Menstrual dyschezia

Specialty: Gynecology and breast.

• Pain when defecating during your period
• menstrual rectal tenesmus
• catamenial dyschezia
• rectal pain associated with menstruation

Why it occurs

• Deep infiltrating endometriosis (located in the rectovaginal septum, uterosacral ligaments or anterior wall of the sigmoid colon/rectum)
• Severe pelvic adhesions secondary to previous pelvic surgery or pelvic inflammatory disease (PID)
• Irritable bowel syndrome with catamenial exacerbation
• Severe functional constipation that worsens due to the action of progesterone in the late luteal phase

Initial workup

Combined rectal and vaginal examination. High-resolution transvaginal ultrasound with prior intestinal preparation performed by an expert gynecologist to visualize deep endometriosis nodules in the rectovaginal septum and rectal wall. Magnetic resonance imaging (MRI) of the pelvis with protocol for endometriosis. Colonoscopy if associated with catamenial rectal bleeding to rule out infiltration of the rectal mucosa.

Standard management

• Ibuprofen 600 mg orally every 8 hours or Naproxen 500 mg every 12 hours started two days before the start of menstruation
• Combined oral contraceptives in a continuous regimen (without a rest period) to suppress menstruation
• Dienogest 2 mg orally daily continuously — specific gestagen for endometriosis
• GnRH analogues (such as Leuprorelin 3.75 mg intramuscularly monthly) associated with support therapy ("add-back therapy") if there is refractoriness to first-line treatments (note: definitive management in severe cases with rectal luminal involvement usually requires segmental or wedge surgical resection by a multidisciplinary team).