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 |
|---|---|---|---|---|
| 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？」 | ~70% |
| 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？」 | ~10% |
| PID (Pelvic Inflammatory Disease) [3] | Fever, abnormal discharge, cervical motion tenderness, sexual risk factors | 「有冇發燒？白帶有冇異味？」 | ~2% | |
| Ectopic pregnancy | Amenorrhoea → acute pain, positive pregnancy test | 「上一次M幾時嚟？有冇可能懷孕？」 | < 1% | |
| 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？」 | ~5% |
| Uterine fibroid [2] | HMB, pelvic pressure, enlarged irregular uterus | 「有冇覺得小腹有嘢頂住？」 | ~3% | |
| Ovarian cyst (torsion/rupture) [2] | Sudden severe unilateral pain, adnexal mass | 「有冇突然間一邊肚好痛？」 | ~1% | |
| Masquerades | IBS | Cyclical bloating/altered bowel but not strictly menstrual | 「肚痛同M有冇關係定平時都痛？」 | ~15% |
| Depression | Low mood amplifying pain perception, functional impairment | 「心情點？有冇對嘢失去興趣？」 | ~5% | |
| 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？」 | ~15% |
| 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.
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