Dysmenorrhea: Causes, Symptoms, Diagnosis, Treatment, and Prevention

Dysmenorrhea is painful menstruation, characterized by pain that occurs shortly before the onset of bleeding or during the first few days of the cycle and may be accompanied by nausea, weakness, diarrhea, headache, dizziness, and a significant decrease in performance. Clinically, it is not "common female discomfort," but rather one of the most common gynecological conditions in adolescents and women of reproductive age, significantly impairing quality of life, education, work, and psycho-emotional well-being. [1]

Modern medicine divides dysmenorrhea into primary and secondary. Primary dysmenorrhea occurs without detectable organic pathology of the pelvic organs and is considered a diagnosis of exclusion. Secondary dysmenorrhea is associated with a specific cause, such as endometriosis, adenomyosis, uterine fibroids, congenital malformations, pelvic inflammatory disease, and other conditions. [2]

The primary form most often begins in adolescence, typically within about 2 years of menarche, when ovulatory cycles are established. The pain is typically cramping, localized in the lower abdomen, and may radiate to the lower back and inner thighs. It peaks in the first 23-48 hours and usually resolves within 72 hours. The secondary form is more often suspected if the pain appears after several years of painless menstruation, gradually intensifies, becomes less cyclical, or is accompanied by abnormal bleeding, pain during intercourse, and other symptoms. [3]

According to current data, dysmenorrhea affects approximately 50% to 90% of adolescents and women of reproductive age and remains one of the leading causes of missed school and work. Up to half of patients miss at least one class or work due to pain, and 10% to 15% experience such missed periods regularly during menstruation. Therefore, in modern gynecology, dysmenorrhea is considered not only a symptom but also a significant medical and social problem. [4]

Early recognition of the cause is also important because painful periods can be a sign of endometriosis. Current guidelines emphasize that in cases of persistent, clinically significant pain that does not respond to nonsteroidal anti-inflammatory drugs and hormonal therapy, especially in adolescents and young women, a secondary cause, primarily endometriosis, should be actively considered. [5]

Key fact	Practical significance
Dysmenorrhea can be primary and secondary.	The examination and treatment tactics depend on the cause.
The primary form often begins soon after menarche.	Typical for teenagers and young women
The secondary form often forces one to look for an organic cause.	Often associated with endometriosis and adenomyosis
The condition is very common.	Requires active identification rather than normalization of pain
Often leads to absences from school and work	It has not only medical but also social significance

The table is compiled based on a review by the American Academy of Family Physicians, StatPearls, and current literature on adolescent dysmenorrhea. [6]

Code according to ICD 10 and ICD 11

In the International Classification of Diseases, 10th revision, dysmenorrhea is coded separately by clinical type. Primary dysmenorrhea is coded N94.4, secondary dysmenorrhea is coded N94.5, and unspecified dysmenorrhea is coded N94.6. This structure is convenient for clinical practice because it immediately reflects the physician's primary concern: is it functional pain without an identified pathology or a symptom of a disease that has yet to be diagnosed? [7]

The situation is slightly different with the International Classification of Diseases, 11th revision. In publicly available indexed mappings and coding reference books, dysmenorrhea is grouped under code GA34.3 as a single symptomatic category, while the causes of secondary dysmenorrhea are additionally coded according to the underlying disease. This reflects a modern approach: painful menstruation itself is recognized as an independent clinical problem, but in the secondary form, coding the underlying cause, such as endometriosis or adenomyosis, is also key. [8]

System	Code	Meaning
ICD 10	N94.4	Primary dysmenorrhea
ICD 10	N94.5	Secondary dysmenorrhea
ICD 10	N94.6	Dysmenorrhea, unspecified
ICD 11	GA34.3	Dysmenorrhea as a symptomatic category
ICD 11	Additional reason code	Used for secondary dysmenorrhea for the underlying disease

The table is based on the World Health Organization browser for the International Classification of Diseases, 10th revision, and on indexed mappings of the International Classification of Diseases, 11th revision. [9]

Epidemiology

Dysmenorrhea is one of the most common gynecological complaints. According to a review by the American Academy of Family Physicians, it occurs in 50% to 90% of adolescents and women of reproductive age. This wide range is due to the fact that different studies define pain severity, age of subjects, and inclusion criteria differently. But even the lower limit shows that this is not a rare symptom, but a widespread condition. [10]

The epidemiological significance of dysmenorrhea is determined not only by its frequency but also by its impact on daily life. Recent reviews indicate a reduced quality of life, an increased risk of anxiety and depressive symptoms, and frequent absences from school and work. For this reason, in many countries, dysmenorrhea is considered a significant cause of short-term but regularly recurring functional disability in young women. [11]

Secondary dysmenorrhea accounts for a smaller proportion of all cases, approximately 10%, but it is precisely this type that requires the most careful investigation. Among the causes of secondary dysmenorrhea, endometriosis plays a leading role. This is especially important in adolescents and young women with severe pain that does not respond to standard treatment, as such symptoms may indicate a chronic condition with a risk of progression. [12]

Primary dysmenorrhea is most typical in adolescents and young women, while secondary dysmenorrhea can appear at any age after menarche and even become noticeable for the first time in one's 30s or 40s. Therefore, epidemiology is closely linked to age: in an adolescent with typical cyclical pain, additional examination is structured one way, while in an adult woman with increasing pain and cycle changes, it is quite different. [13]

Epidemiological indicator	Data
General prevalence	50% to 90% of menstruating adolescents and women
The proportion of female patients visiting a general practitioner for the first time	about 45%
Miss school or work at least sometimes	up to 50%
Regularly miss classes or work during menstruation	10% to 15%
The incidence of secondary dysmenorrhea	about 10% of cases
The most common cause of the secondary form	endometriosis

The table is based on a review by the American Academy of Family Physicians, StatPearls, and adolescent dysmenorrhea literature.[14]

Reasons

The causes of dysmenorrhea depend on its type. In the primary form, no organic pelvic pathology is detected, and the underlying mechanism is related to the local biochemistry of menstruation, primarily increased prostaglandin production. In the secondary form, pain becomes a symptom of a specific disease, and the list of causes is significantly broader. [15]

Endometriosis is considered the most common cause of secondary dysmenorrhea. Current guidelines from the European Society of Human Reproduction and Embryology and clinical review publications emphasize that it should be actively suspected in patients with severe pain, especially if it is poorly controlled by standard therapy. In addition to endometriosis, other important causes include adenomyosis, uterine fibroids, congenital and acquired anatomical anomalies, pelvic inflammatory disease, polyps, cysts, and adhesions. [16]

For practitioners, it's important to remember that painful menstruation alone does not automatically indicate a primary cause. If the pain was severe from the start, if it increases with age, if it is accompanied by infertility, pain during intercourse, urination, or bowel movements, or if there is irregular or excessive bleeding, the likelihood of a secondary cause increases. This is especially true for endometriosis and adenomyosis. [17]

Finally, some causes lie outside the uterus itself. Secondary dysmenorrhea can be associated with structural abnormalities of the cervix, congenital Müllerian anomalies, adhesions after surgery, chronic infection, and even complications of intrauterine contraception. Therefore, modern diagnostics are always based on the principle of "first identify the type of pain, then confirm or exclude the cause." [18]

Type of dysmenorrhea	Main reasons
Primary	There is no detectable organic pathology; prostaglandins play a leading role.
Secondary	Endometriosis, adenomyosis, uterine fibroids, developmental anomalies, inflammation, adhesions, cysts, polyps
A particularly important cause in adolescents and young women	endometriosis
Particularly important causes in adult female patients with increasing pain	endometriosis, adenomyosis, uterine fibroids

The table is based on StatPearls, a review by the American Academy of Family Physicians, and the European Society of Human Reproduction and Embryology guidelines on endometriosis.[19]

Risk factors

A number of fairly consistent risk factors have been identified for primary dysmenorrhea. A review by the American Academy of Family Physicians lists age under 30, a body mass index of less than 20 kilograms per square meter, smoking, early menarche before age 12, longer cycles, heavy menstrual flow, nulliparity, premenstrual syndrome, and a history of pelvic inflammatory disease. These factors do not necessarily mean pain will occur, but they make it more likely. [20]

StatPearls adds to this list a family history of dysmenorrhea, attempts at weight loss, weight fluctuations, anxiety, depression, heavy and prolonged menstrual periods, and psychosocial stressors. This clearly demonstrates that dysmenorrhea is not only a localized gynecological problem but also a condition in which hormonal, inflammatory, behavioral, and psychoemotional factors intersect. [21]

For secondary dysmenorrhea, the main risk factor is not so much lifestyle as the presence of a disease causing the pain. Particularly important are a family history of endometriosis, recurrent severe cyclic pain, infertility, dyspareunia, menstrual irregularities, and symptoms that do not fit the typical picture of the primary form. Current guidelines on endometriosis also emphasize the importance of family history: the presence of the disease in a first-degree relative increases the likelihood of this cause. [22]

Interestingly, some factors are considered protective. A review by the American Academy of Family Physicians identified these as increasing age, childbirth, physical activity, and oral contraceptive use. This is not absolute protection, but it provides important guidance for prevention and long-term treatment strategies. [23]

Risk factor	More related to which form
Age up to 30 years	primary
Early menarche	primary
Smoking	primary
Heavy and prolonged menstruation	most often primary, but require exclusion of secondary causes
Absence of childbirth	primary
Family history of dysmenorrhea	primary
Family history of endometriosis	secondary
Anxiety and depression	increase the risk and severity of symptoms
Previous pelvic inflammatory diseases	secondary and mixed forms of risk

The table is based on a review by the American Academy of Family Physicians, StatPearls, and the updated National Institute for Health and Clinical Excellence guidelines on endometriosis.[24]

Pathogenesis

In modern literature, the pathogenesis of primary dysmenorrhea is primarily associated with prostaglandins. During menstruation, the shedding of the endometrium releases prostaglandins, which enhance myometrial contractility and cause vasoconstriction. This results in uterine tissue ischemia, accumulation of anaerobic metabolites, and irritation of pain receptors. This is why the pain is cramping and is often most pronounced at the onset of menstruation. [25]

Not only prostaglandins but also leukotrienes, the inflammatory response, and increased sensitivity of nociceptive pathways play a significant role. A review by the American Academy of Family Physicians describes primary dysmenorrhea as a condition mediated by elevated levels of prostaglandins and leukotrienes, with inflammation increasing uterine contractility and painful spasms. This helps explain why nonsteroidal anti-inflammatory drugs (NSAIDs) work: they reduce the synthesis of inflammatory and pain mediators. [26]

In secondary dysmenorrhea, the mechanism is determined by the cause. In endometriosis, pain is associated with hormone-dependent inflammation, ectopic endometriotic tissue, and peripheral and central sensitization, while in adenomyosis, it is associated with inflammation and structural reorganization of the myometrium. In fibroids and congenital anomalies, impaired menstrual blood flow and mechanical enhancement of uterine contractility may additionally play a role. [27]

It is precisely this difference in pathogenesis that explains the clinical distinction between the primary and secondary forms. With primary pain, the cycle remains relatively uniform from month to month, whereas with secondary pain, symptoms often become more complex, progress, and extend beyond the first day of menstruation. [28]

Mechanism	What's happening	What does this lead to?
Increased prostaglandins	Uterine contractions and vascular spasms increase	Cramping pain
Myometrial ischemia	Blood flow decreases and tissue stress increases.	Increased pain, weakness, nausea
Leukotrienes and inflammation	Tissue sensitivity increases	More severe course
Endometriosis	Chronic inflammation and sensitization	Progressive secondary pain
Adenomyosis and myoma	Structural changes in the uterus and impaired contractility	Longer lasting and often more severe pain

Table compiled from StatPearls, the American Academy of Family Physicians review, and the Current Review of Treatment Options for Dysmenorrhea.[29]

Symptoms

The main symptom of dysmenorrhea is lower abdominal pain, occurring immediately before menstruation or in the first hours and days. In the primary form, the pain is usually midline, cramping, and can radiate to the lower back and inner thighs. It most often occurs around 72 hours after menstruation. This pattern is considered the most typical. [30]

Often, pain is not isolated. Associated symptoms include nausea, vomiting, diarrhea, headache, dizziness, fatigue, and sleep disturbances. In some patients, the severity of systemic symptoms is almost as severe as the pelvic pain itself and significantly reduces daily activity. [31]

For secondary dysmenorrhea, alarming symptoms include increasing pain intensity, its appearance several years after painless menstruation, acyclic pelvic pain, pain during intercourse, urination, or defecation, intermenstrual bleeding, heavy menstrual bleeding, and abnormal vaginal discharge. It is this picture that should prompt a search for an organic cause. [32]

The extent to which pain impacts life is also important. If a patient is forced to cancel school, work, sports, or social activities, or regularly takes painkillers during the first days of her cycle, this is clinically significant dysmenorrhea, even if menstruation remains formally regular. Modern sources emphasize that the functional impact of symptoms should be considered as seriously as their intensity. [33]

Symptom	More typical for
Cramping pain in the lower abdomen in the first days of the cycle	primary
Radiation to the lower back and hips	primary
Nausea, vomiting, diarrhea	primary and severe form
Fatigue, headache, dizziness	primary and mixed variants
Pain during intercourse	secondary
Intermenstrual bleeding	secondary
Progressive increase in pain with age	secondary
Acyclic pelvic pain	secondary

The table is compiled from StatPearls, a review by the American Academy of Family Physicians, and materials from the National Institute for Health and Clinical Excellence. [34]

Classification, forms and stages

The classical classification of dysmenorrhea includes two forms: primary and secondary. Primary dysmenorrhea is diagnosed when, after examination and basic assessment, there are no signs of organic pathology, and the pain corresponds to a typical cyclic pattern. Secondary dysmenorrhea is considered a symptom of a disease and requires determination of the cause. [35]

In clinical practice, dysmenorrhea is often classified by severity as mild, moderate, and severe. While this is not a universal international staging system, as with tumors or endometriosis, it is useful for the physician's daily work. In mild forms, pain does not interfere with normal activity. In moderate forms, work capacity is reduced and the need for medication increases. In severe forms, pain leads to missed school and work days, bed rest, or a persistent decline in quality of life. [36]

It's important to understand that the staging of secondary dysmenorrhea is determined not by the pain itself, but by the underlying condition. For example, with endometriosis, the prevalence and type of lesions are assessed; with adenomyosis, the depth and severity of myometrial lesions; and with fibroids, the size and location of the nodes. Therefore, in the "forms and stages" section for dysmenorrhea, it's more accurate to discuss the type of pain and its severity, rather than trying to assign a single staging pattern to all cases. [37]

Classification	Characteristic
Primary dysmenorrhea	Pain without an identifiable organic cause
Secondary dysmenorrhea	Pain caused by a specific disease
Light	The pain is bearable, activity is maintained
Moderate	Activity is reduced, medication is needed
Heavy	Significant dropout from school, work, and normal life

The table is based on a review by the American Academy of Family Physicians, StatPearls, and the endometriosis guidelines.[38]

Complications and consequences

The word "dysmenorrhea" itself does not imply direct organ damage, but the consequences of this condition can be significant. The most obvious are regular absences from school, university, and work, and a reduction in everyday activities. For many patients, this means a recurring monthly loss of several days of full life. [39]

Modern reviews have noted a link between dysmenorrhea and a deterioration in quality of life, an increased risk of anxiety and depressive symptoms, sleep disturbances, and decreased concentration. Long-term severe pain can lead to central sensitization, where the nervous system becomes more reactive to pain signals and the pain tolerance threshold decreases. This is especially true in endometriosis. [40]

With secondary dysmenorrhea, complications depend largely on the underlying condition. Endometriosis can be accompanied by infertility, chronic pelvic pain, and significant psychosocial burden. Adenomyosis and fibroids can cause heavy bleeding and iron deficiency. Therefore, underestimating painful menstruation is dangerous not only because the patient "endures pain" but also because the underlying pathology is missed. [41]

Consequence	Why is it important?
School and work absences	Recurring loss of educational and professional activity
Sleep disturbances and fatigue	Increase daytime dysfunction
Anxiety and depressive symptoms	Decreases pain tolerance and quality of life
Risk of chronic pelvic pain	Especially in the secondary form
Delayed diagnosis of endometriosis	May worsen long-term prognosis

The table is based on a review by the American Academy of Family Physicians, materials from the European Society of Human Reproduction and Embryology, and data from the Endometriosis Technology Assessment. [42]

When to see a doctor

You should consult a doctor not only when the pain becomes unbearable, but also when it regularly disrupts your daily routine. If menstrual pain forces you to cancel classes, work, or workouts, or requires constant painkillers, this is already sufficient reason for a full consultation. The modern approach is that painful periods should not be automatically considered normal. [43]

It's especially important to seek medical attention immediately if the pain appears after several years of painless menstruation, progresses, or is accompanied by very heavy bleeding, intermenstrual bleeding, pain during intercourse, bowel movements, or urination, fever, abnormal vaginal discharge, or problems with conception. This is more consistent with a secondary form of the condition and requires an investigation of the underlying cause. [44]

Adolescents and young women should be especially vigilant about pain that does not subside with appropriate nonsteroidal anti-inflammatory drugs and hormonal therapy. Guidelines for adolescent dysmenorrhea explicitly state that in such situations, endometriosis should be considered and the patient referred for further evaluation. [45]

Situation	How urgent is it?
Pain interferes with normal life every cycle	scheduled consultation soon
The pain increases year after year	do not postpone the examination
Pain plus abnormal bleeding	a secondary cause assessment is needed
The pain does not respond to standard therapy	further examination for endometriosis and other causes is needed
Pain plus fever or abnormal discharge	urgent in-person assessment

The table is based on a review by the American Academy of Family Physicians, adolescent dysmenorrhea guidelines, and the National Institute for Health and Clinical Excellence.[46]

Diagnostics

Diagnosis begins with a detailed medical history. The doctor will determine the age of onset of pain, its relationship to the menstrual cycle, duration, location, radiation, intensity, associated symptoms, amount of blood loss, cycle regularity, sexual activity, risk of pregnancy, previous infections and surgeries, family history of endometriosis, and response to previous treatments. This discussion is not a formality, but the key to distinguishing between primary and secondary forms. [47]

If the medical history is typical for primary dysmenorrhea, empirical treatment can sometimes be initiated immediately in an adolescent with regular cycles and no warning signs. This is supported by both clinical reviews and guidelines for primary care. This is why modern diagnostics do not require every patient with a typical presentation to undergo complex imaging immediately. [48]

A physical examination and pelvic examination are especially important if there are signs of a secondary form or if initial therapy has failed. StatPearls emphasizes that a pelvic examination is necessary when the history and nature of pain suggest secondary dysmenorrhea or when symptoms do not respond to treatment. However, a non-sexually active adolescent with typical primary dysmenorrhea and no additional symptoms may not require a pelvic examination. [49]

Pelvic ultrasound is considered the preferred initial imaging method for investigating the causes of secondary dysmenorrhea. It helps identify uterine fibroids, adenomyosis, Müllerian anomalies, cysts, and some signs of endometriosis. In typical primary dysmenorrhea, the benefit of ultrasound is significantly lower, and this is also important to avoid overburdening the patient with unnecessary examinations. [50]

Pregnancy should be excluded in sexually active patients, as pelvic pain and bleeding require a different assessment. The American Academy of Family Physicians specifically recommends including a pregnancy test in the initial evaluation of sexually active patients. Additional tests are selected based on the situation: a complete blood count if anemia is suspected, inflammatory markers and microbiological testing if infection is suspected, and other tests based on the clinical picture. [51]

If a high probability of endometriosis or another secondary cause remains and initial evaluation is inconclusive, the next step may be specialist consultation and, in selected cases, laparoscopy. Current guidelines no longer require diagnostic laparoscopy in all cases at an early stage, but retain it as an important tool for cases where the diagnosis remains unclear or surgical intervention is required. [52]

Diagnostic stage	What is being assessed
Anamnesis	cyclicity of pain, age of onset, severity, associated symptoms
Exclusion of pregnancy	mandatory for sexually active patients
Inspection	needed if a secondary form is suspected or therapy is ineffective
Ultrasound examination	the main starting method for secondary dysmenorrhea
Laboratory tests	as indicated, such as in cases of anemia or infection
Specialist consultation and laparoscopy	in complex, unclear or resistant cases

The table is based on a review by the American Academy of Family Physicians, StatPearls, the National Institute for Health and Clinical Excellence, and the European Society of Human Reproduction and Embryology.[53]

Differential diagnosis

In differential diagnosis, the key question is whether this is typical primary dysmenorrhea or a symptom of another disease. Endometriosis remains the most common secondary cause, but it is far from the only one. Adenomyosis, uterine fibroids, pelvic inflammatory disease, congenital anomalies, ovarian cysts, polyps, adhesions, cervical stenosis, and some rare causes must also be considered. [54]

The primary form is supported by a typical presentation: young age, onset shortly after menarche, cyclic pain on the first day of menstruation, absence of other gynecological symptoms, and a normal examination. The secondary form, on the other hand, is made more likely by increasing pain intensity, occurrence after several years of pain-free cycles, dyspareunia, intermenstrual bleeding, abnormal discharge, infertility, and non-cyclic pelvic pain. [55]

Adolescents and young women with endometriosis pose a particular diagnostic pitfall. Their symptoms may be misinterpreted for a long time as "normal painful periods," especially if an ultrasound scan reveals no obvious changes. This is why current recommendations for adolescents emphasize that the lack of response to appropriate treatment should raise suspicions of endometriosis rather than dismiss the issue. [56]

State	What helps to distinguish
Primary dysmenorrhea	typical cyclicity, early onset, absence of other pathology
Endometriosis	treatment resistance, dyspareunia, chronic pelvic pain, infertility
Adenomyosis	painful and often heavy menstrual periods, more typical in adults
Uterine fibroids	heavy bleeding, pressure, enlarged uterus
Inflammatory diseases of the pelvic organs	discharge, fever, pain outside of menstruation
Congenital anomalies	early onset of severe pain, impaired blood flow, atypical anatomy

The table is based on a review by the American Academy of Family Physicians, StatPearls, and endometriosis guidelines.[57]

Treatment

Treatment of dysmenorrhea begins with correctly identifying its type. If the history is typical of the primary form, current guidelines allow empirical therapy without the long wait for imaging. The goal of treatment is not simply to relieve pain for a few hours, but to restore the patient's ability to study, work, sleep, and live without monthly disruptions to their normal rhythm. [58]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-line treatments for primary dysmenorrhea. Their effect is associated with the suppression of cyclooxygenase and a reduction in prostaglandin synthesis. According to StatPearls and a review by the American Academy of Family Physicians, this group of drugs is the most effective in reducing menstrual pain and remains the initial pharmacological choice for most patients without contraindications. [59]

For optimal results, it's important not only to choose a medication but also to start it correctly. StatPearls emphasizes that scheduled dosing 1-2 days before the expected onset of pain or from the very onset of symptoms is more effective than infrequent dosing "once in a while, when the pain is already severe." In clinical practice, it's the timing of treatment initiation that often creates the impression that medications "don't work." [60]

If nonsteroidal anti-inflammatory drugs (NSAIDs) are insufficiently effective, are not tolerated, or contraception is needed, hormonal methods become the next key option. Combined estrogen-progestin contraceptives are recognized as an effective first-line option or complement to NSAIDs. They reduce endometrial thickness, decrease arachidonic acid levels, and, consequently, reduce prostaglandin production and the strength of uterine contractions. [61]

Continuous combination hormonal therapy regimens may provide faster and more significant pain relief in some patients. This is supported by both systematic reviews and clinical guidelines. However, the choice of regimen must take into account contraindications to estrogen, the risk of side effects, and reproductive plans. There is no one-size-fits-all option. [62]

Progestogen-only methods also play an important role. A review by the American Academy of Family Physicians found the levonorgestrel intrauterine system (IUS) to be effective for both primary dysmenorrhea and secondary pain associated with endometriosis. Other progestogen-only options, including implants and injectables, are also acceptable, especially if estrogens are contraindicated. [63]

Non-pharmacological approaches should not be viewed as a "frivolous add-on." High-quality reviews support the use of physical activity, heat therapy, high-frequency transcutaneous electrical nerve stimulation, and self-acupressure as adjuncts to first-line treatment or as an alternative if the patient prefers to reduce her medication burden. Importantly, physical activity also has broader health benefits beyond menstrual pain itself. [64]

If secondary dysmenorrhea is suspected, the approach changes. In cases of probable endometriosis, current guidelines recommend symptomatic treatment, and if imaging is negative and there is no immediate desire to conceive, they allow the initiation of hormonal therapy, most often in the form of combined contraceptives or progestogens. This reflects the current trend: not delaying treatment until surgical confirmation in every case. [65]

For endometriosis-related pain, the European Society of Human Reproduction and Embryology recommends combined hormonal contraceptives, progestogens, the levonorgestrel intrauterine system (IUS), or a subcutaneous implant as the primary options. Gonadotropin-releasing hormone agonists and gonadotropin-releasing hormone antagonists are considered second-line treatments if contraceptives or progestogens are ineffective or poorly tolerated. For refractory cases, the guidelines also allow aromatase inhibitors as part of a combination regimen. [66]

Surgical treatment is not considered a treatment for primary dysmenorrhea per se, but is important for the secondary form. It is considered when the pain has a confirmed organic cause, such as endometriosis, severe adenomyosis, a developmental anomaly, or another condition requiring intervention. In modern practice, laparoscopy is often used not as a starting test for everyone, but rather for selected patients whose symptoms persist, the cause remains probable, and conservative therapy fails to resolve the problem. [67]

Treatment method	In what situation is it most often used?	What is important to remember
Nonsteroidal anti-inflammatory drugs	primary dysmenorrhea	first line, it is better to start early or at the first symptoms
Combined hormonal contraceptives	primary and part of secondary	suitable both as a first line and as a supplement
Continuous hormonal regimens	primary and endometriosis-associated pain	can reduce pain faster
Levonorgestrel intrauterine system	primary and endometriosis-associated pain	effective and convenient for long-term control
Progestogens and the implant	in case of estrogen intolerance or secondary form	a good option for those with contraindications to estrogens
Physical activity, heat, transcutaneous electrical nerve stimulation	as an addition	help reduce the drug burden
Gonadotropin-releasing hormone agonists and antagonists	refractory endometriosis-associated pain	usually second line due to side effects
Surgical treatment	secondary dysmenorrhea with an established cause	is not standard for typical primary form

The table is based on a review by the American Academy of Family Physicians, StatPearls, the Cochrane review on combined contraceptives, and the European Society of Human Reproduction and Embryology guidelines.[68]

Prevention

It's impossible to completely prevent primary dysmenorrhea, but the risk of its severe course and its impact on life can be reduced. Modern clinical reviews cite physical activity, increasing age, childbirth, and the use of hormonal contraception as protective factors. Of these factors, regular physical activity and early treatment when pain worsens remain the most effective preventative measures. [69]

For secondary dysmenorrhea, prevention is closely linked to early identification of the cause. The sooner endometriosis, adenomyosis, or an anatomical problem is recognized, the greater the chance of avoiding years of monthly pain and unnecessary diagnostic delays. Current guidelines on endometriosis explicitly emphasize that family history and clinical symptoms should be taken seriously and prompt evaluation rather than delayed. [70]

So-called prevention of severe exacerbations is also practically beneficial. This includes keeping a cycle calendar, starting nonsteroidal anti-inflammatory drugs (NSAIDs) on time, adhering to the prescribed hormonal therapy regimen, normalizing sleep, quitting smoking, and controlling factors that aggravate pain. This doesn't eliminate the underlying cause, but it makes the course more manageable. [71]

Preventive approach	What is it for?
Regular physical activity	reduces pain intensity and improves general condition
Early treatment for atypical pain	helps to quickly identify the secondary form
Keeping a calendar of your cycle and symptoms	helps the doctor more accurately understand the type of pain
Timely initiation of prescribed treatment	reduces the severity of each episode
Quitting smoking	reduces the risk of a more severe course

The table is based on a review by the American Academy of Family Physicians, StatPearls, and endometriosis management literature.[72]

Forecast

With primary dysmenorrhea, the prognosis is generally favorable if the pain is recognized early and appropriate treatment is selected. In many patients, symptoms persist throughout their reproductive years, but their severity can be significantly reduced, and quality of life can be restored. In one prospective study cited in a review by the American Academy of Family Physicians, symptoms persisted throughout the menstruating years in most patients, although in some women, the severity decreased, for example, after childbirth. [73]

The prognosis for secondary dysmenorrhea depends less on the pain itself than on the underlying cause. Endometriosis can be chronic and prone to relapse, but early diagnosis and step-by-step treatment can significantly reduce pain, improve daily functioning, and reduce the risk of prolonged diagnostic delays. [74]

An unfavorable functional prognosis is often associated not with the "severity of a single attack," but with long years of untreated pain, anxiety, missed school and work, and underestimation of the secondary cause. Therefore, the main prognostic factor is not the patient's patience, but the timely recognition of pain as a clinically significant problem. [75]

Flow variant	Forecast
Typical primary dysmenorrhea in response to therapy	usually favorable
Primary dysmenorrhea without treatment	frequent monthly relapses and functional losses
Secondary dysmenorrhea with early identification of the cause	the prognosis is better than with late diagnosis
Endometriosis-associated pain	often chronic, but good symptom control is possible

The table is based on a review by the American Academy of Family Physicians, guidelines from the European Society of Human Reproduction and Embryology, and technology assessment materials for endometriosis.[76]

FAQ

Is dysmenorrhea normal or a disease?
Menstruation can be accompanied by discomfort, but pain that significantly disrupts daily life requires medical evaluation. Current guidelines do not consider clinically significant dysmenorrhea "normal to be tolerated." [77]

Does painful periods always indicate endometriosis?
No. Most cases are primary dysmenorrhea and are not associated with identifiable organic pathology. However, endometriosis remains the most common cause of the secondary form, especially if the pain is severe, progressive, or poorly responsive to treatment. [78]

Should everyone have an ultrasound?
No. For typical primary dysmenorrhea, ultrasound is of limited benefit. However, if secondary dysmenorrhea is suspected, it is considered the preferred initial method for investigating the cause. [79]

Do painkillers alone help?
No. Nonsteroidal anti-inflammatory drugs are the first line of treatment, but they are not the only option. Hormonal therapies are also effective, and physical activity, heat, and transcutaneous electrical nerve stimulation can be used as adjuncts. [80]

When should secondary dysmenorrhea be considered?
If the pain does not appear immediately after the onset of menstruation, but rather years later, intensifies, becomes less cyclical, is accompanied by abnormal bleeding, dyspareunia, infertility, or does not respond to standard treatment. [81]

Is it possible to treat dysmenorrhea without hormones?
Yes, if it's a primary condition and contraception is not needed, treatment often begins with nonsteroidal anti-inflammatory drugs. However, if these are ineffective, hormonal treatments often provide more lasting symptom control. [82]

Does exercise help?
Yes, moderate regular physical activity is associated with reduced pain intensity. Systematic reviews suggest that both more intense and gentler programs are beneficial when performed regularly. [83]

If the pills don't help, what next?
The next step shouldn't be endless patience, but a reassessment of the diagnosis. If the response is insufficient, it's necessary to check whether the medications were taken correctly, rule out a secondary cause, and consider other methods, including hormone therapy, in-depth diagnostics, and, if necessary, a specialist consultation. [84]

Key points from experts

Geri D. Hewitt, MD, an internationally recognized expert in pediatric and adolescent gynecology at Ohio State University and Nationwide Children's Hospital, has been emphasizing for many years an important clinical point that aligns well with current guidelines from the American College of Obstetricians and Gynecologists: In adolescents, persistent dysmenorrhea that does not respond to appropriate treatment requires a search for a secondary cause, primarily endometriosis, rather than simply dismissing it as "just painful periods." [85]

Karen R. Gerancher, MD, a specialist in obstetrics, gynecology, and adolescent gynecology at Wake Forest, has also helped shape the current adolescent dysmenorrhea agenda. Her expert opinion reflects the clinical shift of recent years: in adolescents and young women, pain should be treated aggressively and early, and failure to respond to first-line treatment should be considered as a basis for further evaluation, not as a reason for long-term "watchful waiting." [86]

Andrew Horne, Professor of Gynecology and Reproductive Sciences and Director of the Centre for Reproductive Health at the University of Edinburgh, presents a modern perspective on secondary dysmenorrhea through the lens of endometriosis. In line with the guidelines of the European Society of Human Reproduction and Embryology, his position is that pain suspected of endometriosis should not go untreated for years: a gradual initiation of symptomatic and hormonal therapy is acceptable, and the approach should be based on shared decision-making and the patient's quality of life. [87]