Dysmenorrhea: Clinical Guidelines

Applies toadults, children2024 editionN94.0, N94.4, N94.5, N94.6…

Clinical Guidelines of the Russian Ministry of Health, adults, children. 2024 edition, ICD-10 codes: N94.0, N94.4, N94.5, N94.6…. On the page — abridged version by WhiteCoat Pro and the full official text.

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Brief for Practice

WhiteCoat Pro editorial summary based on the 2024 guideline text. Each item links to the original section — verify against it before prescribing.

Dysmenorrhea is cyclic pelvic pain associated with menstruation; it can be primary functional or secondary, caused by organic pathology. The guideline describes diagnostics to rule out causes of pain and treatment: NSAIDs are the first line for primary dysmenorrhea, while secondary dysmenorrhea is treated by addressing the underlying disease.

Key points

Diagnostics

  1. Clarify the nature of the pain: relationship with menstruation, onset immediately before or during menstruation, duration of 8–72 hours, and accompanying symptoms — nausea, vomiting, diarrhea, bloating, fatigue, fainting. → in text
  2. Assess pain severity using a VAS from 0 to 10 points; if necessary, assessment can be performed daily during treatment. → in text
  3. In women of reproductive age who are sexually active, perform a speculum examination of the cervix and bimanual vaginal examination for differential diagnosis. In adolescents who are not sexually active, these methods are inappropriate. → in text
  4. Perform a comprehensive pelvic ultrasound — transvaginal and transabdominal — to rule out organic gynecological pathology. In adolescents with dysmenorrhea within the first 6 months after menstruation onset, ultrasound is also used to rule out malformations. → in text
  5. There are no specific laboratory tests for diagnosing dysmenorrhea. → in text
  6. Pelvic MRI is not routinely performed for isolated dysmenorrhea without echographic signs of organic pathology. The study is advisable for adolescents to rule out congenital malformations, in cases of intense pain and lack of effect from conservative therapy for 3–6 months; to rule out peritoneal endometriosis, an MRI on a 3T scanner is recommended. → in text

Treatment

When to refer and how to monitor

Frequently asked questions

How to distinguish primary dysmenorrhea from secondary?

Primary dysmenorrhea occurs without organic pathology, usually within 6–12 months after menarche. Secondary is a manifestation of pelvic organ disease, such as endometriosis, fibroids, or an inflammatory process. → in text

What therapy is the first line for primary dysmenorrhea?

NSAIDs. They are prescribed 1–2 days before menstruation and in the first 2–3 days of menstrual bleeding in the absence of contraindications. → in text

Do all patients with dysmenorrhea need diagnostic laparoscopy?

No. Diagnostic laparoscopy is not performed routinely; it is performed when conservative therapy fails to rule out endometriosis, pelvic inflammatory disease, adhesions, and in adolescents, congenital malformations of the reproductive system. → in text

What study is recommended for all patients to rule out an organic cause?

All patients are recommended to undergo a comprehensive pelvic ultrasound — transvaginal and transabdominal — to rule out organic gynecological pathology. → in text

Are laboratory tests used to confirm dysmenorrhea?

Specific laboratory diagnostics for dysmenorrhea have not been developed. → in text

Status
Applied · approved by the Scientific and Practical Council of the Russian Ministry of Health
Database ID
833, edition 1 (ID 833_1)
Publication date
November 28, 2024
Age category
adults, children
ICD-10 codes
N94.0N94.4N94.5N94.6N94.8
Specialties
Obstetrics and Gynecology
Developers
Russian Society of Obstetricians and Gynecologists
Official text
Rubricator of the Russian Ministry of Health — 833_1

Abridged Clinical Guidelines: Dysmenorrhea

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Dysmenorrhea is cyclic pelvic pain associated with menstruation.

Clinical forms:

  • Primary dysmenorrhea: presents as an independent gynecological condition (functional disorder without anatomical changes).
  • Secondary dysmenorrhea: is a symptom of concomitant organic pelvic pathology.

Dysmenorrhea is classified into primary and secondary depending on the presence of concomitant organic pathology.

Primary dysmenorrhea (functional)

Manifestation:

  • Predominantly within 6–12 months after menarche.

Clinical picture:

  • Nature of pain: Crampy pelvic pain.
  • Time of onset: Immediately before and/or during menstruation.
  • Duration: 8–72 hours.
  • Irradiation: To the lower back, lower extremities.
  • Accompanying symptoms: Nausea, vomiting, diarrhea, bloating, fatigue.
  • Severe course: Fainting (syncope) is possible with high pain intensity.

Pathogenesis:

  • Main mechanism: Myometrial hypercontractility and vasospasm.
  • Cause: Elevated levels of prostaglandins ($PGF_{2\alpha}$, $PGE_2$) released during the shedding of the functional endometrial layer.

Risk factors:

  • Smoking.
  • Early age at menarche (< 12 years).
  • Young age (< 30 years).
  • Heavy menstrual bleeding.
  • Low body mass index (less than 18.5 kg/m²).
  • Family history (including endometriosis).
  • Presence of psychoemotional triggers (stress, sexual abuse, psychological disorders, etc.).

Secondary dysmenorrhea (organic)

Definition: Menstrual pain associated with pelvic pathology.

Etiology (causes):

  • Endometriosis (external genital endometriosis, adenomyosis).
  • Uterine fibroids (uterine myoma).
  • PID (pelvic inflammatory disease).
  • Pelvic adhesions.

1. Anatomical and topographical anomalies:

  • Developmental anomalies of female genital organs.
  • Malpositions of female genital organs.
  • Classification: congenital and acquired.

2. Pathology of the cervix:

  • Cervical canal stenosis (narrowing of the lumen).

3. Vascular pathology:

  • Pelvic varices (pelvic varicose veins).
  • Synonym: Congestive pelvic pain syndrome (pelvic congestion syndrome).

4. Neoplasms (tumors):

  • Ovarian masses.
  • Benign.
  • Malignant.

Prevalence of dysmenorrhea:

  • Among women of reproductive age: ranges from 45% to 95%.
  • Among adolescents: the figure can reach 93%.

1.4 Coding of the disease or condition according to ICD-10

This section describes the coding of disease and condition groups according to the International Statistical Classification of Diseases and Related Health Problems (ICD).

Rubric N94 codes (Pain and other conditions associated with female genital organs and menstrual cycle):

  • N94.0 — Mittelschmerz (pain in the middle of the menstrual cycle).
  • N94.4 — Primary dysmenorrhea.
  • N94.5 — Secondary dysmenorrhea.
  • N94.6 — Dysmenorrhea, unspecified.
  • N94.8 — Other specified conditions associated with female genital organs and menstrual cycle.

By etiological factor:

  • Primary (functional)
  • Occurs in the absence of concomitant organic pathology.
  • Appears predominantly starting from menarche.
  • Cause: the result of excessive prostaglandin production.
  • Secondary (organic)
  • Is a symptom of concomitant organic pathology.
  • Causes: endometriosis, PID (pelvic inflammatory disease), uterine myoma, etc.
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List of Abbreviations

PID – pelvic inflammatory disease

CHCs – combined hormonal contraceptives (ATC: Progestogens and estrogens, fixed combinations)

COCs – combined oral contraceptives (ATC: Progestogens and estrogens, fixed combinations)

LNG-IUS – levonorgestrel-releasing intrauterine system (#levonorgestrel in the form of a therapeutic intrauterine system)

ICD-10 – International Classification of Diseases, 10th Revision

NSAIDs – non-steroidal anti-inflammatory drugs (ATC: Anti-inflammatory and antirheumatic products, non-steroids)

US – ultrasound examination

MRI – magnetic resonance imaging

Terms and Definitions

Dysmenorrhea is cyclic pelvic pain associated with menstruation, which can be either an independent gynecological condition (primary dysmenorrhea) or a symptom of concomitant organic pathology (secondary dysmenorrhea) [1].

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Dysmenorrhea is cyclic pelvic pain associated with menstruation, which can be either an independent gynecological condition (primary dysmenorrhea) or a symptom of concomitant organic pathology (secondary dysmenorrhea) [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Dysmenorrhea is classified as primary or secondary depending on the presence of concomitant organic pathology.

Primary dysmenorrhea (functional) predominantly manifests within 6–12 months of menarche and is characterized by spasmodic pelvic pain occurring immediately before and/or during menstruation and lasting 8–72 hours [3]. The pain may radiate to the lower back, lower extremities, and be accompanied by nausea, vomiting, diarrhea, bloating, fatigue, and syncope in cases of high pain severity [3, 6].

The main mechanism underlying primary dysmenorrhea is myometrial hypercontractility and vascular spasm resulting from increased levels of prostaglandins released during the shedding of the functional layer of the endometrium (PGF2α, PGE2) [2-3, 6].

Risk factors for primary dysmenorrhea [2, 7-8, 25]:

— Smoking

— Age at menarche <12 years

— Age <30 years

— Heavy menstrual bleeding

— Low body mass index (less than 18.5 kg/m2)

— Family history (including history of endometriosis)

— Presence of psychoemotional trigger factors (stress, sexual abuse, psychological disorders, and others)

Secondary dysmenorrhea (organic) is menstrual pain associated with pelvic pathology [8].

Causes of secondary dysmenorrhea [6, 8]:

— Endometriosis (extragenital endometriosis, adenomyosis);

— Uterine fibroids (leiomyomas);

— Pelvic inflammatory disease (PID);

— Pelvic adhesions;

— Developmental anomalies and malpositions of the female genital organs (congenital, acquired);

— Cervical canal stenosis;

— Pelvic congestion syndrome;

— Benign and malignant ovarian masses.

1.3 Epidemiology of the Disease or Condition

The prevalence of dysmenorrhea ranges from 45% to 95% among women of reproductive age [3-4], and can reach 93% in adolescents [5].

1.4 Features of Coding the Disease or Condition

N94.0 Mittelschmerz

N94.4 Primary dysmenorrhea

N94.5 Secondary dysmenorrhea

N94.6 Unspecified dysmenorrhea

N94.8 Other specified conditions associated with female genital organs and menstrual cycle

1.5 Classification of the disease or condition

By etiological factor [1]:

— primary (functional) – occurs in the absence of concomitant organic pathology, predominantly starting from menarche, as a result of excessive prostaglandin production;

— secondary (organic) – is a symptom of concomitant organic pathology (endometriosis, PID, uterine fibroids, etc.).

By severity [1]:

— mild – menstrual pain is mild, the pain syndrome does not disrupt daily activities, analgesics are occasionally required, systemic symptoms are absent;

— moderate – menstruation is moderately painful, daily activities are disrupted, analgesics effectively relieve the pain, isolated systemic symptoms are observed;

— severe – severe pain, up to fainting, sharp disruption of daily activities, autonomic symptoms are observed: headache, weakness, nausea, vomiting, diarrhea, etc.; low efficacy of analgesics.

1.6 Clinical presentation of the disease or condition

See section "History and Symptoms".

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of dysmenorrhea is established based on patient complaints.

2.1 Complaints and Anamnesis

Complaints of cyclical pelvic pain associated with menstruation, manifesting immediately before and/or during menstruation, lasting 8–72 hours, which may be accompanied by concomitant symptoms such as nausea, vomiting, diarrhea, bloating, fatigue, and fainting in cases of high pain intensity.

2.2 Physical Examination

  • All patients with suspected dysmenorrhea are recommended to undergo a speculum examination of the cervix and bimanual pelvic examination to establish a diagnosis and perform differential diagnosis [28].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: A speculum examination of the cervix and bimanual pelvic examination in sexually active women of reproductive age make it possible to suspect PID, adenomyosis, deep endometriosis, uterine fibroids, and ovarian masses. In primary dysmenorrhea, no pathology is detected. In sexually inactive adolescents, performing a speculum examination of the cervix and bimanual pelvic examination is not advisable [26-28].

2.3 Laboratory Diagnostics

Specific laboratory diagnostics for dysmenorrhea have not been developed.

2.4 Instrumental Diagnostics

It is recommended that all patients undergo comprehensive pelvic ultrasound (transvaginal and transabdominal) to rule out organic gynecological pathology [1, 16]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comment: Pelvic ultrasound in adolescents experiencing dysmenorrhea within the first 6 months from the onset of menstruation is also advisable to rule out congenital malformations of the female reproductive system.

It is not recommended to routinely perform pelvic MRI in the presence of isolated dysmenorrhea and the absence of ultrasound signs of organic pathology [1, 11-12].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: performing a pelvic MRI is advisable in adolescents to rule out congenital malformations of the reproductive system, as well as in cases of intense pain (to rule out endometriosis) and ineffectiveness of conservative therapy for 3–6 months.

  • To rule out peritoneal endometriosis, patients regardless of age are recommended to undergo a pelvic MRI on a superconducting magnetic resonance scanner with a magnetic field strength of 3 tesla [14-16].

GCR BLEL 2Grade of recommendation B (Level of evidence – 2) (for women of reproductive age);

GCR CLEL 5Grade of recommendation C (Level of evidence – 5) (for adolescents).

2.5 Other Procedures

It is recommended to use the 11-point visual analogue scale (Appendix G1), representing pain gradation from 0 (no pain) to 10 (maximum pain) in points, in patients with dysmenorrhea to assess the severity of the pain syndrome and its impact on quality of life [10-11, 41].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comment: the use of the visual analogue scale objectifies the severity of the pain syndrome and also makes it possible to monitor the effect of the therapy.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

It is recommended to use nonsteroidal anti-inflammatory drugs (ATC non-steroidal anti-inflammatory and antirheumatic products) (NSAIDs) in patients with primary dysmenorrhea as 1st-line therapy for pain relief [29-31].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: NSAIDs can be prescribed 1-2 days before menstruation and during the first 2-3 days of menstrual bleeding in the absence of contraindications, either alone or in combination with hormonal therapy. If pain relief is insufficient, another treatment should be prescribed.

It is recommended to prescribe combined oral contraceptives (COCs) (ATC progestogens and estrogens, fixed combinations), progestin contraceptives (ATC Progestogens) to patients with dysmenorrhea starting from the age of menarche, and ATC group drugs: progestogen- and estrogen-containing intravaginal rings to patients of reproductive age as 2nd-line therapy for pain relief [1, 2, 3, 5, 32-33, 40, 42].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

It is recommended to prescribe progestogens in a prolonged cyclic or continuous regimen as an alternative to COCs (ATC Progestogens and estrogens, fixed combinations) [1, 2, 3, 5, 8, 32-34].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: oral progestogens, #Etonogestrel (implant dosage form) subcutaneously, and #Levonorgestrel 52 mg (intrauterine therapeutic system releasing 20 mcg/day of the active substance [LNG-IUS]) can be used in patients aged 18 years and older if there are contraindications to COCs or their insufficient efficacy [1, 38, 41].

In secondary dysmenorrhea, management tactics are carried out in accordance with clinical guidelines hosted in the Russian Ministry of Health Rubricator [35-37]:

— Endometriosis

— Uterine fibroids

— Inflammatory diseases of female pelvic organs

— Others (chlamydial infection, etc.)

3.2 Surgical Treatment

It is not recommended to routinely perform diagnostic laparoscopy to identify the cause of dysmenorrhea. Diagnostic laparoscopy is recommended when conservative therapy is ineffective to rule out endometriosis, PID, adhesions, and in adolescents to rule out congenital malformations of the reproductive system [1, 13, 16-17].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comment: the diagnosis of dysmenorrhea should be based on clinical and instrumental diagnostics. The absence of laparoscopic visualization of endometrioid lesions does not rule out the presence of the disease.

It is recommended to perform surgical treatment if an organic cause of dysmenorrhea is identified, in accordance with the relevant clinical guidelines hosted in the Russian Ministry of Health Rubricator: endometriosis [35], uterine fibroids [36], inflammatory diseases of female pelvic organs [37].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

3.3 Other Treatment

It is not recommended as primary methods of dysmenorrhea treatment to use special diet therapy, dietary supplements, vitamins, and mineral supplements [1-3, 5, 8, 11]

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

It is recommended to use traditional medicine methods (acupuncture), physical therapy, dietary supplements, and lifestyle modification in combination with drug therapy for secondary dysmenorrhea or primary dysmenorrhea in adolescents to alleviate pain [1, 20-24, 40].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

It is recommended to refer patients with complaints of psycho-emotional changes for consultation with relevant specialists (medical psychologist, psychotherapist) to assess the psycho-emotional state of women with dysmenorrhea in order to improve quality of life, and in the presence of sexual disorders, to a medical psychologist [16, 18-19].

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

5. Prevention and Dispensary Observation

Specific prevention of dysmenorrhea has not been developed

6. Organization of Medical Care

Indications for hospitalization: need for surgical treatment

Indications for discharge: Clinical recovery

7. Additional Information

None.

Criteria for Evaluating the Quality of Medical Care

№

Quality criteria

Evaluation of compliance

Yes / No

1

Comprehensive pelvic ultrasound (transvaginal and transabdominal) performed to rule out an organic cause of dysmenorrhea

Yes / No

2

Drug therapy for dysmenorrhea prescribed

Yes / No

3

Surgical treatment performed in case of ineffectiveness of conservative treatment or upon identification of an organic cause of dysmenorrhea

Yes/No

References

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  42. Fox MC, Klipping C, Nguyen AM, Frenkl TL, Cruz SM, Wang Y, Korver T. A phase 2b multicenter, randomized, double-blind, placebo-controlled clinical trial to evaluate the efficacy and safety of vaginal rings containing nomegestrol acetate or etonogestrel and 17β-estradiol in the treatment of women with primary dysmenorrhea. Contraception. 2019;99(2):125-130. doi: 10.1016/j.contraception.2018.10.009. 

Appendix A1. Working Group Composition

Leyla V. Adamyan – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Deputy Director of the V.I. Kulakovo National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, Honored Scientist of Russia, Head of the Department of Obstetrics, Gynecology and Reproductive Medicine at the Russian University of Medicine, Chief Freelance Gynecologist of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Gynecological Endoscopists, the Russian Endometriosis Association, and the Russian Society of Obstetricians and Gynecologists.

Elena N. Andreeva – Doctor of Medical Sciences, Professor, Deputy Director – Director of the Institute of Reproductive Medicine, Head of the Department of Endocrine Gynecology, Professor at the Department of Endocrinology of the National Medical Research Center for Endocrinology of the Russian Ministry of Health, Professor at the Department of Obstetrics, Gynecology and Reproductive Medicine of the Russian University of Medicine, President of the International Association of Obstetricians, Gynecologists and Endocrinologists, member of the Russian Association of Gynecological Endoscopists, the Russian Endometriosis Association, the Russian Society of Obstetricians and Gynecologists, and ROSGEM.

Natalya V. Artymuk – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova at Kemerovo State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Siberian Federal District, member of the Russian Society of Obstetricians and Gynecologists.

Tatiana E. Belokrinitskaya – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology at the Faculty of Additional Professional Education, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Far Eastern Federal District (Chita), member of the Russian Society of Obstetricians and Gynecologists, President of the Transbaikal Society of Obstetricians and Gynecologists.

Antonina A. Smetnik – Candidate of Medical Sciences, Head of the Department of Gynecological Endocrinology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, President of the Russian Society of Gynecological Endocrinology and Menopause Specialists.

Galina E. Chernukha - Doctor of Medical Sciences, Professor, Chief Researcher at the Department of Gynecological Endocrinology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, President of the Interregional Public Organization "Association of Gynecologist-Endocrinologists".

Elena V. Uvarova - Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Head of the 2nd Gynecological Department at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Professor at the Department of Obstetrics, Gynecology and Reproductology of the Institute of Professional Education at the First Moscow State Medical University named after I.M. Sechenov (Sechenov University) of the Russian Ministry of Health, Chief freelance pediatric and adolescent gynecologist of the Russian Ministry of Health.

Elena P. Khashchenko - Candidate of Medical Sciences, Leading Researcher at the 2nd Gynecological Department at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief freelance pediatric and adolescent gynecologist of the Russian Ministry of Health in the Central Federal District.

Maria I. Yarmolinskaya – Professor of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Head of the Department of Gynecology and Reproductive Endocrinology, D.O. Ott Research Institute of Obstetrics and Gynecology, Professor at the Department of Obstetrics and Gynecology, I.I. Mechnikov North-Western State Medical University of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Obstetricians-gynecologists,

2. Surgeons,

3. General practitioners (family doctors),

4. Students, residents, postgraduates, and faculty members of medical universities.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

LoE

Definition

1

Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis

2

Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis

3

Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies

4

Non-comparative studies, case report

5

Only justification of mechanism of action or expert opinion is available

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

LoE

Definition

1

Systematic review of RCTs with meta-analysis

2

Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis

3

Non-randomized comparative studies, including cohort studies

4

Non-comparative studies, case reports or case series, case-control studies

5

There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion

Table 3. Rating scale for the levels of evidentiary validity of recommendations (LEVR) for preventive, diagnostic, treatment, and rehabilitation interventions)

GoR

Definition

A

Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent)

C

Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent)

C

Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines have been developed taking into account the following regulatory legal and other documents:

  1. Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020, "On approval of the Procedure for providing medical care in the field of 'obstetrics and gynecology (excluding the use of assisted reproductive technologies)'" (as amended);

  2. Order of the Ministry of Health of the Russian Federation No. 803n dated July 31, 2020, "On the procedure for using assisted reproductive technologies, contraindications, and restrictions on their use."

  3. ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Human Reproduction Open, Volume 2022, Issue 2, 2022, hoac009, doi:10.1093/hropen/hoac009

  4. Burnett M, Lemyre M. No. 345-primary dysmenorrhea consensus guideline. J Obstet Gynaecol Can 2017;39:585–95.

  5. Leyland N., Casper R., Laberge Ph. Et al. Endometriosis: Diagnosis and Management // Clinical Practice Guideline // JOGC. – 2010. – Vol. 32. – № 7. – P. 1–27.

  6. ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol. 2018;132(6):1517-1518.

  7. Serov V.N., Sukhikh G.T. Clinical Guidelines. Obstetrics and Gynecology // M: GEOTAR-Media. - 4th ed. - 2023. Moscow: Problems of Reproduction.

Appendix B. Physician Action Algorithms

Appendix B. Physician Action Algorithms — Dysmenorrhea

Appendix C. Patient Information

Dysmenorrhea is cyclic pelvic pain that can occur immediately before and during menstruation, accompanied by a wide range of other symptoms such as nausea, vomiting, diarrhea, bloating, and fatigue.

Dysmenorrhea can be an independent gynecological condition as well as a symptom of an underlying disease.

In some cases, dysmenorrhea can be extremely severe and affect your physical, sexual, psychological, and social well-being.

To diagnose dysmenorrhea, taking a medical history and conducting an interview during a doctor's appointment is usually sufficient. However, to rule out potential underlying causes, a pelvic ultrasound is necessary, and an MRI if indicated.

Treatment options include nonsteroidal anti-inflammatory and antirheumatic analgesics and hormonal medications. In some cases, when pain relief cannot be achieved with medications and the cause of dysmenorrhea cannot be identified via imaging, surgical intervention may be performed. Surgery is most commonly performed via a laparoscopic approach.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1 Visual Analog Scale (VAS) for Pain

Russian title: Visual Analogue Scale for pain

Original title: Visual analogue scale.

Source (official developer website, publication with validation): Huskisson EC. Measurement of pain. Lancet 1974;2:1127–31.

Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis 1978;37:378–81.

Type (underline):

- rating scale

Content (template):

Appendix G1 - G... Rating scales, questionnaires — Dysmenorrhea

The VAS is a 10 cm straight line. The patient is asked to make a mark on the line corresponding to the intensity of the pain they are experiencing. The starting point of the line indicates no pain (0), followed by mild, moderate, severe, and the endpoint, unbearable pain (10). The distance between the left end of the line and the made mark is measured in millimeters.

Key (interpretation): the higher the score, the greater the pain intensity.

Notes: the patient is asked to rate the severity of pain at the present moment from 0 (minimal) to 10 (maximal). Since filling out the VAS questionnaire does not take much time, the assessment can be performed daily throughout the entire course of treatment. The data obtained in this way can serve as a valuable reflection of the analgesic effect of the ongoing treatment. To the extent possible, the volume of analgesic therapy should also be recorded and its analysis included in the reporting data when assessing the pain syndrome.

Scales and calculators from this guideline

VAS for Pain (Visual Analog Scale)Assessment of pain intensity using a 10-point visual analog scale

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