Q: How can I tell whether my teen daughter’s painful menstrual cramps could be a sign of a more serious health issue?

A: Dysmenorrhea is the medical term used to describe painful menstrual cycles. It can be classified as either primary (cramps with no pelvic abnormality) or secondary (when cramps are associated with a pelvic abnormality or medical condition). The most common cause of secondary dysmenorrhea is endometriosis.

It is normal for an adolescent to have cramps during her menstrual cycle. It is not normal when:

  • Pain is not controlled with a heating pad or over-the-counter anti-inflammatory medications (such as ibuprofen).
  • She is missing school or other activities.
  • Experiencing acyclic pain (having pain throughout the month and not just with the menstrual cycle).
  • Over time, there is worsening pain during each menstrual cycle.
  • Severe menstrual cramps occur right after the onset of her first menstrual cycle.
  • She has mid-cycle pain.
  • There is pain during sex.

When adolescents experience painful menstrual cycles that are not improved with conservative measures, seeking prompt evaluation with a health-care provider is strongly recommended.

Before seeing a physician, adolescents should track their menstrual cycles, documenting when each cycle occurs, the duration, and how many pads and/or tampons are used each day. Also, consider keeping a pain diary to record when discomfort is experienced during the menstrual cycle, if pain occurs at other times during the month, and what relieves the pain.

An initial evaluation will start to identify whether a patient has primary or secondary dysmenorrhea. The assessment includes a medical, gynecologic, menstrual, family, and psychosocial history.

When adolescents experience pain for more than three to six months after conventional measures such as hormonal birth control, a more comprehensive evaluation of chronic pelvic pain will be performed. A physical exam will look for musculoskeletal, gastrointestinal, urological, and psychosocial causes of pain. Based on the symptoms, a physician may consider performing a pelvic exam, too.

Counseling the adolescent about what to expect with a pelvic exam provides reassurance. The exam might assist in identifying whether there is abnormal vaginal discharge (a sign of pelvic inflammatory disease), whether there is a pelvic floor disorder, an obstructed reproductive tract abnormality, or an enlarged uterus. Pelvic imaging with ultrasound can also be ordered to evaluate the uterus, ovaries and fallopian tubes. The pelvic ultrasound can be performed either vaginally or abdominally. For adolescents who are not sexually active, an abdominal pelvic ultrasound is all that is required.

Endometriosis has been reported to affect 6% to 10% of women of reproductive age, and the incidence among adolescents with chronic pelvic pain has been reported between 45% and 70%. In addition, patients with an affected relative have nearly a seven- to 10-fold increased risk of having the disease.

Unfortunately, there has been a reported two- to five-year delay in diagnosis among adolescent patients with endometriosis. On average, an adolescent will see three providers before receiving a diagnosis. Delays can result from visits with non-gynecologic specialists, misdiagnoses, normalization of symptoms, and prolonged referral time to see a gynecologist. It should be noted that a normal physical exam and pelvic ultrasound do not exclude the diagnosis of endometriosis. A delay in diagnosis can lead to chronic pain and scarring, and can affect future fertility.

When adolescents experience painful menstrual cycles that are not improved with conservative measures, seeking prompt evaluation with a health-care provider is recommended.

Rachael L. Polis is a pediatric and adolescent gynecologist at Crozer-Keystone Health System.