A 16-year-old girl is brought to the office by her mother for evaluation of painful menstrual periods. Since menarche, the patient has had increasingly painful menses that now cause her to miss track practice a few days each month. Menstrual periods occur every 25-27 days with 5 days of moderate bleeding. For the first 4 days of her menses, the patient has cramping pain in the right lower quadrant that radiates to the right flank. The pain improves with ibuprofen and a heating pad. She has fatigue and nausea that start the day prior to menses and resolve when the pain stops. The patient has no chronic medical conditions and has had no surgeries. She is not sexually active. Her last menstrual period was 3 weeks ago. Blood pressure is 114/70 mm Hg and pulse is 68/min. BMI is 19 kg/m². Pelvic examination is deferred but physical examination is unremarkable. Which of the following findings is most concerning for a secondary cause of dysmenorrhea in this patient?

Question

Quizplus · Accepted Answer

Explanation: Dysmenorrhea, or painful menses, is common in reproductive-aged women and is divided into primary (physiologic) and secondary (pathologic) causes. Primary dysmenorrhea is the most common cause of painful menses and typically presents in adolescents after ovulatory, regular menstrual cycles are established (Choices A and D). Patients typically have midline pelvic pain that can radiate to the bilateral legs or back as well as associated systemic symptoms such as fatigue, nausea, vomiting, and diarrhea (Choice B). Primary dysmenorrhea can be diagnosed based on history alone and does not require physical examination. In contrast, patients with any of the following clinical features should be evaluated for secondary causes of dysmenorrhea: Symptom onset at age >25 Unilateral (nonmidline) pelvic pain (as seen in this patient's right lower quadrant pain that radiates to the right flank) No systemic symptoms (eg, fatigue, nausea) during menses Abnormal uterine bleeding (eg, intermenstrual bleeding, postcoital spotting) These features are suggestive of a variety of pathologic causes of dysmenorrhea, including pelvic inflammatory disease, endometriosis, adnexal masses, and a uterine anomaly (eg, rudimentary uterine horn). Physical examination is performed to evaluate for these possible causes; patients with abnormal examination findings (eg, adnexal mass, cervical motion tenderness) may require additional imaging (eg, pelvic ultrasound) and possible surgery (eg, laparoscopy). (Choice E) Dysmenorrhea typically improves with nonsteroidal antiinflammatory drugs (NSAIDs) (eg, ibuprofen) because the pain results from an inflammatory response and increased prostaglandin release. Pain that does not improve with NSAIDs can be suggestive of a secondary cause of dysmenorrhea, though this is nonspecific, as many secondary causes of dysmenorrhea will improve with NSAIDs. Educational objective: Dysmenorrhea, or painful menses, is common in reproductive-aged women and is divided into primary (physiologic) and secondary (pathologic) causes. Clinical features suggestive of a secondary cause (eg, endometriosis) include age >25 at onset, unilateral (nonmidline) pelvic pain, lack of systemic symptoms, and abnormal uterine bleeding. References: Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. (http://www.ncbi.nlm.nih.gov/pubmed/26841639) Dysmenorrhea and related disorders. (http://www.ncbi.nlm.nih.gov/pubmed/28944048)

A 16-Year-Old Girl Is Brought to the Office by Her