• crampy lower abdominal or low back pain, temporally associated with menses
• can be severe enough to interfere with normal activities
• 60% of adolescents have dysmenorrhea; 14% frequently miss school
• over 35% of women treat themselves with medications
• often resolves after bearing children

• dysmenorrhea in the absence of pelvic pathology (common)
• onset usually within three years of menarche, below age 19
• pain starts with the menstrual flow and lasts from hours to a few days
• pain is often associated with nausea, vomiting, diarrhea and/or headache
• occurs with in ovulatory cycles
• Variation in Prostaglandin F2a explains why some women experience dysmenorrhea and others don’t:
• Excessive endometrial PG F2a correlates to high baseline intrauterine pressure and strong contractions
• anovulatory teenagers have Endometrium that does not make PG, therefore no cramps
• Systemic symptoms probably due to circulating prostaglandins
• Treatment: Goal is to reduce contraction strength; effective therapies include NSAIDs and Oral contraceptives

Secondary dysmenorrhea – several etiologies:

• (1) Endometriosis: endometrial tissue (glands and stroma) growing outside the uterus
• causes bleeding, inflammation, fibrosis, adhesions
• Usual sites: Ovaries, Uterine ligaments, Cul de sac, Recto-vaginal septum, Pelvic peritoneum, ectosigmoid
• Epidemiology: common in 3-10% women, 25-35% infertile women (cause-effect relationship not clear)
• a disease of "thirty-something" nulliparas ; estrogen dependent
• Clinical presentation:
• incidental finding: may be found at exam or surgery, tubal ligation, laproscopic endoscopy
• pain, including secondary dysmenorrhea; often begins at an older age than does 1° dysmenorrhea
• infertility: can be improved by finding and treating endometriosis; voluntary infertility associated with endometriosis
• unusual presentations: nose bleeds with period that result from endometriosis in the nasal cavity
• Theories of histiogenesis: Transplantation – retrograde menstruation: out fallopian tubes
• blood was found in peritoneal dialisate of menstrual women
• endometriosis correlates to risk of retrograde menstruation: risk Ý with obstruction: risk ß with ß menstrual flow
• explains the most common locations of endometriosis
• does not explain incidence and variable relationship between amount of endometriosis, pain and infertility.
• Hematogenous and Lymphatic spread: explains distribution of endometriosis to places like nose
• Iatrogenic Causes: endometriosis in episiotomy
• Immunological factors may explain why all women have retrograde menstruation but only some get endometriosis
• Hormonal factors: estrogen is critical for viable ectopic endometrium
• estrogen withdrawal or constant progesterone are effective treatments
• Natural history: begins after menarche, can cause pain and infertility, rare unusual presentation, ends with menopause
• (2) Adenomyosis: "glands in muscle"
• Pathology: endometrial glands found within myometrium (2.5 mm below basalis); uterus is enlarged and soft
• occurs in later reproductive years (35-50) more common in parous (given birth) women
• usually not clearly diagnosed until hysterectomy; can be asymptomatic and found incidentally
• can cause dysmenorrhea and menorrhagia (excessive menstrual bleeding)
• Treatment: hysterectomy only real treatment
• For Pain: pain medication (NSAIDs), hysterectomy; Menorrhagia: NSAIDs, iron supplements, hysterectomy
• (3) Uterine fibroids: benign smooth muscle tumor (leiomyoma): monoclonal expansion of myometrium.
• estrogen – not progesterone-dependent, peak incidence pre-menopause
• prevalence: African American = 50%; White = 25%
• Location:
• Submucosal = Endometrial
• Interstitial = in the wall
• Subserosal = out of wall
• Clinical Presentation:
• Leiomyoma Bleeding: most common presentation is Menorrhagia; can be anemic; cycle independent
• Leiomyoma Growth: most common pelvic tumor; can get hugeÞ discomfort; ureteral obstructionÞ kidney loss
• Leiomyoma Degeneration: tissue growth > vascular growth; types: red (carneous) – rapid, pain, pregnancy
• Malignant transformation: rare (<3% of fibroids); usu.diagnosed by rapid growth; looks like Leiomyosarcoma
• Leiomyoma Regression: hormonal deprivation: menopause GnRH analogues: constant stimuli = antagonism
• Treatment: Observation, Myomectomy (transabdominal/cervical to save uterus for pregnancy), Hysterectomy