas🧭 When to suspect
Dysmenorrhoea is painful, cramping lower abdominal pain occurring just before or during menstruation, and is one of the commonest gynaecological presentations in primary care – around 1 in 10 women have pain severe enough to disrupt school, work or daily activities.
First separate primary dysmenorrhoea from secondary dysmenorrhoea, because this changes investigation, treatment and referral:
• Primary: no pelvic pathology; driven by excess endometrial prostaglandins.
• Secondary: an underlying structural or inflammatory cause.
The discriminators are the age at onset relative to menarche and the pattern of the pain.
A practical rule: typical cyclical pain in a young woman with a normal examination needs no investigation and can be treated empirically.
Any of these warrants examination and a search for a secondary cause:
• New, worsening, or non-cyclical pain
• Pain extending beyond menstruation
• Any red-flag feature
| Feature | Primary dysmenorrhoea | Secondary dysmenorrhoea |
|---|---|---|
| Onset | Typically 6–12 months after menarche, once cycles become ovulatory | • Often years after menarche • New pain after previously pain-free or mild periods |
| Mechanism | • Excess prostaglandins → uterine hypercontractility and ischaemia • No pelvic pathology |
Underlying pathology – endometriosis, adenomyosis, fibroids, pelvic inflammatory disease (PID), ovarian pathology |
| Timing of pain | • Begins with or just before bleeding • Usually lasts 8–72 hours |
• May extend beyond menses • Often with non-cyclical pelvic pain |
| Associated features | • Nausea, headache, fatigue • Otherwise well |
Deep dyspareunia, menorrhagia, IMB/PCB, cyclical bowel/bladder symptoms, subfertility |
| Examination | Normal | May be normal, or pelvic signs (mass, fixed/enlarged uterus, fornix nodularity, adnexal tenderness) |
|
🧠 Clinical pearl • Cyclical bowel or bladder symptoms are the tell. • Period-related painful bowel motions, or cyclical haematuria or dysuria, are easily mislabelled for years as IBS or recurrent UTI before endometriosis is considered. • It is the cyclicity – symptoms tracking the period – that should send you down the gynaecology pathway rather than the gastroenterology or urology one. |
Source: NICE NG73
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