A 16-year-old girl comes to the office for evaluation of painful menstrual periods. The patient underwent menarche at age 13 and initially had irregular menses. Her menstrual cycles now occur every 30 days, with 4 days of moderate bleeding. Her menses have become increasingly painful; lower abdominal pain starts a few hours prior to menses and lasts 1 or 2 days with associated fatigue, dizziness, and diarrhea. She misses school at least 1 day per month due to the pain but is able to maintain her grades and has no pain or other symptoms after completion of menses. The patient has a history of depression, for which she sees a therapist, but has had no recent changes in mood. She recently became sexually active and uses condoms for contraception. Her last menstrual period was a week ago. Vital signs are normal. Pelvic examination shows normal external genitalia and a clear discharge emerging from the cervical os. On bimanual examination, the uterus is mobile, nontender, and normal in size and contour. Bilateral adnexa have no masses or tenderness. Which of the following is the most likely diagnosis in this patient?

Question

A 16-year-old girl comes to the office for evaluation of painful menstrual periods.  The patient underwent menarche at age 13 and initially had irregular menses.  Her menstrual cycles now occur every 30 days, with 4 days of moderate bleeding.  Her menses have become increasingly painful; lower abdominal pain starts a few hours prior to menses and lasts 1 or 2 days with associated fatigue, dizziness, and diarrhea.  She misses school at least 1 day per month due to the pain but is able to maintain her grades and has no pain or other symptoms after completion of menses.  The patient has a history of depression, for which she sees a therapist, but has had no recent changes in mood.  She recently became sexually active and uses condoms for contraception.  Her last menstrual period was a week ago.  Vital signs are normal.  Pelvic examination shows normal external genitalia and a clear discharge emerging from the cervical os.  On bimanual examination, the uterus is mobile, nontender, and normal in size and contour.  Bilateral adnexa have no masses or tenderness.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d262_f48e_bc81_8b4089aa7b0b_MD0003_00 At the onset of menarche, adolescents typically have irregular, nonpainful menses due to the lack of ovulation from an immature hypothalamic-pituitary-ovarian axis. As this axis matures, ovulation can cause excessive endometrial prostaglandin release during menses, which results in lower abdominal cramping and other associated symptoms (eg, fatigue, dizziness, diarrhea) known as primary dysmenorrhea. Primary dysmenorrhea is common in adolescents (up to 90%). Patients typically have crampy, bilateral, lower abdominal pain that begins 1 or 2 days prior to menses (as uterine contractions initiate endometrial sloughing) and resolves a few days after onset of menses (as the endometrial lining thins). Patients have a normal pelvic examination and no chronic pain symptoms. First-line treatment in nonsexually active patients is with nonsteroidal anti-inflammatory drugs because they decrease prostaglandin production. In sexually active patients, such as this one, combination oral contraceptives are an option because they suppress ovulation, thereby providing contraception as well as decreasing prostaglandin release. Most women have decreasing symptoms with increasing age. (Choice A) Adenomyosis typically causes dysmenorrhea in women age >40 rather than adolescents. Due to the endometrial glands and stroma within the uterine myometrium, patients typically have a tender, symmetrically enlarged ("globular") uterus, which is not seen in this patient. Adenomyosis (Choice B) Endometriosis may present in adolescents with dysmenorrhea. In contrast to this patient, those with endometriosis have pain that typically begins a few days prior and persists throughout the entire menstrual cycle. In addition, patients may have uterosacral ligament tenderness, cul-de-sac nodularity, or adnexal enlargement (ie, endometrioma) on examination. Endometriosis (Choice C) Adolescents are a high-risk group for sexually transmitted infections. However, pelvic inflammatory disease is unlikely because this patient has no fever, uterine and adnexal tenderness, or purulent cervical discharge. Her clear cervical discharge is likely physiologic. (Choice E) Somatic symptom disorder occurs due to a preoccupation with 1 or more somatic symptoms (ie, pelvic pain) that result in significant dysfunction or distress. Although the patient has some risk factors (eg, depression), this disorder is unlikely due to the temporal pattern of the pain, which causes no significant impairment (eg, no grade changes). Educational objective: Primary dysmenorrhea commonly occurs in adolescents after the establishment of ovulatory menstrual cycles. Excessive endometrial prostaglandin production results in lower abdominal cramping and other associated symptoms (eg, fatigue) during menses. Symptoms typically decrease with age. References: Diagnosis and initial management of dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/24695505) Primary dysmenorrhea in adolescents: prevalence, impact and recent knowledge. (http://www.ncbi.nlm.nih.gov/pubmed/26841639) Adolescent dysmenorrhea. (http://www.ncbi.nlm.nih.gov/pubmed/22846528)

A 16-Year-Old Girl Comes to the Office for Evaluation of Painful