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.
The single most useful clinical task is to separate primary dysmenorrhoea (no pelvic pathology; driven by excess endometrial prostaglandins) from secondary dysmenorrhoea (an underlying structural or inflammatory cause), because this changes investigation, treatment and referral. 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; new, worsening, or non-cyclical pain, pain extending beyond menstruation, or any red-flag feature warrants examination and a search for a secondary cause.
| 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, 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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