Supporting teenagers with period pain in general practice: clinical review.

Period pain (dysmenorrhoea) affects approximately 70–90% of teenagers who menstruate; one-third report marked pain and 20–30% regularly miss school. When at school, menstrual pain impacts on schoolwork and contributes to missing social and sporting opportunities. 1 – 3 Despite evidence-based treatment options, worldwide literature suggests that most adolescents do not seek health care. 4 Reasons include thinking period pain is normal, which can be reinforced if family and friends experience similar pain, or distrust or wariness of healthcare professionals (HCPs), and not knowing whether their pain is serious enough (or will be taken seriously). 5 Although adolescents are encouraged to seek advice if their pain is abnormal, 6 this can be a difficult assessment for teenagers to make. A recent survey of 442 UK school students found that over a quarter did not know whether their periods were normal or not, and that 29.5% had seen an HCP about their periods. 7 Health professionals also experience uncertainty about when menstrual pain is normal, or not. 8 , 9 Talking about menstruation can be experienced as difficult or stigmatised, and occurs within ‘menstrual etiquette’ governing how and when menstruation is discussed. 10

The priorities and needs of the young person influence which treatment options are offered or considered acceptable. This includes preferences around hormonal treatment, and whether they need or want contraception. If hormonal contraception is not an acceptable option, and alternatives are not effective or possible, guidance suggests considering specialist referral. 16 Any intervention trialled for adolescent dysmenorrhoea should be followed up, and young people should have a clear understanding of their options if treatment is ineffective. Young people with debilitating or difficult symptoms after a trial of treatment, or for whom a trial of treatment is contraindicated, unacceptable, or not tolerated, should be offered specialist referral. 16 Self-care and non-pharmacological strategies can be helpful. A Cochrane review demonstrated that exercise is an effective intervention for dysmenorrhoea, 17 although accounts from young people illustrate that rest and exercise avoidance are also well-documented self-care strategies. External heat application and TENS machines can be beneficial. There is conflicting evidence for acupuncture, but some may find this helpful. There is no consistent evidence for dietary supplements, but replacing vitamin D if deficient can be valuable. 5 Non-steroidal anti-inflammatories are an evidence-based treatment for dysmenorrhoea. 5 While embedded in guidance, and effective for some, there is less trial evidence for their effectiveness in endometriosis-associated pain, reinforcing the importance of ensuring follow-up after trials of treatment. Hormonal treatments are effective in reducing dysmenorrhoea. Combined hormonal (CH) treatment is the best studied. Continual rather than cyclical CH treatment has a therapeutic advantage though can be associated with irregular bleeding. 5 Progestogen-only methods that reduce ovulation (for example, desogestrel, implant, or intrauterine system [IUS]) are often used, and clinical experience testifies to their effectiveness, although there is little trial evidence in adolescents.

Menstrual pain is common and impactful on activities that are critical to teenagers’ wellbeing and social/educational development. Promptly treating and validating all menstrual pain can make a major difference to a teenager now and in their future life. GPs need to keep their doors and minds open to ensure that, if initial therapeutic approaches are not effective, tolerated, or acceptable, opportunities can be created to review the young person and consider next steps.