Key takeaways:
- A Delphi procedure was used to establish a standardized definition and diagnostic criteria for primary dysmenorrhea.
- Experts agreed that “primary” refers to pain without identifiable pathology and does not require occurrence within a set time after menarche.
- Conditions such as PID, STIs, congenital anomalies, adenomyosis, and fibroids must be excluded before diagnosing primary dysmenorrhea.
- Pelvic examination and systemic symptoms are not required for diagnosis, and no minimum pain duration is necessary.
- Endometriosis should be considered but cannot be fully ruled out, with diagnosis recommended when suspicion for endometriosis is low.
Research published in the Journal of Pediatric & Adolescent Gynecology has established a definition and diagnostic criteria for primary dysmenorrhea through a Delphi procedure.1
Increased research addressing menstrual complaints has been conducted in recent years, with dysmenorrhea being one of the most common in 34% to 94% of patients. Significant adverse impacts on quality of life have been reported from the condition, including rates of school absenteeism up to 57%.2 However, consensus has not been reached about the criteria of primary dysmenorrhea.1
“Overall, an accepted clear definition of primary dysmenorrhea promotes uniformity in diagnosis, treatment, and research, ultimately benefiting patients worldwide with primary dysmenorrhea,” wrote investigators.
Delphi procedure used to build expert consensus
The study was conducted to develop a standardized definition and diagnostic criteria for primary dysmenorrhea. This was accomplished using a Delphi procedure, an iterative methodology used to obtain expert opinions and reach a consensus in situations with insufficient or contradictory information.
This was a modified Delphi procedure conducted digitally. During the first round, a systematic review was conducted to obtain definitions of primary dysmenorrhea for the questionnaire. The questionnaire included multiple rounds, allowing participants to reflect on the results of prior rounds.
A topic was considered finalized when it reached consensus. Topics that failed to reach consensus continued to be discussed in the next round alongside anonymous expert comments. Questions for subsequent rounds were developed based on answers from the previous round.
Expert participation and evaluation criteria
During the systematic review, articles providing definitions of primary dysmenorrhea were obtained from PubMed. A single author performed the search, while 2 authors completed screening. Study characteristics and primary dysmenorrhea definitions were extracted from the included articles.
Experts from the Dutch Gynecological Adolescent Care Network participated in the first round’s focus group discussion through videoconferencing. Content in the questionnaire covered nomenclature, inclusion of systemic symptoms, definition based on severity and duration of pain, diagnostic evaluation with pelvic examination, and imaging.
Experts were defined as professionals treating over 30 patients with dysmenorrhea per year, with more than 1 scientific publication about dysmenorrhea, or part of a national or international pediatric or adolescent gynecology association. A Rate of Agreement (RoA) over 70% indicated consensus.
Consensus findings
There were 20 experts who completed the baseline questionnaire, 17 the first round, 14 the second round, and 12 the final round. The word ‘primary’ was agreed to mean the absence of known pathology, with an RoA of 76%. An RoA of 76% was also reached for the statement that primary dysmenorrhea does not have to be present within a certain period after menarche.
The RoA that pain can be present a few days before and during menstrual blood loss was also 76%. Conditions agreed to be excluded before a primary dysmenorrhea diagnosis could be made included pelvic inflammatory disease, sexually transmitted infections, congenital uterine anomaly, adenomyosis, and fibroids, with an RoA of 71%.
An RoA of 71% was also reported for the consensus that endometriosis should be considered before primary dysmenorrhea. However, 2022 guidelines indicate endometriosis cannot be fully ruled out. Primary dysmenorrhea was recommended for diagnosis when suspicious of endometriosis is low, with an RoA of 92%.
Final definition and recommendation
A pelvic examination was agreed as not needed to diagnose primary dysmenorrhea, with an RoA of 82%. Further investigation was defined as ultrasound, magnetic resonance imaging, or laparoscopy. An RoA of 82% was reported for the statement that no minimal duration of pain is required to diagnose primary dysmenorrhea.
Systemic symptoms were also not indicated as necessary for a diagnosis, with an RoA of 93%. Overall, this procedure established a definition and diagnostic criteria for primary dysmenorrhea.
“Accordingly, we recommend using this definition and these diagnostic criteria for primary dysmenorrhea,” wrote investigators.
References
- Özcan H, Albana J, Yarde F, et al. Definition and criteria for diagnosing primary dysmenorrhea: a modified Delphi procedure. Journal of Pediatric & Adolescent Gynecology. 2025. doi:10.1016/j.jpag.2025.11.007
- Armour M, Parry K, Manohar N, et al. The prevalence and academic impact of dysmenorrhea in 21,573 young women: a systematic review and meta-analysis. Journal of Women's Health. 2019;28:1161-1171. doi:10.1089/jwh.2018.7615
