Questionnaire/history: (Also to differentiate between primary dysmenorrhoea (PD) and secondary dysmenorrhoea (SD)) Symptom onset in relation to menarche? - 6-12 months after menarche once cycles are regular (most likely PD)? - Several years of painless periods (most likely SD)? Characteristics of the pain? - Type of pain? - Timing and duration? - Pain starts shortly before the onset of menstruation and last for up to 72 hours, improving as the menses progresses (most likely PD)? - Pain not consistently related to menstruation alone and may persist after menstruation finishes or may be present throughout the menstrual cycle but is exacerbated by menstruation (most likely SD)? - Severity? - Exacerbating and alleviating factors? - Usually cramping in nature, occurring in the lower abdomen but may radiate to the back and inner thigh (most likely PD)? Associated symptoms? - Other gynaecological symptoms (most likely SD)? - Dyspareunia? - Vaginal discharge? - Menorrhagia? - Intermenstrual bleeding? - Postcoital bleeding? - Non-gynaecological symptoms (most likely PD)? - Nausea/vomiting? - Diarrhoea? - Fatigue? - Irritability? - Dizziness? - Bloating? - Headache? - Lower back pain? - Emotional symptoms? - Non-gynaecological symptoms which may be associated with endometriosis) (most likely SD)? - Rectal pain? - Rectal bleeding? Risk factor? - Early age at menarche? - Heavy menstrual flow? - Nulliparity? - Family history of dysmenorrhoea? - Stress? Past medical history (eg irritable bowel syndrome, lactose intolerance)? Obstetric history (eg plans for pregnancy)? Current medication? Treatment(s) tried and the effect? Drug allergies? Examination: Abdomen? - Large fibroids and/or other masses? Pelvic examination (including speculum examination of the cervix) except in young women who are not sexually active if the symptoms are suggestive of primary dysmenorrhoea? Investigations: Ultrasound (to rule out fibroids, adnexal pathology and endometriosis or to assess and intrauterine contraceptive device)? High vaginal and endocervical swabs (if the woman is at risk of a sexually transmitted infection, especially if pain is associated with vaginal discharge and abnormal vaginal bleeding)? Pregnancy test (to exclude an ectopic pregnancy)? Diagnosis: Primary dysmenorrhoea? Secondary dysmenorrhoea (causes? endometriosis/adenomyosis, fibroids (myomas), pelvic inflammatory disease, ovarian cancer, cervical cancer, intrauterine device (IUD) insertion?)? Management Reference(s): NICE CKS: Dysmenorrhoea Information for patients/carers? NHS Health A to Z: Period pain Patient: Period pain (Dysmenorrhoea)