Dysmenorrhea Across the Lifespan

A Biopsychosocial Perspective to Understanding the Dysmenorrhea Trajectory and Association With Comorbid Pain Experiences

Michelle M. Gagnon; Dehlia Moussaoui; Jennifer L. Gordon; Nicole M. Alberts; Sonia R. Grover

Disclosures

Pain. 2022;163(11):2069-2075. 

In This Article

Abstract and Introduction

Introduction

Dysmenorrhea affects 45% to 93% of individuals who menstruate (Although women and girls are those most affected by this condition, we recognize that dysmenorrhea can impact individuals with female reproductive organs, regardless of gender).[27,40,76,120] Despite 20% to 51% of individuals with dysmenorrhea reporting symptoms that interfere with daily functioning,[4,27,39,40,120] dysmenorrhea has received considerably less attention than other pain conditions. Like many women's health conditions, it has largely been dismissed and undertreated.[25,62,73]

Dysmenorrhea can be primary or secondary in nature. Primary dysmenorrhea refers to pain occurring with or just before menses in the absence of identified conditions that are considered potentially pathological.[101] Secondary dysmenorrhea is menstrual pain associated with underlying pathology.[101] Significantly, more research focuses on secondary dysmenorrhea;[7,69,129] yet, across dysmenorrhea types, biomedical etiological and treatment models have prevailed. For example, endometriosis is the commonest condition associated with period and pelvic pain, with the gold standard for identification necessitating laparoscopic surgery. However, no specific symptoms or symptom combination[51,131,135] predict endometriosis, the correlation between the extent of endometriosis lesions and symptoms is uncertain,[36,51,135,143] and surgical excision of lesions may not affect pain outcomes.[14] Thus, although the guidelines[89] largely consider menstrual pain unresponsive to first-line treatments (eg, nonsteroidal anti-inflammatory drugs)[28] as a condition requiring surgical intervention,[11,14,42] dysmenorrhea is likely multifactorial, and this should be reflected in its conceptualization and management.

Biopsychosocial models of persistent and chronic pain emphasize psychological[60,141] and social[65] factors in the development and maintenance of pain; yet, inclusion of such factors in clinical practice and research has lagged in the area of dysmenorrhea. Developmental and contextual considerations have also been overlooked, despite growing recognition that such variables affect pain experiences across the lifespan.[23,65,102] Moreover, central sensitization theories recognize that poorly managed pain early in life can affect long-term pain.64,112,156 Increasingly, researchers have argued that recurrent menstrual pain may alter central nervous system pain processing.[72,156]

The individual and societal impacts of dysmenorrhea are substantial. In adolescence, one-third to two-thirds of students who menstruate miss at least 1 day of school per cycle,[107,130] and dysmenorrhea affects attention and school performance.[10,46] Interference in daily functioning persists in adulthood.[53] Healthcare costs are 2 to 3 times higher in patients with dysmenorrhea than those without.[3] Although the paucity of research examining this condition is alarming,[22] increased attention has recently been brought to dysmenorrhea. This provides an opportune time to synthesize the literature.

In this review, we examine dysmenorrhea from a developmental perspective, with focus on (1) biopsychosocial factors associated with dysmenorrhea across the lifespan and with consideration of premenarche, adolescent, peripartum or postpartum, and perimenopausal phases and (2) evidence of the relationship between dysmenorrhea and comorbid pain conditions. We subsequently delineate clinical and research priorities.

Notably, pain experiences in primary and secondary dysmenorrhea may be similar; however, the identification of "pathology" legitimizes pain and its impact on the individual.[18] This is to the detriment of those who experience pain without identified pathology. Where possible we highlight the primary dysmenorrhea literature, recognizing that much research does not differentiate between the two. A systematic review was not conducted.

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