Dysmenorrhoea
Dysmenorrhoea is painful menstrual cramping, typically caused by excessive prostaglandin-mediated uterine contractions (primary) or underlying pelvic pathology such as endometriosis (secondary).
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Primary (spasmodic) dysmenorrhoea [1] | Onset at/near menarche, crampy suprapubic pain 1st 1–2 days, no pelvic pathology, responds to NSAIDs | 「經痛係唔係由第一次嚟M就開始？食止痛藥有冇幫助？」 |
| Serious Not To Miss | Endometriosis [1] | Progressive worsening, deep dyspareunia, cyclical bowel/bladder Sx, subfertility | 「經痛有冇越嚟越嚴重？親密嗰陣深處有冇痛？」 |
| PID (Pelvic Inflammatory Disease) [3] | Fever, abnormal discharge, cervical motion tenderness, sexual risk factors | 「有冇發燒？白帶有冇異味？」 | |
| Ectopic pregnancy | Amenorrhoea → acute pain, positive pregnancy test | 「上一次M幾時嚟？有冇可能懷孕？」 | |
| Pitfalls | Adenomyosis [2] | Older parous woman, heavy periods + progressive dysmenorrhoea, bulky tender uterus | 「你生過BB未？經量有冇越嚟越多？」 |
| Ovarian cyst (torsion/rupture) [2] | Sudden severe unilateral pain, adnexal mass | 「有冇突然間一邊肚好痛？」 | |
| Uterine fibroid [2] | HMB, pelvic pressure, enlarged irregular uterus | 「有冇覺得小腹有嘢頂住？」 | |
| Masquerades | IBS | Cyclical bloating/altered bowel but not strictly menstrual | 「肚痛同M有冇關係定平時都痛？」 |
| Depression | Low mood amplifying pain perception, functional impairment | 「心情點？有冇對嘢失去興趣？」 | |
| Trying to Tell Me Something? | Psychosocial stress / fear of infertility / relationship/sexual concerns / school pressure | Hidden agenda behind presentation | 「你最擔心呢個痛代表啲咩？有冇其他嘢想傾？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生，今日由我同你傾吓。你可以叫我X醫生。今日想了解吓你嚟睇醫生最主要係咩事？」 | Warm greeting + patient-centred opening scores interpersonal marks |
| 0:30–1:30 | Elicit chief complaint & HPI — onset, duration, timing in cycle, severity (VAS), character, location, radiation, aggravating/relieving, associated symptoms | 「你嘅經痛係幾時開始㗎？每次嚟M之前定嚟緊嗰陣先痛？痛咗幾耐？如果0係唔痛、10係最痛，你會俾幾多分？」 | Structured symptom analysis = HPI marks; discriminates primary vs secondary |
| 1:30–2:30 | Red flags & secondary causes — intermenstrual bleeding, dyspareunia, heavy flow/clots, infertility, bowel/bladder symptoms, fever | 「經期之間有冇出血？同伴侶親密嗰時有冇痛？經量多唔多？有冇血塊？有冇試過想要BB但懷唔到？」 | Catches endometriosis, PID, fibroids; avoids missing serious pathology |
| 2:30–3:30 | Menstrual/Obstetric/Sexual Hx, PMH, Drug Hx, FHx | 「你幾歲開始有M？每次隔幾多日？有冇懷過孕？有冇性生活？有冇食避孕藥或者其他藥物？屋企人有冇類似問題？」 | Completes case report; contraception use affects management |
| 3:30–4:30 | ICE — Ideas, Concerns, Expectations | 「你自己覺得呢個痛可能係咩原因？你最擔心啲咩？你今日嚟最希望醫生幫到你咩？」 | Direct marks on case report Q3; uncovers hidden agenda |
| 4:30–5:15 | Psychosocial impact — school/work absence, mood, sleep, relationships, coping | 「經痛有冇影響你返學或者返工？心情點？瞓得好唔好？平時點樣處理？食過止痛藥有冇用？」 | Biopsychosocial problem marks; functional impact is a scoring domain |
| 5:15–6:00 | Summarise, signpost, safety net, close | 「咁我總結吓：你主要係經痛困擾咗你X年，影響到日常生活，你擔心係唔係有啲問題。我建議我哋做個檢查了解多啲，如果痛到好嚴重或者有異常出血就要即刻返嚟。你有冇其他嘢想問？」 | Summarising + safety net + checking understanding = interpersonal marks |
Hidden agenda tip: A young woman presenting with dysmenorrhoea may actually be worried about endometriosis → infertility, or concerned about a pelvic mass/cancer after reading online, or seeking contraception (OCP doubles as treatment). Ask: 「你今日嚟其實最擔心嘅嘢係咩？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset & duration | When did the pain start? Since menarche or recent onset? | 「經痛係幾時開始？一開始有M就痛定係最近先開始？」 | Since menarche → primary; new onset/worsening → secondary [1] | Primary vs secondary dysmenorrhoea |
| Timing | Pain before, during, or after period? | 「痛係嚟M之前定嚟緊嗰陣？定M完之後都仲痛？」 | Pre-menstrual + during → primary; pain extending beyond menses → endometriosis [1] | Endometriosis, adenomyosis |
| Severity | Rate pain 0–10; does it stop you from daily activities? | 「如果10分係最痛，你每次大概幾多分？有冇痛到返唔到學/工？」 | Functional impact → biopsychosocial problem; severity guides Mx | Severe → consider secondary cause |
| Character & location | Crampy? Where exactly? Radiation to back/thighs? | 「痛法係點㗎？攣住痛定脹住痛？邊度最痛？有冇痛到落腰或者大髀？」 | Suprapubic cramping = typical primary; lateralised/deep = endometriosis | Endometriosis, ovarian cyst |
| Heavy menstrual bleeding | Heavy flow? Clots? How many pads/day? | 「經量多唔多？有冇血塊？每日要換幾多塊M巾？」 | HMB + dysmenorrhoea → adenomyosis/fibroid [2] | Adenomyosis, fibroid |
| Intermenstrual/post-coital bleeding | Bleeding between periods or after sex? | 「經期之間有冇出血？親密之後有冇流血？」 | Red flag for cervical/endometrial pathology | Cervical pathology, endometrial polyp |
| Dyspareunia | Pain during or after intercourse? | 「同伴侶親密嗰時有冇痛？係入嗰陣痛定深處痛？」 | Deep dyspareunia → endometriosis, PID [1] | Endometriosis, PID |
| Bowel/bladder symptoms | Cyclical bowel pain, dyschezia, urinary symptoms? | 「嚟M嗰陣有冇肚痾、大便痛或者小便唔舒服？」 | Cyclical bowel Sx → deeply infiltrating endometriosis | Endometriosis |
| Vaginal discharge/fever | Abnormal discharge? Fever? | 「有冇白帶異常或者發燒？」 | PID → fever + discharge + pelvic pain | PID |
| Infertility | Trying to conceive? How long? | 「有冇打算生BB？試咗幾耐？」 | Endometriosis → subfertility; hidden concern | Endometriosis |
| Contraception/sexual Hx | Sexually active? Contraception method? | 「有冇性生活？有冇用避孕方法？」 | OCP is Rx for dysmenorrhoea; also rules out ectopic | Ectopic, PID risk |
| Drug Hx | Painkillers tried? Which ones? Effective? | 「有冇食過止痛藥？食邊隻？有冇效？」 | NSAID response → likely primary; no response → think secondary [1] | Refractory → secondary cause |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety for prescribing NSAIDs/OCP | — |
| PMH | Prior surgery, STI, IUD? | 「以前有冇做過手術？有冇性病紀錄？有冇用子宮環？」 | IUD copper → worsens dysmenorrhoea; STI → PID | PID, IUD-related pain |
| FHx | Mother/sister with similar pain or endometriosis? | 「屋企人有冇嚴重經痛或者子宮內膜異位？」 | Positive FHx ↑ risk endometriosis | Endometriosis |
| Psychosocial | Mood, sleep, stress, school/work impact | 「心情點？有冇因為經痛影響情緒或者社交？」 | Psych comorbidity; biopsychosocial marks | Depression, anxiety |
| Health-seeking | Why come today specifically? | 「點解揀今日嚟睇醫生？」 | Uncovers trigger/hidden agenda | Fear of serious disease |
Case Report Form Answer Builder
- CC: Dysmenorrhoea × [duration]
- HPI high-yield points: Age of onset relative to menarche; cycle regularity; timing of pain within cycle; severity (VAS); character (cramping/dull); location & radiation; associated Sx (HMB, clots, nausea, vomiting, diarrhoea); response to analgesics; progression over time; aggravating/relieving factors; menstrual history (menarche age, cycle length, duration of flow); obstetric & sexual history
- Examples: "Pain affecting school/work attendance," "Worried the pain indicates a serious problem," "Wants effective treatment," "Concerned about fertility"
- Best phrasing: Choose the patient's own words. E.g., "Patient consulted because severe menstrual pain is causing repeated school absence and she is worried something is wrong."
| Likely Content | Example Written Answer | |
|---|---|---|
| Ideas | "Maybe it's normal period pain" / "Could it be endometriosis?" | Patient thinks the pain may be caused by endometriosis after searching online |
| Concerns | Worried about infertility / cancer / missing school | Patient is worried the pain may affect her ability to have children in the future |
| Expectations | Wants effective painkiller / investigation / specialist referral | Patient hopes to get stronger medication and know if further tests are needed |
- Primary dysmenorrhoea — if: onset near menarche, cyclical crampy suprapubic pain in first 1–2 days of menses, no red flags, normal examination expected, responds to NSAIDs [1]
- Minimum supporting evidence: typical age, timing, no features of secondary cause
High yield from GC lecture [1]: Primary dysmenorrhoea — excess prostaglandin production → myometrial hypercontractility → ischaemic pain. No pelvic pathology. First-line Rx = NSAIDs (mefenamic acid) ± OCP.
| Domain | Problem |
|---|---|
| Biological | Recurrent moderate-to-severe menstrual pain inadequately controlled by current analgesics |
| Psychological | Anxiety about underlying serious cause / fear of infertility / low mood due to chronic pain |
| Social/Functional | Repeated school/work absenteeism; impaired social activities during menses |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Primary dysmenorrhoea | Normal pelvic examination (no adnexal mass, no cervical motion tenderness, normal uterine size) | Bimanual pelvic examination + speculum | Absence of pathology supports primary diagnosis by exclusion [1] |
| Endometriosis | Fixed retroverted uterus with tender nodularity in posterior fornix / uterosacral ligaments | Bimanual exam ± rectovaginal exam | Nodularity/tenderness suggests deeply infiltrating endometriosis |
| Adenomyosis | Diffusely enlarged, boggy, tender uterus | Bimanual pelvic examination | Bulky uterus without discrete mass distinguishes from fibroid |
| PID | Cervical motion tenderness (chandelier sign) | Bimanual exam: gently move cervix laterally | Highly suggestive of pelvic peritoneal inflammation |
| Fibroid | Irregularly enlarged, firm, non-tender uterus | Bimanual pelvic examination | Discrete firm masses palpable |
Must-Not-Miss Red Flags — Refer Urgently
- Acute severe unilateral pain + amenorrhoea → ectopic pregnancy (do urine pregnancy test!)
- Fever + purulent discharge + cervical motion tenderness → PID (risk of tubo-ovarian abscess)
- Progressive worsening pain refractory to NSAIDs + OCP → endometriosis — refer for laparoscopy
- Sudden severe pain + signs of peritonism → ovarian torsion/rupture — surgical emergency
- Post-menopausal pelvic pain + bleeding → exclude malignancy
Top Traps That Lose Marks:
- Forgetting to ask about pregnancy — always exclude pregnancy in any woman of reproductive age with pelvic pain.
- Not distinguishing primary from secondary dysmenorrhoea — the key pivot is onset (menarche vs later), progression, and presence of associated features (dyspareunia, HMB, discharge).
- Omitting ICE — direct marks; don't assume you know the concern.
- Writing "period pain" without specifying primary vs secondary — examiners want the specific diagnosis.
- Not asking about functional impact — school/work absence is an easy biopsychosocial mark.
- Forgetting drug history — NSAIDs, OCP, IUD type (copper worsens; LNG-IUS treats).
Shortest Safe Management / Safety-Net Line:
「如果食咗止痛藥都冇改善，或者痛越嚟越嚴重、有異常出血或者發燒，就要即刻返嚟睇。」 (If painkillers don't help, or pain worsens, or you have abnormal bleeding or fever, come back immediately.)
First-line Rx (GC lecture [1]): NSAIDs (mefenamic acid 500mg TDS during menses) started at onset of pain or just before. If inadequate, add or switch to combined OCP (cyclical or continuous). Second-line: LNG-IUS (Mirena). Refractory → investigate for secondary cause.
High Yield Summary
What to ASK: Onset relative to menarche (primary vs secondary), severity/functional impact, dyspareunia, HMB, cyclical bowel/bladder Sx, pregnancy possibility, NSAID response, ICE, psychosocial impact.
What to WRITE: CC = "Dysmenorrhoea × [duration]"; Dx = Primary dysmenorrhoea (if no red flags); DDx = Endometriosis, Adenomyosis, PID; Biopsychosocial = pain control problem / anxiety or mood impact / school-work absence; Physical sign = Normal pelvic exam (for primary) or specific finding if secondary suspected.
What NOT to MISS: Pregnancy test in reproductive-age women; progressive pain → endometriosis; fever + discharge → PID; hidden concern about infertility or cancer.
Active Recall - Family Medicine Clinical Test
Dizziness / Vertigo
Dizziness is a nonspecific term encompassing sensations of lightheadedness, unsteadiness, or presyncope, while vertigo is the illusory perception of rotational movement of oneself or the environment, typically arising from vestibular system dysfunction.
Dyspareunia
Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse, which can occur in both women and men due to various structural, inflammatory, hormonal, or psychogenic causes.