Period problems in teens are common. They can cause significant disruption and distress to adolescents and their parents but rarely have a significant or medically worrying underlying cause. In this series of articles, I’ll try to provide a logical and systematic approach to assessing and managing period problems in teenagers (recognizing that this may often be able to be extrapolated to adults too for those of you who do not only see children). The first article in the series “Menorrhagia” can be found here.
Roisin is 14. She has attended your paediatric emergency department on three occasions in the past 3 months with lower abdominal pain/pelvic pain coinciding with the first few days of her menstrual cycle. Each time she has been given ibuprofen, once with some codeine phosphate and discharged with the diagnosis code “dysmenorrhoea” on the A&E record. She arrives today with her mother in pain and clutching a hot water bottle. Her mother is angry and upset saying, “Don’t fob us off with Nurofen again, we need some answers” when she is initially triaged.
Dysmenorrhoea is defined as “painful cramping, usually in the lower abdomen, which occurs shortly before or during menstruation, or both”. It is extremely common, especially in the adolescent population. 16-93% of all menstruating teenagers are affected, with up to 29% reporting severe pain. Studies have suggested that around one-third of menstruating teenagers miss one or more days of education or employment each month as a result of dysmenorrhoea.
90% of dysmenorrhea in adolescents is primary dysmenorrhoea, that is, dysmenorrhoea with no clear secondary underlying cause. Of the 10% that is secondary, pelvic inflammatory disorder (almost exclusively as a result of STIs) or endometriosis make up the vast majority.
The pathophysiology of primary dysmenorrhoea is uncertain, however, it is presumed that uterine prostaglandins causing uterine cramping are the underlying mechanism and would explain why primary dysmenorrhoea commonly coexists with menorrhagia. In endometriosis ectopic deposits of endometrial tissue appear in locations outside the uterine cavity, typically on ovaries, fallopian tubes and in the peritoneum. These deposits respond to hormones during the menstrual cycle and at menstruation, these deposits bleed causing irritation and pain. Classically the pain is cyclical, worst in the day or two before menstruation but, as the condition progresses and becomes more chronic, adhesions can form and pain can be more severe and constant. It is worth being aware that laparoscopy findings do not always correlate well with symptoms; some patients can have severe symptoms with what appears visually to be small/minimal deposits and others have minimal symptoms with quite “severe disease”. On average it takes six years from presentation to diagnosis. Management is usually symptomatic with the combined contraceptive pill, analgesia and sometimes surgery.
What to cover in the history
The key to most history taking is the ICE (ideas, conditions and expectations). Ask why Roisin has presented now (Helman, “why me, why now?”) and what she and her mum are hoping for from the encounter. What are they worried about? Is this causing her to miss significant amounts of school? Is seeing her daughter in distress having a big impact on mum? Is mum missing work as a result of her daughter’s symptoms? What are they hoping will happen? Mum has said she doesn’t want “to be fobbed off with Nurofen” – is she hoping for different drugs, a better explanation, reassurance, scans, operations?
Things to cover:
- Ideas, Concerns, Expectations
- Effect on activities of daily living – missed education, missed hobbies/sports activities
- When was menarche?
- Has the dysmenorrhea been a feature since menarche?
- Is there associated menorrhagia?
- Which days are the painful days?
- What has been tried for the pain? What works? What doesn’t help?
- Are they having sex or have they ever had sex? (remember PID and the prevalence of chlamydia)
Roisin tells you she started her period eight months ago. She has a period around every 30 days. It is really painful for the first two to three days. She sometimes takes paracetamol but it doesn’t help much. She has found ibuprofen more helpful, but her dad read the box and said it wasn’t safe as she has asthma and threw it away the last time she was given some. Her periods are always painful but not especially heavy. She has seen her GP about this, but her mum was horrified that they suggested the pill as she thinks Roisin is too young for that. They’ve attended ED three times in the last three months as Roisin was crying with pain, wanting to stay home from school with a hot water bottle. Her mum thinks if you miss school you are ill enough to need a doctor.
Examination and Investigation
The vast majority of patients with dysmenorrhoea will have a normal examination though they may well be very tender in the lower abdomen and prefer to adopt a curled-up position with hips flexed. A vaginal bimanual examination is almost never indicated in an adolescent in this context but clear history, especially of STI risk, may guide you to consider self-taken swabs or an ultrasound. Again, it is important to consider their Ideas, Concerns and Expectations – they may be expecting an examination and/or a scan, so an explanation of why this isn’t happening is key to ensuring that the management plan is effectively shared and mutually agreeable.
NSAIDs are first-line and patients can usually be encouraged to take ibuprofen dosed by weight/age and bought over the counter. Mefenamic acid is no longer the NSAID of choice due to lack of increased efficacy over other NSAIDs, the narrow therapeutic window and the risk of overdose. Paracetamol is, of course, always worth trying as the first-line.
The combined oral contraceptive pill is often used, and extended regimens can be used such as tricycling with a two to three-day pill-free interval. Eligibility to take the COCP will need to be checked using the oral contraceptive pill is often used, and extended regimens can be used such as UKMEC. Any anovulant contraceptive, especially those with a likelihood of amenorrhoea, is likely to improve primary dysmenorrhoea. First-line treatment for endometriosis is usually an anovulant contraceptive. PID needs treating as per local or national antimicrobial guidelines (see DFTB article on vaginal discharge).
There is no clear evidence for the use of hot water bottles or TENS, but NICE CKS do suggest they can be helpful for some patients.
You explain carefully to Roisin and her mother how to take NSAIDs. You reassure them that as her asthma is well controlled and she has previously taken NSAIDs without any ill effects she is safe to take over the counter ibuprofen and paracetamol. You discuss possible next steps including the combined oral contraceptive pill, explaining that anovulant contraceptives are frequently prescribed for dysmenorrhoea and not as contraception. You discuss the use of local heat pads/hot water bottles and gentle exercise. You give them a patient leaflet such as the one recommended by NICE from Women’s Health Concern. They leave your department reassured and happy with a plan to review with their GP if regular NSAIDs are ineffective.
De Sanctis, S. et al. Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge [Internet]. Paediatric Endocrinology Reviews. 2015 [cited 13th January 2021]. 13(2): 512-20. Available from: https://pubmed.ncbi.nlm.nih.gov/26841639/
Helman, C. Disease versus illness in general practice. The Journal of the Royal College of General Practitioners 1981; 31(230): 548-552
Iacovides, S., Avidon, I., Baker, F, C. What we know about primary dysmenorrhea today: a critical review [Internet]. Human Reproduction Update. 2015 [cited 13th January 2021]. 21(6): 762-78. Available from: https://pubmed.ncbi.nlm.nih.gov/26346058/
Ju, H., Jones, M., Mishra, G. The prevalence and risk factors of dysmenorrhea [Internet]. Epidemiologic reviews. 2014. 36: 104-13. Available from: https://pubmed.ncbi.nlm.nih.gov/24284871/.
NICE. Dysmenorrhoea [Internet]. 2018 [cited 13th January 2021]. Available from: https://cks.nice.org.uk/topics/dysmenorrhoea/
Osayande, A. and Mehulic, S. 2014. Diagnosis and initial management of dysmenorrhea. American Family Physician. 89(5), 341-346.