Delphi Round 3 – Research Survey

Welcome to the third and last round of our Delphi study on primary dysmenorrhea. We thank you for your participation. In the first and second 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
Assessing the severity of dysmenorrhea using a VMSS of grade 2 or higher is a part of the diagnostic criteria of primary dysmenorrhea

Consensus has not been reached yet on the following questions and we would like to invite you to complete the following questions.

Which email address did you use to sign up for this Delphi?(Required)

In the previous round we asked whether further investigation is necessary and if so, which method should be used. Experts stated that further investigation should be performed if empirical treatment is unsuccessful, if there is a suspicion of underlying pathology or as an alternative if pelvic (gynecological) examination is not possible in adolescents. Other experts stated that further ultrasound investigation, is necessary, because it can exclude most conditions. Every expert who indicated the need for further investigation, opted for performing an ultrasound (RoA 100%). Given the consensus that "primary" is defined as the absence of pathology and the consensus that pelvic examination is not required to diagnose primary dysmenorrhea, we propose that ultrasound examination is warranted for further investigation to exclude or consider underlying pathology and if ultrasound examination is inconclusive, there is an indication for additional further investigation using MRI.

Question 1: Would you agree with the following statement: Further investigation, using an ultrasound (transabdominal ultrasound in not sexually active adolescents and transvaginal ultrasound in sexually active adolescents), is necessary to diagnose primary dysmenorrhea. If the ultrasound is inconclusive, further investigation using a magnetic resonance imaging (MRI) is necessary to diagnose primary dysmenorrhea.(Required)

Yes

No

Please explain your answer:(Required)

We would like to know whether you, as an expert in this Delphi, perform gynaecological ultrasounds yourself or not.

Question 2: Pick the most suitable option about performing ultrasounds:

I perform both the transvaginal ultrasound (in sexually active adolescents) and the transabdominal ultrasound (in non-sexually active adolescents)

I perform the transvaginal ultrasound (in sexually active adolescents) and the radiologist performs the transabdominal ultrasound (in non-sexually active adolescents)

I don’t perform ultrasounds. I refer to an ultrasound technician or radiologist to perform the ultrasound.

Please explain your answer:(Required)

EXCLUSION OF CONDITIONS

There is consensus that we should consider conditions before diagnosing primary dysmenorrhea. Consensus was gained on the following conditions: Sexually transmitted disease / Pelvic Inflammatory Disease, congenital uterine anomaly, endometriosis, adenomyosis and fibroids. Consensus was also gained how to exclude Sexually Transmitted Diseases and Pelvic Inflammatory Disease (patient’s history and if it is necessary a vaginal swab); congenital uterine anomaly (In sexually active adolescents transvaginal ultrasound and in non-sexually active adolescents abdominal ultrasound. In both groups, experts believe that if ultrasound is inconclusive, there is an indication for MRI) and fibroids (in sexually active adolescents transvaginal ultrasound and in non-sexually active adolescents abdominal ultrasound).
The following questions will focus on the potential methods of excluding endometriosis and adenomyosis on which no consensus was reached in the previous rounds

Endometriosis

There is consensus that we should consider endometriosis before diagnosing primary dysmenorrhea. However, it is also important to gain consensus how to exclude or consider endometriosis before diagnosing primary dysmenorrhea.

Question 3: Would you agree with the following statement: The ESHRE guideline applies to both sexually active and sexually inactive adolescents. As the ESHRE guideline also states, endometriosis can never be completely ruled out. To diagnose primary dysmenorrhea it is sufficient to consider endometriosis.(Required)

Yes

No

Please explain your answer:

Adenomyosis

There is consensus that we should consider adenomyosis before diagnosing primary dysmenorrhea. Using a transvaginal ultrasound is sufficient in sexually active adolescents to exclude adenomyosis (rate of agreement is 78%). However, there is no consensus on how to exclude adenomyosis in non-sexually active adolescents.

Question 4: Would you agree with the following statement: To exclude adenomyosis in non-sexually active adolescents, the first preference is a transabdominal ultrasound. If this is inconclusive, then an MRI is indicated(Required)

Yes

No

Please explain your answer:

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

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