A 15-year-old girl is brought to the office for evaluation of lower abdominal pain associated with her menses that has occurred over the past few months. She describes the pain as "dull" and "crampy" and radiating to her back and lower thighs. The pain is associated with nausea and bloating, and the patient vomited twice during her last menstrual cycle. She has tried using a heating pad with minimal relief of symptoms. The patient "dreads" her periods and has missed several days of school due to the pain and vomiting. She has had no dysuria, diarrhea, abnormal vaginal discharge, or abdominal pain between periods. Her menses started at age 14, have occurred every month, and last 5 days. When interviewed alone, she reports that she had a boyfriend last year but is not currently in a relationship and has never had sexual intercourse. The patient has no chronic medical conditions and takes no daily medications. Her immunizations, including the human papillomavirus vaccine, are up to date. She does not use tobacco, alcohol, or illicit drugs. The patient's aunt was diagnosed with endometrial cancer at age 40 and has been in remission for several years. Temperature is 37 C (98.6 F), blood pressure is 110/60 mm Hg, and pulse is 68/min. BMI is 25 kg/m². Cardiopulmonary examination is normal. The abdomen is soft and nondistended. Pelvic examination reveals normal external female genitalia and a small, nontender uterus without masses. On speculum examination, a small amount of clear discharge is seen throughout the vaginal vault. The cervix is nulliparous and has no lesions or areas of friability. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_beea_5067_8f63_5b9c42ab8ade_MD0005_00 This patient has primary dysmenorrhea - painful lower abdominal cramping associated with menses and no identifiable pathologic cause. The production of excess prostaglandins stimulates uterine contraction, resulting in lower abdominal pain that can radiate to the back and thighs. Increased gastrointestinal stimulation may also occur, leading to nausea, vomiting, bloating, and diarrhea. Symptoms are typically worse during the first few days of menstruation and can interfere with daily activities. In patients with severe symptoms that limit daily functioning, a pelvic examination is performed to exclude secondary causes (eg, infection, endometriosis, Müllerian anomalies). The first-line management in non-sexually active patients with primary dysmenorrhea is a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen. NSAIDs reduce prostaglandin synthesis and are most effective at or before the onset of symptoms, prior to significant prostaglandin production. If NSAIDs are ineffective or cannot be tolerated, combined oral contraceptives can serve as second-line therapy (Choice B). Oral contraceptives may be considered as first-line management in sexually active patients. (Choice A) CA-125 is a biomarker used to monitor tumor burden in patients with ovarian cancer. Patients with ovarian cancer have persistent abdominal bloating and an adnexal mass rather than cyclical bloating at the onset of menses. (Choice D) A pelvic ultrasound is indicated if a secondary cause of dysmenorrhea is suspected based on pelvic examination (eg, endometrioma, leiomyoma) or if both NSAIDs and hormonal contraception have failed. This patient has a normal pelvic examination. (Choice E) Wet mount microscopy is performed if vaginal discharge is malodorous or there is associated vulvovaginal pruritus or cervical friability (eg, cervicitis, vaginitis). This patient's scant, clear discharge is consistent with physiologic leukorrhea; therefore, wet mount microscopy is not indicated. Educational objective: Primary dysmenorrhea, lower abdominal cramping associated with menstrual periods, is common in adolescents and is due to excessive prostaglandin production. The first-line management of primary dysmenorrhea in non-sexually active patients is nonsteroidal anti-inflammatory drugs (eg, naproxen). References: Diagnosis and initial management of dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/24695505) The treatment of dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/28292449) Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. (http://www.ncbi.nlm.nih.gov/pubmed/26224322)

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