8.01 Dysmenorrhea (Menstrual Cramps)
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agk's Library of Common Simple Emergencies

Presentation
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A young woman complains of crampy, labor-like 
pains which began before the visible bleeding 
of her menstrual period. The pain is focused in 
the lower abdomen, low back, suprapubic area or 
thighs, and may be associated with nausea, 
vomiting, increased defecation, headache, 
muscular cramps, and passage of clots. The pain 
is most severe on the first day of the menses, 
and may last from several hours to several 
days. Often, this is a recurrent problem, 
dating back to the first year after menarche. 
Rectal, vaginal and pelvic examination disclose 
nothing abnormal.

What to do:
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- Ask about the duration of symptoms and onset 
    of similar episodes (onset of dysmenorrhea 
    after menarche suggests other pelvic 
    pathology). Ask about appetite, diarrhea, 
    dysuria, dyspareunia and other symptoms 
    suggestive of other pelvic pathology.
- Perform a thorough abdominal and speculum and 
    bimanual pelvic examination, looking for 
    signs of infection, pregnancy, or uterine 
    or adnexal disease.
- Confirm that the patient is not pregnant with 
    a urine pregnancy test (or serum beta hCG 
    if available stat).
- For uncomplicated dysmenorrhea, try 
    nonsteroidal antiinflammatory medications 
    such as ibuprofen (Motrin) 600-800mg, 
    indomethacin (Indocin) 50mg, or naproxen 
    (Naprosyn) 500mg po initially, tapering to 
    maintenance doses (half the loading dose 
    q6h).
- Arrange for workup of endometriosis or other 
    underlying causes and suggest aspirin or 
    oral contraceptives for prophylaxis.

What not to do:
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Do not treat acute dysmenorrhea with aspirin 
alone. Aspirin begun three days before the 
period, 650mg qid, is effective prophylaxis, 
but it is not as good once symptoms exist.

Discussion
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Prostaglandins E and F in menstrual blood 
appear to stimulate uterine hyperactivity, and 
thus many of the symptoms of dysmenorrhea.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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