Common cause of dysmenorrhea : 

1. Pelvic endometriosis.
2. PID : acute or chronic
3. Adenomyosis
4. Fibroid uterus
5. IUCD in situ

Classification of dysmenorrhea :

There are two types of dysmenorrhea : 

1. Primary dysmenorrhea
2. Secondary dysmenorrhea

Primary dysmenorrhea :

Define : The primary dysmenorrhoea is one where there is no identifiable pelvic pathology.

Cause of Primary dysmenorrhea : 

1. Behavioral and psychological factors : 

• Tension and anxiety during adolescence
• Lower  pain threshold
• Unhappiness at home or at work.
• Fear or loss of employment.
• Anxiety over examinations.

2. Muscular incoordination and uterine hyperactivity

3. Hormonal imbalances and excessive prostaglandin

4. Other factors : 

• Higher circulating vasopressin
• Platelet activating factors (PAF)

Clinical features of primary dysmenorrhea  : 

1. Pain :

• Site : Pain is felt in the hypogastrium
• Onset : Few hours before and after the onset of menstruation
• Duration : Usually lasts for few hours, rarely, lasts longer then 12 hours.
• Character : Spasmodic and colicky in nature.
• Radiation : Inner and front aspects of the thigh
• Relief : When flow is properly established.

2. Systemic discomfort :

• . Nausea
• . Vomiting
• . Fatigue
• . Diarrhoea
• . Headache 

Investigation of dysmenorrhea :

• USG is very useful.

Treatment of dysmenorrhea :

A. General treatment : 

1. Correction of unfavorable environmental factors, malnutrition, general ill health
2. Regular physical exercise
3. Reassurance
4. Usual activities should be continued.
5. Analgesics : Aspirin , Paracetamol
6. Antispasmodics : Hyoscine butyl bromide
7. Newer NSAIDS : 

•   Indometacin 250 mg tds.
• . Ibuprofen 400 mg tds

B. Hormonal therapy : 

1. Combined oral pill is taken nightly on each of the 5th to 25th days of the cycle continued for 6 months.

C. Surgical treatment : It is considered when the pain is proven to be truly spasmodic incapacitating medical treatments fails.

1. Dilatation of the cervix.
2. Presacral neurectomy
3. Bllateral block of the pelvis plexus
4. Hysterectomy.
5. Treatment of retroversion if present.

Secondary dysmenorrhea : 

 Define : Menstruation- associated pain occurring in the presence of pelvic pathology is called secondary dysmenorrhoea.