A Contemporary Approach to Dysmenorrhea in Adolescents

Dysmenorrhea is the most common gynecologic complaint among adolescent girls. Despite progress in understanding the physiology of dysmenorrhea and the availability of effective treatments, many adolescent girls do not seek medical advice or are undertreated. Dysmenorrhea in adolescents is usually primary (functional), and is associated with normal ovulatory cycles and no pelvic pathology. In approximately 10% of adolescents with severe dysmenorrhea, pelvic abnormalities such as endometriosis or uterine anomalies may be found. Potent prostaglandins from the second series and potent leukotrienes from the fourth series play an important role in generating dysmenorrhea symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common pharmacologic treatment for dysmenorrhea. A loading dose of NSAIDs (typically twice the regular dose) should be used as initial treatment for dysmenorrhea in adolescents followed by a regular dose until symptoms abate. Adolescents with symptoms that do not respond to treatment with NSAIDs for three menstrual periods should be offered combined estrogen/progestin oral contraceptive pills for three menstrual cycles. Adolescents with dysmenorrhea who do not respond to this treatment should be evaluated for secondary causes of dysmenorrhea. Adolescent care providers have the important roles of educating adolescent girls about menstruation-associated symptoms, as well as evaluating and effectively treating patients with dysmenorrhea. Similar content being viewed by others Notes The use of tradenames is for product identification purposes only and does not imply endorsement.

Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics 1981; 68: 661–4 Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol 1982; 144: 655–60 Johnson J. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea. J Adolesc Health 1988; 9: 398–402 Banikarim C, Chacko MR, Kelder SH. Prevalence and impact of dysmenorrhea on Hispanic female adolescents. Arch Pediatr Adolesc Med 2000; 154: 1226–9 Hillen TI, Grbavac SL, Johnston PJ, et al. Primary dysmenorrhea in young western Australian women: prevalence, impact and knowledge of treatment. J Adolesc Health 1999; 25: 40–5 Bergsjo P. Socioeconomic implications of dysmenorrhea. Acta Obstet Gynecol Scand Suppl 1979; 87: 67–8 Harlow SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obstet Gynaecol 1996; 103: 1134–42 Campbell MA, McGrath PJ. Non-pharmacologic strategies used by adolescents for the management of menstrual discomfort. Clin J Pain 1999; 15: 313–20 Campbell MA, McGrath PJ. Use of medication by adolescents for the management of menstrual discomfort. Arch Pediatr Adolesc Med 1997; 151: 905–13 Balbi C, Musone R, Menditto A, et al. Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol 2000; 91: 143–8 Deutch B. Menstrual pain in Danish women correlated with low n-3 polyunsaturated fatty acid intake. Eur J Clin Nutr 1995; 49: 508–16 Hornsby PP, Wilcox AJ, Weinber CR. Cigarette smoking and disturbance of menstrual function. Epidemiology 1998; 9: 193–8 Alvin PE, Litt IF. Current status of etiology and management of dysmenorrhea in adolescents. Pediatrics 1982; 70: 516–25 Simopoulos AP. Omega-3 fatty acids in health and disease and in growth and development. Am J Clin Nutr 1991; 54: 438–63 Chan WY, Hill JC. Determination of menstrual prostaglandin levels in non-dysmenorrheic and dysmenorrheic subjects. Prostaglandins 1978; 15: 365–75 Rees MCP, Anderson ABM, Demers LM, et al. Prostaglandins in menstrual fluid in menorrhagia and dysmenorrhea. Br J Obstet Gynaecol 1984; 91: 673–80 Lundstrom V, Green K. Endogenous levels of prostaglandin F2α and its main metabolites in plasma and endometrium of normal and dysmenorrheic women. Am J Obstet Gynecol 1978; 130: 640–6 Rees MCP, Di Marzo V, Tippins JR, et al. Leukotriene release by endometrium and myometrium throughout the menstrual cycle in dysmenorrhea and menorrhagia. J Endocrinol 1987; 113: 291–5 Levinson SL. Peptidoleukotriene binding in guinea pig uterine membrane preparations. Prostaglandins 1984; 28: 229–40 Nigam S, Benedetto C, Zonca M, et al. Increased concentrations of eicosanoids and platelet-activating factor in menstrual blood from women with primary dysmenorrhea. Eicosanoids 1991; 4: 137–41 Harel Z, Lilly C, Riggs S, et al. Urinary leukotriene (LT)-E4 in adolescents with dysmenorrhea. J Adolesc Health 2000; 27: 151–4 Laufer MR, Goitein L, Bush M, et al. Prevalence of endometriosis in adolescent women with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol 1997; 10: 199–202 Goldstein DP, DeCholnoky C, Leventhal JM, et al. New insights into the old problem of chronic pelvic pain. J Pediatr Surg 1979; 14: 675–80 Simpson JL, Elias S, Malinak LR, et al. Heritable aspects of endometriosis (I). Genetic studies. Am J Obstet Gynecol 1980; 137: 327–31 Goldstein DP, DeCholnoky C, Emans SJ. Adolescent endometriosis. J Adolesc Health Care 1980; 1: 37–41 Kotani N, Sakai I, Hashimoto H, et al. Analgesic effect of a herbal medicine for treatment of primary dysmenorrhea: a double blind study. Am J Chin Med 1997; 25: 205–12 Kaplan B, Rabinerson D, Lurie S, et al. Clinical evaluation of a new model of transcutaneous electrical nerve stimulation device for the management of primary dysmenorrhea. Gynecol Obstet Invest 1997; 44: 255–9 Golub LJ, Menduke H, Lang WR. Exercise and dysmneorrhea in young teenagers: a 3-year study. Obstet Gynecol 1968; 32: 508–11 Akin MD, Weingand KW, Hengehold DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol 2001; 97: 343–9 Harel Z, Biro FM, Kotenhahn RK, et al. Supplementation with omega-3 fatty acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol 1996; 174: 1335–8 Boctor AM, Eickholt M, Pugsley TA. Meclofenamate sodium is an inhibitor of both the 5-lipoxygenase and cycloxygenase pathways of the arachidonic acid cascade in vitro. Prostaglandins Leukot Med 1986; 23: 229–38 Chan WY, Dawood MY. Prostaglandin levels in menstrual fluid of nondysmenorrheic and of dysmenorrheic subjects with and without oral contraceptive or ibuprofen therapy. Adv Prostaglandin Thromboxane Res 1980; 8: 1443–7 Hanson FW, Izu A, Henzyl MR. Naprosyn sodium in dysmenorrhea: its influence in allowing work/school activities. Obstet Gynecol 1978; 52: 583–7 Budoff PW. Zomepirac sodium in the treatment of primary dysmenorrhea syndrome. N Engl J Med 1982; 307: 714–9 Smith RP, Powell JR. Intrauterine pressure changes during dysmenorrhea therapy. Am J Obstet Gynecol 1982; 143: 286–9 Mehlisch DR. Ketoprofen, ibuprofen, and placebo in the treatment of primary dysmenorrhea: a double-blind crossover comparison. J Clin Pharmacol 1988; 28: S29–33 Mehlisch DR. Double-blind crossover comparison of ketoprofen, naproxen, and placebo in patients with primary dysmenorrhea. Clin Ther 1990; 12: 398–409 Marchini M, Tozzi L, Bakshi R, et al. Comparative efficacy of diclofenac dispersible 50mg and ibuprofen 400mg in patients with primary dysmenorrhea: a randomized, double-blind, within-patient, placebo-controlled study. Int J Clin Pharmacol Ther 1995; 33: 491–7 Owen PR. Prostaglandin synthetase inhibitors in the treatment of primary dysmenorrhea. Am J Obstet Gynecol 1984; 148: 96–103 Roy S. A double-blind comparison of a propionic acid derivative (ibuprofen) and a fenamate (mefenamic acid) in the treatment of dysmenorrhea. Obstet Gynecol 1983; 61: 628–32 DuRant RH, Jay MS, Shofitt T. Factors influencing adolescents’ responses to regimens of naproxen for dysmenorrhea. Am J Dis Child 1985; 139: 489–93 Morrison BW, Daniels SE, Kotey P, et al. Rofecoxib, a specific cyclooxygenase-2 inhibitor, in primary dysmenorrhea: a randomized controlled trial. Obstet Gynecol 1999; 94: 504–8 Dawood M. Non-steroidal anti-inflammatory drugs and changing attitudes toward dysmenorrhea. Am J Med 1988; 84: 23–9 Bieglmayer C, Hofer G, Kainz C, et al. Concentrations of various arachidonic acid metabolites in menstrual fluid are associated with menstrual pain and are influenced by hormonal contraceptives. Gynecol Endocrinol 1995; 9: 307–12 Hauksson A, Akerlund M, Forsling ML, et al. Plasma concentrations of vasopressin and a prostaglandin F2α metabolite in women with primary dysmenorrhea before and during treatment with a combined oral contraceptive. J Endocrinol 1987; 115: 355–61 Creatsas G, Deligeoroglou E, Zachari A, et al. Prostaglandins: PGFα PGE2, 6-keto-PGF1α and TXB serum levels in dysmenorrheic adolescents before, during and after treatment with oral contraceptives. Eur J Obstet Gynecol Reprod Biol 1990; 36: 292–8 Ekstrom P, Juchnicka E, Laudanski T, et al. Effect of an oral contraceptive in primary dysmenorrhea: changes in uterine activity and reactivity to agonists. Contraception 1989; 40: 39–47 Ekstrom P, Akerlund M, Forsling M, et al. Stimulation of vasopressin release in women with primary dysmenorrhea and after oral contraceptive treatment: effect on uterine contractility. Br J Obstet Gynaecol 1992; 99: 680–4 Milsom I, Andersch B. Effect of various oral contraceptive combinations on dysmenorrhea. Gynecol Obstet Invest 1984; 17: 284–92 Larsson G, Milsom I, Lindstedt G, et al. The influence of a low-dose combined oral contraceptive on menstrual blood loss and iron status. Contraception 1992; 46: 327–34 Weber-Diehl F, Unger R, Lachnit U. Triphasic combination of ethinyl estradiol and gestodene: long-term clinical trial. Contraception 1992; 46: 19–27 Robinson JC, Plichata S, Weisman CS, et al. Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic. Am J Obstet Gynecol 1992; 166: 578–83 Ulstein M, Svendsen E, Steier A, et al. Clinical experience with a triphasic oral contraceptive. Acta Obstet Gynecol Scand 1984; 63: 233–6 Louden NR, Foxwell M, Potts DM, et al. Acceptability of an oral contraceptive that reduces the frequency of menstruation: the tri-cycle pill regimen. BMJ 1977; II: 487–90 Sulak PJ, Cressman BE, Waldrop E, et al. Extending the duration of active oral contraceptive pills to manage hormone withdrawal symptoms. Obstet Gynecol 1997; 89: 179–83 Guillebaud J. Reducing withdrawal bleeds. Lancet 2000; 355: 2168–9 Ortiz A, Hiroi M, Stancyk FZ, et al. Serum medroxyprogesterone acetate (MPA) concentrations and ovarian function following intramuscular injection of Depo-MPA. J Clin Endocrinol Metab 1977; 44: 32–8 Harel Z, Biro F, Kollar L. Depo-provera in adolescents: effects of early second injection or prior oral contraception. J Adolesc Health 1995; 16: 379–84 Cox DJ, Meyer RG. Behavioral treatment parameters with primary dysmenorrhea. J Behav Med 1978; 1: 297–310 Chatman DL, Ward AB. Endometriosis in adolescents. J Reprod Med 1982; 27: 156–60 American Society of Reproductive Medicine. Revised American Society of Reproductive Medicine classification of endometriosis. Fertil Steril 1997; 67: 817–21 Davis GD, Thillet E, Lindemann J. Clinical characteristics of adolescent endometriosis. J Adolesc Health 1993; 14: 362–8 Propst AM, Laufer MR. Endometriosis in adolescents: incidence, diagnosis, and treatment. J Reprod Med 1999; 44: 751–8 Cook AS, Rock JA. Role of laparoscopy in the treatment of endometriosis. Fertil Steril 1991; 55: 663–80 Lubianca JN, Gordon CM, Laufer MR. ‘Add-back’ therapy for endometriosis in adolescents. J Reprod Med 1998; 43: 164–72

The authors thank Wendy Wholey and Karen Autieri for their skillful preparation of the manuscript. The author has provided no information on sources of funding or on conflicts of interest directly relevant to the content of this review. Author information Authors and Affiliations Corresponding author Rights and permissions About this article Cite this article Harel, Z. A Contemporary Approach to Dysmenorrhea in Adolescents. Pediatr-Drugs 4, 797–805 (2002). https://doi.org/10.2165/00128072-200204120-00004 Published: Issue date: DOI: https://doi.org/10.2165/00128072-200204120-00004