Behold, children are a heritage from the LORD, the fruit of the womb is His reward - Psalm 127:3
Visualizing the parts of the female reproductive system (see figure), one can systematically formulate a differential diagnosis of this common malady. At the cervix, stenosis, cervical polyps, and other neoplasms may obstruct the egress of blood and induce dysmenorrhea. In the uterus, polyps, fibroids, adenomyosis, and deformities such as anteflexion, retroflexion, anteversion, or retroversion may be the cause. Pelvic congestion syndrome is a possibility. The tubes may be involved by endometriosis, abscess, or ectopic pregnancy.
The ovaries may be involved by the same processes as the tubes, but they should suggest the most common cause of dysmenorrhea: hormonal. Thus, any condition—thyroid, pituitary, or ovarian—that might disturb the cyclic output of oestrogen and progesterone in the proper sequence may induce dysmenorrhea. Psychogenic disturbances are especially significant.
Approach to the Diagnosis
The clinical approach to dysmenorrhea is simply to rule out significant organic disease by a thorough pelvic and rectal examination. A smear and culture for gonococcus and Chlamydia should be done. A course of contraceptives or progesterone in adequate doses may then be tried. Diuretics may be indicated if examination suggests pelvic congestion. When the aforementioned measures fail, a dilatation and curettage (D & C) may be indicated. A gynaecologist may decide to do a culdoscopy, a peritoneoscopy, or an exploratory laparotomy.
Other Useful Tests
Sonogram (pelvic inflammatory disease [PID], ectopic pregnancy)
Fern test and basal body temperature charting (endometriosis)