Secondary dysmenorrhea refers to menstrual pain of new onset in a woman previously void of menstrual pain or the presence of worsening menstrual pain over a period of time. It is secondary to an underlying pelvic disease.
The presentation varies and depends on the underlying disease condition. It typically presents as any other pattern of menstrual pain different from that described for primary dysmenorrhea. It has no singular pattern of presentation and may occur at any phase of the menstrual cycle as well as during menstruation and unlike primary dysmenorrhea that typically appears few months after menarche, it may appear at anytime during the reproductive years. It may also present as worsening primary dysmenorrhea or as a new onset of cyclical lower abdominal pain felt in a woman who have never experienced primary dysmenorrhea. With multiple possible causes, its severity varies with its cause and its resolution often occurs following the treatment of the underlying cause.
It may also present with other symptoms typical of the underlying cause of the dysmenorrhea. For example, secondary dysmenorrhea may be associated with heavy menstrual bleeding in uterine fibroids, adenomyosis and in women with IUCD contraceptives. Similarly, women with uterine fibroid and adenomyosis may present with secondary dysmenorrhea associated with a lower abdominal swelling and an abdominal mass on clinical examination while those with PID may present with an offensive vaginal discharge associated with fever along with a secondary dysmenorrhea. Endometriosis, a notorious cause of severe secondary dysmenorrhea is often associated with painful intercourse on deep penetration (deep dyspareunia).
This involves taking a detailed history, performing a thorough clinical examination and employing the use of necessary investigations. Usually from the clinical history, it is easy to differentiate primary dysmenorrhea from secondary dysmenorrhea, but further investigations are often required to differentiate the different causes of secondary dysmenorrhea. Specific presentation, investigations and treatment of the various causes of secondary dysmenorrhea will be discussed in detail in respective articles written on each and specific pelvic disease or disorder. In the main time, basic investigations necessary for the diagnosis of secondary dysmenorrhea are discussed below.
This includes primary dysmenorrhea as well as any of the above listed causes of secondary dysmenorrhea.
Investigations commonly done are;
1. Abdominal ultrasound: This is important in making a diagnosis of uterine fibroids, adenomyosis as well as the coexistence of ovarian masses in suspected cases of endometriosis
2. Laparoscopy: This is the gold standard of diagnosis of PID, endometriosis and pelvic adhesions. It can also be used to view first hand, the presence of any other pelvic diseases such as the uterine fibroids and ovarian cysts. It has the advantage in expert hands to be used for the treatment of many of the causes of secondary dysmenorrhea.
3. Chlamydia and Gonorrhea screening tests: Patients with vaginal discharge and those with symptoms suggestive of pelvic inflammatory disease (PID) should be screened for Gonorrhea and Chlamydia infection. These include antibody tests or culture or PCR for Chlamydia and endo-cervical swab M/C/S for Gonorrhea. If present, other STDs should be investigated and all contacts traced to disrupt the chain of transmission.
The definitive treatment of secondary dysmenorrhea is by the treating its cause. However, many of the above listed approach for the treatment of primary dysmenorrhea may help to reduce the symptoms till a definitive approach to treatment is available or desirable. For example, patients with uterine fibroids, endometriosis and adenomyosis presenting with secondary dysmenorrhea may benefit from the use of NSAIDs, OCPs or the insertion of Mirena for the relief of their menstrual pains pending their definitive management with surgery is available or desirable. For treatment of specific causes of secondary dysmenorrhea, please look up various articles on these or CHAT WITH OUR CONSULTANTS online.
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1. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. British Medical Journal 2006; 332: 1134–8.