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Referral and warning signs
When to refer
Refer to HC4/Specialist if no response to initial treatment after 5 days or if symptoms are recurrent/severe, or if secondary cause suspected.
Red flags
- Severe pain unresponsive to simple analgesics.
- Symptoms suggestive of secondary cause (e.g., heavy bleeding, infertility, fever).
Signs and symptoms
- Lower abdominal cramping
- Backache
- Headache
- Nausea
- Vomiting
- Diarrhoea
- Fainting
- Fever
- Fatigue
- Dizziness
Risk factors
- For Secondary Dysmenorrhoea:
- - Pelvic inflammatory disease (PID)
- - Endometriosis
- - Uterine fibroids
- - Older age (>30 years)
Diagnosis
Clinical assessment
Diagnosis based on characteristic history of cyclical lower abdominal pain related to menstruation. Differentiate primary (occurs 6-12 months after menarche, decreases with age/childbirth) from secondary (older onset, underlying cause suspected). Rule out other causes of lower abdominal pain.
Differential diagnosis
- Endometriosis
- Pelvic Inflammatory Disease
- Uterine Fibroids
- Other causes of lower abdominal pain
Investigations
- Clinical history and examination are primary.
- Investigations focus on ruling out secondary causes if suspected (e.g., pelvic exam, ultrasound, STI screening).
Diagnostic criteria
Clinical diagnosis based on cyclical pain related to menstruation.
Management
Non-pharmacological management
- Rest or sleep.
- Exercise.
- Warm compress application to abdomen.
- Wear loose fitting clothes.
- Dietary advice: Low fat diet; supplements like magnesium, vitamin B1, vitamin E, zinc.
- (LOC: HC2)
Pharmacological treatment
- NSAIDs: Ibuprofen 200–400 mg PO Q8H PRN. (LOC: HC2)
- Alternative NSAID: Diclofenac 50 mg PO Q8H PRN for severe forms. (LOC: HC2)
- Alternative (Mild pain): Paracetamol 1 g PO Q6H. (LOC: HC2)
- Treat underlying cause if secondary dysmenorrhoea (e.g., treat PID). (LOC: HC3/HC4)
Monitoring
Review patient after 5 days. If no response or recurrent, refer for specialist management.
Complications
- Impact on quality of life, school/work attendance.
- Complications related to underlying cause if secondary dysmenorrhoea.
Prevention
- Addressing underlying causes for secondary dysmenorrhoea.
Patient education
- Reassurance about nature of primary dysmenorrhoea.
- Explanation of non-pharmacological measures (rest, heat, exercise, diet).
- How to use analgesics effectively.
- When to seek further medical attention.
Uganda-specific notes
Common complaint, especially among adolescents. Need to consider PID as a cause of secondary dysmenorrhoea.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 14, Section 14.1.1