Fertility-oriented management of dysmenorrhea in women of reproductive age: from symptom control to secondary dysmenorrhea assessment and reproductive decision-making

Dysmenorrhea is common among women of reproductive age and may be primary, without identifiable pelvic pathology, or secondary to conditions such as endometriosis, adenomyosis, uterine fibroids, and pelvic inflammatory disease. Reproductive endocrine disorders, including polyendocrine metabolic ovarian syndrome [PMOS; formerly polycystic ovary syndrome (PCOS)], may coexist with menstrual pain and influence reproductive assessment and treatment decisions, particularly when irregular cycles or ovulatory dysfunction are present. However, treatment should address current symptom burden and its effects on daily functioning and quality of life while also considering reproductive timing and fertility-related risks when relevant. Some hormonal therapies used for symptom control are incompatible with attempts at natural conception, while continued symptomatic treatment without reassessment may delay recognition of secondary causes that can affect fertility. This narrative review integrates evidence on symptom control, the fertility implications of secondary causes of dysmenorrhea and coexisting reproductive endocrine disorders, clinical features that warrant earlier etiologic assessment, pain management during the preconception period, and the influence of diagnostic findings and etiologic treatment on reproductive decisions. We propose a clinically oriented framework in which the timing of symptom control, further evaluation, and treatment is adjusted according to symptom characteristics, treatment response, clinical concern for secondary causes, and reproductive goals. Such an approach may help balance effective pain relief with timely etiologic assessment and individualized fertility planning.