A 15-year-old girl is brought to the office for evaluation of her menstrual periods. The patient underwent menarche at age 12 and initially had irregular, heavy, nonpainful menses. Menses now occur monthly and consist of 4 days of light bleeding. For the past 3 months, the girl has developed malaise and dizziness 2 days prior to her menstrual period and has had associated, continuous lower abdominal pain that radiates to her thighs. Symptoms resolve on the second day of menses. She has no chronic medical conditions and takes no daily medications. The patient is not sexually active. Her last menstrual period was a week ago. Vital signs are normal. The abdomen is soft, nontender, and nondistended and has no palpable masses. Pelvic examination is deferred. Which of the following is the best next step in management of this patient?

Question

A 15-year-old girl is brought to the office for evaluation of her menstrual periods.  The patient underwent menarche at age 12 and initially had irregular, heavy, nonpainful menses.  Menses now occur monthly and consist of 4 days of light bleeding.  For the past 3 months, the girl has developed malaise and dizziness 2 days prior to her menstrual period and has had associated, continuous lower abdominal pain that radiates to her thighs.  Symptoms resolve on the second day of menses.  She has no chronic medical conditions and takes no daily medications.  The patient is not sexually active.  Her last menstrual period was a week ago.  Vital signs are normal.  The abdomen is soft, nontender, and nondistended and has no palpable masses.  Pelvic examination is deferred.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d264_5420_bc81_012586b45515_MD0003_00 This adolescent's regular, painful menses after the establishment of ovulatory menstrual cycles is consistent with primary dysmenorrhea. During menses, the endometrium produces and releases prostaglandins, stimulating uterine contractions and promoting endometrial sloughing. Patients with primary dysmenorrhea have increased endometrial prostaglandin production, which causes uterine hypercontractility and hypertonicity and resultant ischemia. Therefore, lower abdominal pain (which can radiate to the back and thighs) is typical, usually beginning 1 or 2 days prior to menses (as uterine contractions initiate endometrial sloughing) and resolving a few days after onset of menses (as the endometrial lining thins). Patients also often have associated malaise, dizziness, and gastrointestinal symptoms. Pelvic examination is normal and can be deferred in patients who are not sexually active, as in this case. First-line treatment in nonsexually active patients, such as this one, with primary dysmenorrhea is nonsteroidal anti-inflammatory drugs because they inhibit prostaglandin synthesis. In sexually active patients, combination oral contraceptives are an option because they suppress ovulation, providing contraception as well as decreasing prostaglandin release. (Choice A) A copper-containing intrauterine device is not used for the treatment of primary dysmenorrhea because a common side effect of this is painful, heavy menses. (Choice B) Gonadotropin-releasing hormone agonists (eg, leuprolide) can be used in the treatment of endometriosis by suppressing ovulation. In contrast to this patient, those with endometriosis have pain throughout the menstrual cycle and often have chronic pelvic pain. (Choice D) Progestin-only pills are not as effective as nonsteroidal anti-inflammatory drugs or combination oral contraceptives because they do not decrease endometrial prostaglandin synthesis. (Choice E) A selective serotonin reuptake inhibitor is first-line treatment in patients with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Although this patient has associated malaise, she does not have enough (5) systemic symptoms to meet PMS/PMDD criteria. (Choice F) Tranexamic acid is used in women who have heavy, regular bleeding and for whom combination oral contraceptives are contraindicated (eg, thromboembolism). This patient has light bleeding. Educational objective: Primary dysmenorrhea occurs due to increased endometrial prostaglandin production during menses that causes uterine hypercontractility (eg, crampy lower abdominal pain) and associated systemic symptoms (eg, malaise). First-line treatment is with nonsteroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis. References: Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. (http://www.ncbi.nlm.nih.gov/pubmed/26224322) Diagnosis and initial management of dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/24695505)

A 15-Year-Old Girl Is Brought to the Office for Evaluation