The Painful Uterus and the Brain

Dysmenorrhea is the most common pain disorder among women, estimated to affect 40% to 90% of women in their reproductive years. Up to 20% of women report menstrual pain severe enough to interfere with usual activities. As such, it is a leading cause of school and work absenteeism in young women. Despite its high prevalence and negative impact on quality of life, dysmenorrhea remains undertreated and often disregarded by clinicians, researchers, and even women themselves, who may consider it a normal manifestation of the menstrual cycle. However, emerging data suggests that while untreated dysmenorrhea is often a precursor to chronic pelvic pain and other centralized pain conditions, some women with dysmenorrhea already display evidence of centralized pain. Therefore, early and prompt treatment of dysmenorrhea may be an important target for prevention of central sensitization, as well as the progression to various chronic pain conditions. This lecture will provide an overview of the impact of dysmenorrhea on daily function, mood, and quality of life. We will present emerging evidence that dysmenorrhea is not just a localized pelvic disorder, but is associated with central nervous system changes in pain processing. This lecture will then review a systematic approach to the evaluation and management of dysmenorrhea, including the differential diagnosis and treatment strategies of both primary and secondary dysmenorrhea. Primary dysmenorrhea is defined as pain associated with menstruation in the absence of organic pathology, whereas secondary dysmenorrhea is associated with identifiable pathology, such as endometriosis. We will emphasize diagnostic and treatment strategies for the primary care clinician, and when to refer to a gynecologic surgeon or other specialist. (Recorded at PAINWeek 2017)