UNASSIGNED: Dysmenorrhoea affects many adolescents with significant impacts on education and well-being. In the UK, most of the adolescents who seek care (and many never do), will do so through general practice (primary care). Knowing how best to care for adolescents reporting menstrual pain is an area where UK general practitioners would like better guidance and resources.
UNASSIGNED: This mixed-methods narrative synthesis collates community and specialist evidence from 320 papers about adolescent dysmenorrhoea, with a UK general practice community health perspective.
UNASSIGNED: We report a narrative summary of symptoms, cause, consequences and treatments for adolescent dysmenorrhoea. We highlight areas of tension or conflicted evidence relevant to primary care alongside areas of uncertainty and research gaps identified through this synthesis with input from lived experience advisers.
UNASSIGNED: There is little evidence about primary care management of adolescent dysmenorrhoea or specific resources to support shared-decision making in general practice, although there are evidence-based treatments to offer. Primary care encounters also represent potential opportunities to consider whether the possibility of underlying or associated health conditions contributing to symptoms of dysmenorrhoea, but there is little epidemiological evidence about prevalence from within community health settings to inform this. The areas where there is little or uncertain evidence along the care journey for adolescent dysmenorrhoea, including at the interface between experience and expression of symptoms and potential underlying contributory causes warrant further exploration.
UNASSIGNED: https://www.crd.york.ac.uk/PROSPEROFILES/256458_STRATEGY_20210608.pdf, identifier (CRD42021256458).

Gonadotrophin-releasing hormone (GnRH) antagonists have been demonstrated to reduce endometriosis-associated pain. Because of the hypo-oestrogenic state they induce, however, higher dosages of GnRH antagonists are not recommended for used long term. This unwanted effect may be eliminated by so-called add-back therapy (ABT). This review was conducted to assess the safety and efficacy of GnRH antagonists, with or without add-back hormonal replacement therapy. Out of the 345 studies selected through the initial search, seven randomized controlled trials were included, comparing different oral GnRH antagonists at varying dosages, from a minimum of 50 mg to a maximum of 200 mg once or twice daily. Women treated with the lowest dose of GnRH antagonists had significantly greater mean pain score reductions from baseline throughout treatment compared with those treated with placebo (odds ratio [OR] -13.12, 95% CI -17.35 to -8.89 and OR -3.08, 95% CI -4.39 to -1.76 for dysmenorrhoea and non-menstrual pelvic pain, respectively). Compatible with the dose-response effect, a positive correlation was found between response rates and adverse event rates. While GnRH antagonists offer an advantage in terms of pain reduction for endometriosis, the more recent literature suggests using GnRH antagonists with ABT, which, while mitigating the hypo-oestrogenic effects of GnRH antagonists, maintain their efficacy, while allowing their long-term use.

UNASSIGNED: A biopsychosocial approach to the understanding of pelvic pain is increasingly acknowledged. However, there is a lack of standardised instruments - or their use - to assess risk factors and their impact on pelvic pain in both clinical and research settings. This review aims to identify validated tools used to assess known contributory factors to pelvic pain, as well as the validated tools to measure the impact of pelvic pain in adolescents and young adults, in order to provide a framework for future standardised, adolescent specific assessment and outcome tools.
UNASSIGNED: Literature searches were performed in MEDLINE, PsycInfo and PubMed. Search terms included pelvic pain, dysmenorrhoea, endometriosis, adolescent, pain measurement, quality of life, sleep, mental health, coping strategies and traumatic experience.
UNASSIGNED: We found validated instruments to assess adverse childhood experiences and coping strategies, both known contributing factors to pelvic pain. The impact of pain was measured through validated tools for health-related quality of life, mental health and sleep.
UNASSIGNED: Pelvic pain evaluation in adolescents should include a multi-factorial assessment of contributing factors, such as childhood adversity and coping strategies, and impacts of pelvic pain on quality of life, mental health and sleep, using validated instruments in this age group. Future research should focus on the development of consensus amongst researchers as well as input from young women to establish a standardised international approach to clinical trials involving the investigation and reporting of pelvic pain in adolescents. This would facilitate comparison between studies and contribute to improved quality of care delivered to patients.
Pelvic pain is pain located in the lower abdomen, and includes period pain, which is the most common gynaecologic condition in adolescents and young adults. An approach that includes biological, psychological and social factors is important to understand and manage pelvic pain. Nonetheless, these factors are often poorly assessed in the clinic and research setting. We performed a literature review to identify tools that measure risk factors for pelvic pain, and those that evaluate the impact of pelvic pain. We found instruments that measure exposure to childhood trauma and coping strategies, which are risk factors for developing pelvic pain. We found tools to assess quality of life, mental health and sleep as an impact of pelvic pain. A standardised approach to pelvic pain, including instruments to measure risk factors and impact of pelvic pain, would facilitate comparison between studies and improve quality of care for patients.

BACKGROUND: Dysmenorrhoea-Related Pelvic Pain (DRPP) is a common condition, which may or may not include bladder-related symptoms. Primary health care practitioners (PHCP) rely heavily on language for diagnosis of DRPP-related conditions. However, there are no established pain descriptors to assist PHCP to determine whether an individual\'s DRPP may include a bladder component.
OBJECTIVE: To identify differences in the use of pain descriptors in women with DRPP with and without a co-existing bladder pain component, through an exploratory study of the language of pelvic pain in women.
METHODS: A cross-sectional online survey of Australian and New Zealand women (n = 750, ages 18-49) who have self-identified pelvic pain. Free text and predetermined pain descriptors used by women with a self-perceived bladder pain component (DRPPB+, n = 468) were compared to those without bladder pain (DRPPB-, n = 282). Statistical analysis included Pearson χ2, logistic regression and analysis of variance tests using StataCorp Stata Statistical Software combined with qualitative data from AntConc concordance software.
RESULTS: Within free-form text, bloating (P = 0.014) and pressure (P = 0.031) were used more commonly to describe dysmenorrhoea in women with DRPPB+, while the word excruciating (P < 0.001) was more commonly used by women with DRPPB-. From a pre-determined list of descriptors, pounding (P < 0.001), tingling (P < 0.001), stabbing (P = 0.010), burning (P = 0.002) and cramping (P = 0.021) were more commonly used by women with DRPPB+, than women with DRPPB-.
CONCLUSIONS: Systematic patterns of word use should encourage practitioners to further enquire about bladder symptoms that may co-exist with dysmenorrhoea. Knowledge of these words may be useful in targeting diagnostic and therapeutic interventions.

Cystic adenomyosis is a rare type of adenomyosis. The main clinical manifestation of uterine cystic adenomyoma is severe dysmenorrhoea, and the condition can be diagnosed by relevant clinical examination. The preferred treatment, with a good prognosis, is lesion resection. The clinical data of a patient with uterine cystic adenomyoma recorded at the Third Hospital of Hebei Medical University are reported herein. A 39-year-old female patient presented with tolerable menstrual pain and aggravated dysmenorrhoea, which she had experienced for 4 years, and menorrhagia, which she had had for approximately 1 year. Ultrasound and tumour marker tests suggested abnormalities, and magnetic resonance imaging confirmed a diagnosis of uterine cystic adenomyoma. A hysteroscopy and intrauterine lesion electrocision were performed, and the results of postoperative pathology tests suggested that the endometriosis cysts had returned to normal after the postoperative intervention. The analysis of the clinical manifestations and diagnosis and treatment of uterine cystic adenomyoma can improve the understanding of the disease and reduce the rates of misdiagnosis and missed diagnoses to ensure early detection with timely diagnosis and treatment.

OBJECTIVE: How do different warning indicators help to identify disabling dysmenorrhoea among women in young adulthood?
METHODS: A nationwide cross-sectional study of women aged 18-25 years from the CONSTANCES cohort was constructed. Disability was assessed with the Global Activity Limitation Indicator question \'For the past 6 months, have you been limited in routine activities?Yes, severely limited/Yes, limited/ No, not limited\'. Dysmenorrhoea pain intensity and other chronic pelvic pain symptoms (dyspareunia and non-menstrual pain) were evaluated according to questions from a specific questionnaire. Probability of disability was estimated using a logistic prediction model according to dysmenorrhoea intensity, other indicators of pelvic pain symptoms and other obvious covariates. The results of the predictive model of disabling dysmenorrhoea were presented on a nomogram.
RESULTS: Among 6377 women, the rate of disability was estimated at 7.5%. Increased intensity of dysmenorrhoea (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.04-1.13), increased frequency of dyspareunia (from OR 1.69, 95% CI 1.33-2.14 up to OR 3.41, 95% CI 2.16-5.38) non-menstrual chronic pelvic pain (OR 1.75, 95% CI 1.40-2.19), body mass index over 25 kg/m2 (OR 1.45, 95% CI 1.17-1.80) and non-use of the hormonal contraceptive pill (OR 1.29, 95% CI 1.05-1.59) were significantly associated with disability. According to the nomogram, a predicted probability of 15% or more could be chosen as a threshold. This represents almost 4.6% of young women in this sample being classified at risk of disabling dysmenorrhoea.
CONCLUSIONS: Dysmenorrhoea pain intensity and associated pelvic pain symptoms are warning indicators that can be measured to help screen young women who may suffer from disabling dysmenorrhoea.

Vitamin D reduces prostaglandin levels and inflammation, making it a promising treatment option for dysmenorrhoea. However, its effects on pain intensity in different types of dysmenorrhoea remain unclear. We examined whether vitamin D supplementation decreases pain intensity in patients with dysmenorrhoea. The Cochrane Library, Embase, Google Scholar, Medline, and Scopus databases were searched from inception to 30 December 2023. Randomised controlled trials (RCTs) evaluating vitamin D supplementation effects on such patients were included. The primary and secondary outcomes were measured by the changes in pain intensity and rescue analgesic use, respectively. Pooled mean differences and rate ratios were calculated using a random-effect model; trial sequential analysis (TSA) was also performed. Overall, 11 studies involving 687 participants were included. Vitamin D supplementation significantly decreased pain intensity in patients with dysmenorrhoea compared with controls (pooled mean difference, -1.64; 95% confidence interval, -2.27 to -1.00; p < 0.001; CoE, moderate; I2 statistic, 79.43%) and indicated substantial heterogeneity among the included studies. TSA revealed that the current RCTs provide sufficient information. In subgroup analyses, vitamin D supplement reduced primary dysmenorrhoea pain but not secondary dysmenorrhoea pain. In conclusion, although substantial heterogeneity persists, vitamin D supplementation decreased pain intensity in patients with dysmenorrhea, especially in those with primary dysmenorrhoea.

OBJECTIVE: What is the prevalence of adenomyosis at ultrasonography among adolescents and young women reporting dysmenorrhoea and/or heavy menstrual bleeding (HMB)?
METHODS: This observational cohort study involved adolescents and young women referred for dysmenorrhoea and/or HMB to the Adolescent Medicine Unit at Careggi University Hospital, Italy. Patients with endometriosis and bleeding disorders were excluded. Transvaginal ultrasonography or transrectal sonography using a transvaginal probe was performed. The myometrium was described according to the Morphological Uterus Sonographic Assessment criteria. Details of baseline characteristics, clinical data and symptoms were collected. The presence of sonographic features of adenomyosis and the association between imaging findings and clinical symptoms were evaluated.
RESULTS: The cohort included 95 patients aged between 13 and 25 years, referred for dysmenorrhoea (88.4%), HMB (23.2%) or both (13.7%). According to the MUSA criteria the sonographic diagnosis of adenomyosis was made in 27.4% of patients, with the diffuse type the most prevalent. Uterine wall asymmetry, hyperechoic intramyometrial islands, translesional vascularity and an interrupted junctional zone were the most common features. Patients with imaging findings of adenomyosis had significantly higher rates of HMB than those with a normal myometrial appearance (38.5% versus 17.4%, P = 0.030). In addition, the coexistence of dysmenorrhoea and HMB was significantly associated with adenomyosis (odds ratio 5.68, 95% confidence interval 1.65-19.5).
CONCLUSIONS: Adenomyosis may be diagnosed among teenagers and young women referred with dysmenorrhoea and/or HMB. The clinical presentation is relevant for the diagnosis, with HMB alone and HMB plus dysmenorrhoea significantly associated with the sonographic identification of adenomyosis.

OBJECTIVE: What is the contribution of sociodemographic, psychosocial, lifestyle and reproductive factors up to the age of 11-12 years to the occurrence of dysmenorrhoea at age 15-16 years within the Amsterdam Born Children and their Development (ABCD) study?
METHODS: Data of 1038 female adolescents were used. Participants\' baseline characteristics were obtained using self-reported questionnaires up to the age of 11-12 years, as well as the obstetric information of their mothers during pregnancy. Dysmenorrhoea was assessed at the age of 15-16 years, and was deemed to be present if an adolescent reported menstrual abdominal and/or back pain and therefore took medication and/or hormonal contraception. Using a backward selection approach, potential determinants of dysmenorrhoea were selected and multivariable associations were determined.
RESULTS: The overall prevalence of dysmenorrhoea was 49.5% among the participants. Intake of 3-4.5 sugar-sweetened beverages/day (P = 0.035) and higher gynaecological age (i.e. years since menarche) (P < 0.001) were significantly associated with higher occurrence of dysmenorrhoea in the final model, which explained 8.1% of the total variance in the occurrence of dysmenorrhoea. No significant associations were found between the occurrence of dysmenorrhoea and sociodemographic or psychosocial factors.
CONCLUSIONS: This investigation of various potential risk factors for dysmenorrhoea suggests that diet and reproductive factors are particularly important predictors of the occurrence of dysmenorrhoea among young adolescents. Specifically, intake of sugar-sweetened beverages and higher gynaecological age were predictive of the occurrence of dysmenorrhoea. Other lifestyle factors were also identified as possible risk factors. Using this knowledge, effective strategies can be developed to reduce the burden of dysmenorrhoea among adolescents, and to provide appropriate care for those suffering from the condition.

Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor\'s opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients\' choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen-progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.