* Approved by CPG Committee; PIC endorsement pending

See also

Adolescent gynaecology - lower abdominal pain 

Adolescent gynaecology - heavy menstrual bleeding 

Engaging and assessing the adolescent 

Contraception

Key points

1. Primary dysmenorrhoea accounts for approximately 90% of cases
2. Investigations are not routinely required
3. First line treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) and/or hormonal treatment
4. Consider secondary dysmenorrhoea and refer to local gynaecology service for further assessment if there are atypical features or persistent pain despite an adequate trial of empiric treatment for at least 3-6 months

Background

• Dysmenorrhoea is the most common menstrual symptom in adolescents and affects 50-90% of young women
• Leading cause of recurrent short-term school absenteeism in adolescent females, has a negative effect on physical and psychosocial functioning and mental health, and associated with other chronic pain conditions
• Primary dysmenorrhoea (approximately 90% of cases)
  • Painful menstruation in absence of pelvic pathology
  • Believed to arise from high concentrations of uterine prostaglandins, resulting in increased myometrial contractility, followed by ischaemia and hypoxia of the myometrium, causing pain
  • Typically begins within 6-12 months of menarche
• Secondary dysmenorrhea (approximately 10% of cases)
  • Painful menstruation due to pelvic pathology. Causes include
    • Endometriosis (most common cause)
    • Obstructive reproductive tract anomalies
    • Adenomyosis
    • Infection including pelvic inflammatory disease
    • Ovarian cysts

Assessment

Consider acute and serious causes of abdominal pain (see Adolescent gynaecology - lower abdominal pain). The aim of assessment is to differentiate between primary and secondary causes of dysmenorrhea and understand the impact on daily life

Features suggestive of primary dysmenorrhoea

• Pain typically starting 6-12 months post menarche
• Cramping, intermittent lower abdominal pain starting prior to or with menses, lasting up to 72 hours
• Associated symptoms include headache, breast tenderness, diarrhoea, nausea, vomiting, muscles cramps

Atypical features which are more suggestive of secondary dysmenorrhoea

• Pain worsening towards the end of bleeding days
• Pain present from menarche
• Pain commencing after pelvic infection or features suggestive of pelvic inflammatory disease
• Dysuria or dyschezia during menses
• Family history of endometriosis
• Persistent pain despite an adequate trial of empiric treatment for 3-6 months

History

• Requires a sensitive approach (see Engaging with and assessing the adolescent patient)
• Menstrual history: menarche, last menstrual period, frequency/irregular or regular cycle, flow/frequency of pad/tampon changes, duration, flooding, large clots (>2 cm in diameter)
• Pain assessment (severity, exacerbating and relieving factors, cyclic vs noncyclic, chronic vs acute, relationship to menstruation ie mid cycle or acyclical pain)
• Associated symptoms: premenstrual syndrome, menorrhagia, migraine, non-gynaecological symptoms (urinary, bowel, musculoskeletal)
• Impact on daily life: missing school, sports, social activities
• Medication use or management trialled
• Sexual history and contraception
• Family history (endometriosis, gynaecological cancers)
• Previous pelvic infection or abdominal surgery
• Renal anomaly or other congenital anomalies (especially spine, cardiac, gastrointestinal)
• Adolescent assessment (HEADSS screen)

Examination

• Abdominal examination for tenderness and/or palpable mass
• Vaginal examination is rarely indicated in an adolescent. It should be discussed with a senior clinician, and if needed should only be performed once

Management

Investigations

• Consider ßhCG (with consent) especially if sexually active, unprotected intercourse and/or late/missed period
• Consider STI screen if features suggestive of STI or pelvic inflammatory disease
• Other investigations are not routinely required
• Pelvic ultrasound, usually transabdominal, should be considered in those with atypical features, or those not responding to an adequate trial of hormonal therapy

Treatment

• Management should be focused on quality-of-life improvement, particularly minimising disruption to school attendance and participation in extra-curricular activities
• First line medications include NSAIDs and/or hormonal therapies
• Continuous or extended use of hormonal contraceptives is recommended over cyclic use
• Non-pharmacological therapies can be used to complement medical therapies or as an alternative if medications are unsuitable/unacceptable

Non-hormonal medications

• Can be safely used with hormonal medications
• NSAIDs: Naproxen 5 mg/kg (max 500 mg) BD or Mefenamic acid 500 mg TDS with food
  • Most effective when started 1--2 days before the onset of menses and continued through the first 2--3 days of bleeding
  • Can reduce blood loss
  • May reduce nausea, vomiting, diarrhoea
• Antifibrinolytics: Tranexamic acid 1 gram TDS on days of heavy bleeding
  • Especially useful in those with concomitant heavy menstrual bleeding
  • Reduces blood loss, may reduce pain

Hormonal Medications

Follow-up

• 3 months after treatment to assess efficacy
• Earlier review may be required if unacceptable or intolerable side effects are present

Consider consultation with gynaecology team when

• Suspicion of secondary dysmenorrhoea
  • Atypical features
  • Pain not responding adequately to first line treatment

Consider transfer when

Care required beyond comfort level of local services

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Management initiated and clear plan for follow up made

Parent information

Period pain: pre-teens and teenagers 

Painful periods (dysmenorrhoea) 

Oral contraceptives -- skipping periods when taking the pill

*Last updated October 2025

Reference List

1. American College of Obstetricians and Gynecologists. Dysmenorrhea and endometriosis in the adolescent. ACOG Committee Opinion No. 760. Obstetrics & Gynecology. 2018. Vol 132:e249--58. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/12/dysmenorrhea-and-endometriosis-in-the-adolescent
2. AMH Children's Dosing Companion Adelaide: Australian Medicines Handbook Pty Ltd; [2024] [March]. Available from: https://amhonline.amh.net.au/
3. Australian clinical practice guideline for diagnosis and management of endometriosis (2021). RANZCOG, Melbourne, Australia. Retrieved from https://ranzcog.edu.au/news/australian-endometriosis-guideline/
4. Bahrami A, Avan A, Sadeghnia HR, et al. High dose vitamin D supplementation can improve menstrual problems, dysmenorrhea, and premenstrual syndrome in adolescents. Gynecological Endocrinology. 2018. Vol 34, p659 -- 63.
5. Chaudhuri A, Singh A, Dhaliwal L. A randomised controlled trial of exercise and hot water bottle in the management of dysmenorrhoea in school girls of Chandigarh, India. Indian Journal of Physiology and Pharmacology. 2013. Vol 57, p114 -- 22.
6. Christensen, K. Dysmenorrhoea: An update on primary healthcare management. Australian Journal of General Practice. 2024. Vol 53. No 1-2. Retrieved from https://www1.racgp.org.au/ajgp/2024/january-february/dysmenorrhea
7. European Society of Human Reproduction and Embryology (ESHRE). Endometriosis: Guideline. 2022. Retrieved from https://www.eshre.eu/guideline/endometriosis
8. Geysenbergh B, Dancet EAF, D'Hooghe T. Detecting Endometriosis in Adolescents: Why Not Start from Self-Report Screening Questionnaires for Adult Women? Gynecologic and Obstetric Investigation. 2017. Vol 82, p322-328.
9. Grover SR, Joseph K. Endometriosis and pelvic pain: Time to treat the symptoms not the assumptions? Australian & New Zealand Journal of Obstetrics & Gynaecology. 2021. Vol 61(4), p.625-627.
10. Jamieson D, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstetrics & Gynecology. 1996. Vol 87(1), p55--58.
11. Lacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Human Reproduction Update. 2015. Vol 21(6), p762-78.
12. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. British Medical Journal. 2006. Vol 332(7550), p1134--1138.
13. Rowlands IJ, Abbott JA, Montgomery GW, et al. Prevalence and incidence of endometriosis in Australian women: a data linkage cohort study. British Journal of Obstetrics and Gynaecology. 2021. Vol Mar;128(4), p657-665.
14. Sanfilippo J, Erb T. Evaluation and management of dysmenorrhea in adolescents. Clinical Obstetrics and Gynecology. 2008. Vol 51(2), p257-67.
15. Weir E, Mustard C, Cohen M, et al. Endometriosis: What is the risk of hospital admission, readmission, and major surgical intervention? Journal of Minimally Invasive Gynecology. 2005. Vol 12(6), p486--93.