Delphi Round 2

Welcome to the second round of our Delphi study on primary dysmenorrhea. We thank you for your participation. In the first round, consensus has been reached on the following topics:

Nomenclature The term ‘primary’ in primary dysmenorrhea is defined as ‘absence of known pathology’. We have defined dysmenorrhea as pain that can be present a (few) day(s) before AND during menstrual blood loss.

Pelvic examination It is not necessary to perform a pelvic examination to diagnose primary dysmenorrhea.

Duration of dysmenorrhea There is no minimal duration of dysmenorrhea as criteria to diagnose primary dysmenorrhea.

Additional symptoms Additional symptoms do not have to be present to diagnose primary dysmenorrhea.

Severity of dysmenorrhea

In the previous questionnaire we asked whether assessing the severity of dysmenorrhea is necessary and if so, which method should be used. There was consensus on the fact that severity of dysmenorrhea should be assessed as a part of the diagnostic criteria of primary dysmenorrhea. However, there has been no consensus yet on the tool that should be used to assess the severity of dysmenorrhea. The Rate of agreement was 50% for VMSS and 33% for the impact of dysmenorrhea on daily activities. The majority of the experts chose a cut-off value of grade 2 for VMSS, which means that one experiences moderate pain, that daily activities are affected, analgesics are required and provide relief so that absence from work or school is unusual. NRS and VAS both had a RoA of 8%. The experts stated that the VMSS is the most complete tool, because it gives insight into the effects of pain on daily life as well as the quality of life.

Since VMSS also consists of the impact of dysmenorrhea on daily activities, we would like to ask the following question:

Sexually Transmitted Diseases (STDs) / Pelvic Inflammatory Disease (PID)

Congenital uterine anomaly

Endometriosis

To explore how to consider endometriosis in adolescents, the ESHRE guideline (1) was used for the next questions. The guideline states that clinical examination, including vaginal examination where appropriate, should be considered to identify deep nodules or endometriomas in patients with suspected endometriosis, although the diagnostic accuracy is low. In women with suspected endometriosis, further diagnostic steps, including imaging, should be considered even if the clinical examination is normal.. Clinicians are recommended to use imaging (US or MRI) in the diagnostic work-up for endometriosis, but they need to be aware that a negative finding does not exclude endometriosis, particularly superficial peritoneal disease. In patients with negative imaging results or where empirical treatment was unsuccessful or inappropriate, the guideline recommends that clinicians consider offering laparoscopy for the diagnosis and treatment of suspected endometriosis. The guideline recommends that laparoscopic identification of endometriotic lesions is confirmed by histology although negative histology does not entirely rule out the disease.

Adenomyosis

Fibroids

The previous questions were on the diagnostic criteria of primary dysmenorrhea. The outcome of those questions are necessary for the diagnosis primary dysmenorrhea.

The following questions are on the associated factors of primary dysmenorrhea. This means that these factors are not necessary for diagnosing primary dysmenorrhea. We would like to explore these factors, to gain more insight in symptoms of patients, possible non-pharmacological treatment and to improve care for adolescents with menstrual complaints.

ASSOCIATED FACTORS

There are many risk factors and comorbidities associated with primary dysmenorrhea. Multiple articles found that a more favourable nutrition style and more regular activity reduces primary dysmenorrhea (2-4). Other articles found a relationship between poor mental health, low BMI and primary dysmenorrhea (5-8). On the other hand, other authors state there is not enough evidence to claim these relationships between primary dysmenorrhea (9-12). Multiple articles found that family history, low parental education, low social support, low sleep quality, history of sexual abuse and inappropriate parental bonding is a risk factor for primary dysmenorrhea (13-19). It has also been stated that there is an association between autism and ADHD and primary dysmenorrhea (20, 21).

This was the questionnaire for the second round of the Delphi procedure. We would like to thank you for your participation. If you have any comments, please mention them below.

Depending on the consensus on the questions, there may be a third round. We will inform you if that will be the case.