HNY Policy and Pathway Repository - York

Primary Dysmenorrhoea:

• Period pains not associated with underlying pathology
• Usually D1-3 of menses, present from menarche
   

Secondary Dysmenorrhoea:

• Painful periods suggestive of underlying pathology
• Eg. Endometriosis, adenomyosis, PID presents in 20-30yrs olds
• Pain often persists for 1-7d after menstruation ends

• Consider Pelvic Inflammatory Disease (acute or chronic) especially in the under 25s with new onset
• Ovarian cancer can cause bloating and lower abdominal pain, see NICE Guidance for Ovarian Cancer.

Primary dysmenorrhoea

• Offer NSAID such as ibuprofen, naproxen, or mefenamic acid unless contraindicated. Mefenamic acid is licensed for the treatment of dysmenorrhoea, however be aware that there are concerns that it is more likely to cause seizures in overdose than other NSAIDs.
• Offer paracetamol if NSAIDs are contraindicated or not tolerated, or in addition to an NSAID if the response is insufficient.
• If the woman does not wish to conceive, consider prescribing a 3–6 month trial of hormonal contraception:
• Monophasic combined oral contraceptive (COC) preparations containing 30–35 micrograms of ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually first choice.
• Oral (desogestrel 75 micrograms), parenteral (Depo-Provera® or Sayana Press®, and Nexplanon® and intrauterine progestogen-only (Mirena®) contraceptives may also be considered, after a full discussion of the advantages and disadvantages.
• Combination of an NSAID (or paracetamol) and hormonal contraception is also an option if the response to individual treatments is insufficient.
• In addition to drug treatments consider the following non-drug measures to reduce pain:
  • Local application of heat (for example, a hot water bottle or heat patch); Transcutaneous electrical nerve stimulation (TENS) — set to a high frequency
     

Secondary dysmenorrhoea

• Secondary causes for dysmenorrhoea must be excluded before considering a diagnosis of primary dysmenorrhoea.

Indications for referral

• Pain not controlled by management above or pelvic pathology suspected
   

Information to include in referral letter

• History of problem and effect on activities of daily living (commonest cause of school absence in girls) and impact on work.
• History of any IMB or PCB
• Examination (will depend on age/ whether sexually active)
• Swabs – HVS and ECS
• Bimanual - check for cervical excitation/ uterine mobility and tenderness/ retrovaginal nodules (endometriosis)
• Smear - if over 25 and due.
• Any image results if available
   

Investigations prior to referral

• Consider a pelvic USS if pathology is suspected

Patient information leaflets/ PDAs

http://www.patient.co.uk/health/period-pain-dysmenorrhoea

Endometriosis
https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline.aspx
 

References

NICE CKS Guidelines – Dysmenorrhoea – May 2014 https://www.nice.org.uk/Guidance/CG122