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Dysmenorrhoea

NICE CKS Dysmenorrhoea. Last Revised Oct 2023.

Article Last Updated: 17 March 2025

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Dysmenorrhoea

Dysmenorrhoea refers to painful menstrual cramps occurring shortly before and/or during menstruation. It is a symptom rather than a diagnosis, and may be primary (no underlying pelvic pathology) or secondary to conditions such as endometriosis, adenomyosis, or fibroids.

This updated UKMLA guide to dysmenorrhoea, based on NICE CKS covers classification, causes, diagnosis, and management.

Definition

Types of Dysmenorrhoea

Type	Description
Primary dysmenorrhoea	Dysmenorrhoea with no identifiable underlying pelvic pathology
Secondary dysmenorrhoea	Dysmenorrhoea caused by an underlying pelvic pathology

Causes and Risk Factors

Assessment, Investigation and Diagnosis

Primary dysmenorrhoea features	Secondary dysmenorrhoea features
Primary dysmenorrhoea is a diagnosis of exclusion, after secondary causes have been ruled out Onset: typically 6-12 months after menarche Pain related to menstruation Onset of pain shortly before menses Pain improves as menses progresses, lasting up to 72 hours No other gynaecological symptoms Non-gynaecological symptoms (e.g. nausea, vomiting, diarrhoea, fatigue, irritability, dizziness, bloating, headache, lower back pain, and emotional symptoms) may be present Normal pelvic examination	Onset: several years after painless periods Pain not consistently related to menstruation May persist after menstruation finishes, or Present throughout the cycle, but exacerbated by menstruation Presence of gynaecological symptoms Abnormal pelvic examination However, a normal examination does NOT exclude secondary dysmenorrhoea

Management

Category	Recommended management
Conservative management	Consider: Local application of heat (e.g. hot water bottle, heat patch) TENS
Pharmacological management	Patient wishes to conceive: 1st line: NSAIDs 2nd line: paracetamol If NSAIDs alone not sufficient → add paracetamol If NSAIDs not tolerated / contraindicated → give paracetamol instead Patient does NOT wish to conceive: NSAIDs (if not tolerated / contraindicated → paracetamol), or COCPCombined oral contraceptive Offer a 3-6 month trial Alternative: POPProgesterone only pill, LNG-IUSLevonorgestrel intrauterine system, progesterone-only implant / injection If monotherapy is not sufficient → consider NSAIDs PLUS hormonal contraception

References

NICE CKS Dysmenorrhoea

Endometriosis

Uterine Fibroids (Leiomyoma)

Pelvic Inflammatory Disease (PID)

Contraception (Non-Emergency)

Ovarian Cancer

Cervical Cancer

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Dysmenorrhoea

Dysmenorrhoea

Definition

Types of Dysmenorrhoea

Causes and Risk Factors

Primary Dysmenorrhoea

Secondary Dysmenorrhoea

Assessment, Investigation and Diagnosis

Management

Primary Dysmenorrhoea

Secondary Dysmenorrhoea

References

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