Family Medicine 32: 33-year-old female with painful periods

Family Medicine 32: 33-year-old with painful cycles

,Author: Jessica Servey, Lt. Col, USAF, MC; Case Editor: Rebecca E. Cantone, MD; Associate Editor: Katie Margo, MD

INTRODUCTION

HISTORY

Dr. Barnett instructs you to evaluate the next patient.

You are working with Dr. Barnett. He instructs you, “I would like you to go in and evaluate the next patient. I have seen her before but not for this issue. It looks as if she has dysmenorrhea. Do a physical exam yourself, but please come and get me so we can perform the pelvic exam together.”

You walk into the exam room and see Ann Tomlin, a 33-year-old. After introducing yourself, you ask how the patient would like to be addressed, to which she replies “Ann or Ms. Tomlin is fine.” You then ask:

“Tell me, what brings you in today?”

“It sounds as if this pain is really affecting your life,” you empathize. “Can you tell me if you have any other symptoms during your periods?”

Question

What are the risk factors for primary dysmenorrhea? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. High levels of stress
• B. Increasing parity
• C. Menarche late in adolescence
• D. Obesity
• E. Smoking
• F. Younger age

SUBMIT

Answer Comment

The correct answers are A, E, F.

TEACHING POINT

Primary Dysmenorrhea Definition, Prevalence, and Risk Factors

Primary dysmenorrhea is defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea is defined as painful menses secondary to some additional pathology.

Primary dysmenorrhea is associated with increasing amounts of prostaglandins. The actual prevalence is unknown but ranges from 45% to 97% including teens and older adults. Ten to fifteen percent of people with a uterus feel their symptoms are severe and have to miss school or work. Dysmenorrhea accounts for 1-3 percent of absenteeism or 600 million hours a year. Dysmenorrhea usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours. It can also include symptoms of headache, dizziness, fatigue, diarrhea, and sweating so a broad differential may be helpful.

Dysmenorrhea is thought to be secondary to increased prostaglandin synthesis, leading to uterine contractions and decreased blood flow.

Risk Factors for Primary Dysmenorrhea

• Mood disorders such as depression or anxiety have been associated with dysmenorrhea, especially in adolescents. This may be a complex association as other factors may be comorbid with the mood disorder diagnosis, and the cause and effect is not well-proven. However, there is an association with stress independently as a risk factor for dysmenorrhea.
• There is also an association between tobacco use and dysmenorrhea.
• People who give birth to more children are noted to have a decreased incidence of primary dysmenorrhea.
• Additionally, those who report an overall lower state of health or other social stressors have a tendency for dysmenorrhea. These stressors include social, emotional, psychological, financial, or family stressors.
• Primary dysmenorrhea most commonly occurs in menstruating patients in their teens and twenties. It is notably associated with ovulatory cycles. Classically, an adolescent will start experiencing dysmenorrhea one or two years after menarche. This is the time it takes naturally for an adolescent to develop regular ovulatory cycles. The earlier the onset of menarche the more likely dysmenorrhea may occur.
• Dysmenorrhea is not consistently related to high BMI but has been associated with attempts at weight loss for any BMI.

This means that a detailed history regarding the nature of menses during adolescence and after children is important. It will also be important to ask about birth control and what types have been used as some can alter the symptoms.

The first-line treatment for primary dysmenorrhea is nonsteroidal anti-inflammatory agents, such as ibuprofen. Oral contraceptive pills may also be helpful as a second-line choice. NSAIDs inhibit the production and release of prostaglandins but have long-term side effects, and oral contraceptives inhibit ovulation, reduce endometrial proliferation, and mimic the lower prostaglandin phase of the cycle. Complementary alternatives can include herbs (chamomile, ginger, fennel, cinnamon, aloe vera), yoga, relaxation, psychotherapy, massage, hypnosis, vitamins E, B, and C, calcium, magnesium, and acupuncture/acupressure.

TEACHING POINT

Gender

People who are born with a uterus may identify as female or male. We can therefore identify this population as “female assigned at birth,” meaning they had a sex assigned at birth as female based on the genitalia seen, or “person with a uterus” to acknowledge the biologic presence of a uterus in someone who may identify as anything other than female in their life. Please note that transgender men should not be excluded in this consideration, for which calling periods “cycles” and utilizing terminology of a person with a uterus or exam of the pelvis is more appropriate than “gynecologic.” See below for additional gender Teaching Points.

References

Balık G, Ustüner I, Kağıtcı M, Sahin FK. Is there a relationship between mood disorders and dysmenorrhea?. J Pediatr Adolesc Gynecol. 2014;27(6):371-4.

Morrow C, Naumburg EH. Dysmenorrhea. Prim Care. 2009;36(1):19-vii.

Sharghi M, Mansurkhani SM, Larky DA, et al. An update and systematic review on the treatment of primary dysmenorrhea. JBRA Assist Reprod. 2019;23(1):51-7. Published 2019 Jan 31.

HISTORY 1

HISTORY

You continue to interview Ann Tomlin.

You continue asking about her reproductive history.

“Can you tell me about your menstrual cycles?”

“I need to ask some personal questions that we ask all patients to ensure we can best evaluate your uncomfortable periods. Do you have sex with men, women, or both?”

“Do you feel safe at home?”

“Has anyone hit, slapped, pushed, or hurt you in any way—physically, emotionally, or sexually—now or in the past?”

“How many partners have you had over your lifetime?”

“How do you identify your gender and sexual orientation?”

“Have you ever been pregnant?”

“How did the pregnancies go?”

“How have your periods changed over the years?”

“Have you ever tried anything to make the cramping better?”

“Do you have pain at any other time other than with your periods, or have pain with intercourse?”

Do you and your partner use birth control?”

“Do you take any other medicines or have any other medical problems?”

At this time, you ask Ms. Tomlin to change into a gown and have a seat on the exam table so you can perform a physical exam. You excuse yourself from the room while she changes.

TEACHING POINT

Gender and Sexual Identity Questions

It is important to know how your patient self-identifies and to not make assumptions. To avoid mis-gendering patients, we recommend asking early in a visit either how they would like to be addressed and/or what pronouns they use. Common answers are he/him, she/her, and they/them, but countless other pronouns exist within the LGBTQ community (lesbian, gay, bisexual, transgender, queer/questioning; this also includes a broad range of sexual, romantic, and gender minorities, and is more inclusively referred to as LGBTQIA with intersex and asexual/ally also represented).

Cisgender refers to a person whose sex assigned at birth, based on genitalia, matches their current gender identity.

Transgender refers to a person who identifies in a different way than their sex assigned at birth. The terms “assigned female” and “person with a uterus” acknowledge that this population may include people who have a uterus and cycles who do not identify as female.

Sex refers to the physical organs present or expected to develop at birth.

Gender Identity refers to the patient’s identity as male, female, non-binary or others, and is not the same as sex.

Gender Expression refers to the patient’s presentation as male, female or non-binary, and can be different from sex or gender identity.

Non-binary, gender-nonconforming, and gender-expansive are all terms some patients use to identify their gender as on a spectrum rather than binary.

Sexual orientation refers to the gender that people have sex with. This can be different from romantic orientation as people can be romantically and sexually attracted to different genders or vary based on the person or their own identity. It is also important to consider the anatomy of partners, as a “male” partner may have a uterus and not a penis, and a “female” partner may have a penis. This is important for health risks, screening, and prevention.

For example, if a patient with a pelvic problem stated that they actually used he/him pronouns and identified as male, you would want to use he/him pronouns, despite talking about problems related to a uterus. You should not assume based on physical appearance what organs a patient may or may not have, in the same way, that you cannot know without asking if someone has had a hysterectomy.

TEACHING POINT

Questioning About Reproductive History

It is good to start with open-ended questions. Some patients may have had pregnancy outcomes that they are not comfortable talking about, such as miscarriages or abortions (reported as SAB, or spontaneous abortion, or TAB, or therapeutic abortion). This requires sensitivity, as it may bring up trauma for that patient, and it may also require specific questions, such as “Tell me the outcomes of each pregnancy,” or “Any other pregnancies besides those children you mentioned?”

PHYSICAL EXAM

PHYSICAL EXAM

You check the patient’s thyroid gland.

When you return, Ms. Tomlin is sitting on the exam table.

Physical Exam

Vital signs:

• Pulse is 82 beats/minute
• Respiratory rate is 16 breaths/minute
• Blood pressure is 115/74 mmHg
• Weight is 65.8 kg (145 lbs)
• Height is 165 cm (65 in)

Head, eyes, ears, nose, and throat (HEENT): She has a normal-sized thyroid gland without any nodules or tenderness. Note: Though traditionally done from behind, examining the thyroid from an anterior approach is less traumatic for patients with a history of trauma.

Pulmonary: Her lungs are clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm without any murmur.

Abdominal: Normal bowel sounds. Non-tender to palpation over the entire abdomen but slightly tender in the suprapubic area. She has no rebound tenderness.

When you have finished the exam, you explain to her, “Please leave your gown on for just a bit more. I’m going to go get Dr. Barnett and we will finish the exam together.”

ABNORMAL FINDINGS

TEACHING

You present the case to Dr. Barnett concluding, “I forgot to ask a few important questions.”

He responds,

“What other questions would you like to ask?”

Dr. Barnett responds, “Those are all excellent questions, let’s go back and get the answers. But before we do, let’s think about what we may find on the pelvic exam.”

Question

What are always abnormal findings on a pelvic exam? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. 12-week-size uterus when not pregnant
• B. Mildly tender ovaries to palpation
• C. Nabothian cysts on the cervix
• D. Non-mobile uterus
• E. Scant white vaginal discharge

SUBMIT

Answer Comment

The correct answers are A, D.

For more detailed teaching about pelvic exam findings, see the Teaching Point below.

TEACHING POINT

Normal Pelvic Exam Findings

Unless a person is pregnant, a normal uterus is not larger than eight weeks in size, approximately the size of a clenched fist. It is also mostly flat, not round as you see in some pictures. A normal uterus may be mildly tender on exam just prior to or during menses. A normal uterus can be tilted anteriorly (anteverted or anteflexed), midline, or tilted posteriorly (retroverted or retroflexed). An anteflexed or retroflexed uterus may be difficult to assess for size because of its position. The uterus should be smooth in contour around the entire surface area. Serosal fibroids or large mucosal fibroids may cause a “knobby” feel to the uterus.

The uterus should be mobile. The uterus is held in the pelvis by a series of ligaments on each side. With endometriosis, the uterus may become non-mobile because of fibrous tissue sticking to the peritoneum along these ligaments.

Ovaries are normally 2 cm x 3 cm in size—roughly the size of an oyster. In an obese person, the ovaries may be nonpalpable. During ovulation, the ovaries may be slightly larger secondary to physiologic cysts. Caution should be taken while palpating the ovaries since the patient may have a mild sickening feeling. Mild tenderness on palpation of the ovaries is normal.

Nabothian cysts are physiologically normal on the cervix. These are formed during the process of metaplasia where normal columnar glands are covered by squamous epithelium. They are merely inclusion cysts that may come and go and are of no clinical significance. While looking at the cervix white discharge can also normally be seen coming from the os or in the vagina. If there are endometrial growths on the cervix or vagina, these may be bluish.

Vaginal discharge can be normal or abnormal. Normal vaginal discharge is termed physiologic leukorrhea. This patient has no symptoms like itching, burning, or foul-smelling discharge. It is normal to have physiologic clear to white vaginal discharge. The volume of discharge may get so heavy that it requires a pad for comfort; the volume may change during the course of a menstrual cycle.

References

Casey PM, Long ME, Marnach ML. Abnormal cervical appearance: what to do, when to worry?. Mayo Clin Proc. 2011;86(2):147-51.

Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Boston: Butterworths; 1990.

HISTORY 2

HISTORY

Ms. Tomlin asks if all her symptoms are normal.

You and Dr. Barnett return to see Ann Tomlin. He greets her warmly and explains, “We have a few more questions for you and then we will do your pelvic exam.”

“Can you tell us how heavy your periods are?”

“Have you ever had a sexually transmitted infection?”

“Have you ever had an abnormal Pap test?”

“Do you feel pain when you have intercourse?”

“Do you ever get bloating or breast tenderness right before or at the beginning of your period?”

“Do you have pain with urination or when having a bowel movement?”

After those questions, Ms. Tomlin looks at Dr. Barnett, “Is it normal for me to have all of these things happening?” Dr. Barnett leans forward and assures her that all of this could be normal.

He then asks you to step out to get a same-gender chaperone.

DEEP DIVETracking Pap Screening

PELVIC EXAMINATION

PHYSICAL EXAM

Once you and the chaperone return, you ask for permission and then help Ms. Tomlin lay back in the lithotomy position. After checking with her if she is okay with you helping do the pelvic exam, you both help her get into the lithotomy position. Dr. Barnett gives you gloves and you sit down on the stool. You ask Ms. Tomlin to relax her legs without pushing them aside, you vocalize each step of your exam before touch, and you gently insert the speculum at an angle to allow for maximum comfort, readjusting as you continue to insert the speculum. As you describe what you are doing, you also ask her to tell you if anything is painful during the exam.

Pelvic Exam

Speculum exam: Minimal white non-foul smelling discharge in the vagina. There are no abnormal lesions on the cervix. No other lesions in the vagina.

Bimanual exam: The uterus feels enlarged, about 10 to 12 weeks in size, but non-tender and easily mobile. The ovaries are normal size and not-tender on exam.

When you are done you say, “Ms. Tomlin, why don’t you go ahead and get dressed, and then Dr. Barnett and I will come back to explain everything.”

SUMMARY STATEMENT

CLINICAL REASONING

You present your findings to Dr. Barnett.

You and Dr. Barnett return to his office to talk privately. He asks you,

“What do you think may be going on?”

When Dr. Barnett asks why you think she may have abnormal uterine bleeding, you elaborate: “I think that having to use so many pads and tampons per day would be abnormal, as well as passing clots. Her periods are regular every 29 days and menstrual cycles normally last 21 to 35 days. She has no bleeding between periods, it just seems heavy but not irregular.”

TEACHING POINT

Menorrhagia

Menorrhagia is very difficult to define precisely and is only one of the terms associated with abnormal uterine bleeding. The absolute criterion for menorrhagia is blood loss of more than 80 milliliters. Some providers try to use pad or tampon count. However, there is variability in the absorption of different pads and how much blood one has on the pad prior to changing. Asking about clots may help, but again not easy to quantify. In fact, many women either overestimate or underestimate the blood loss. Another important criterion is the length of menses. Anything longer than seven days is most likely menorrhagia.

• Metrorrhagia is irregular frequent bleeding but it doesn’t have to be heavy.
• Menometrorrhagia is irregular, frequent, and heavy bleeding.

TEACHING POINT

Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria

Premenstrual syndrome (PMS) is characterized by physical and behavioral symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms must not be present at other times through the cycle, and must also cause significant impairment. Premenstrual Dysphoric Disorder (PMDD), the more severe form of the disorder, is classified in the DSM-5 as a mental health diagnosis.

The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess.

The patient must also have one of the following: food cravings, changes in sleep, a sense of being overwhelmed or out of control, decreased energy, anhedonia, and some physical symptoms.

The patient must have a minimum of five symptoms out of the above groups. How these are expressed may differ based on culture and social norms. It may be helpful to get the perspective of other close contacts of the patient.

Question

Based on what you know about the patient so far, write a one-to-three sentence summary statement to communicate your understanding of the patient to other providers.

Guidelines for summary statements.

Your response is recorded in your student case report.

Letter Count: 119/1000

SUBMIT

Answer Comment

Ann Tomlin is a 33-year old G2P2 cisgender female with several months of dysmenorrhea that causes her to miss work. She has associated menorrhagia on days one and two of menses, fatigue, and abdominal bloating. She also reports intermittent diarrhea and dyspareunia. Physical examination reveals an enlarged, mobile, non-tender uterus.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

1. Epidemiology and risk factors: 33-year-old female, G2P2
2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

• Associated menorrhagia on days one and two of menses
• Associated fatigue and abdominal bloating
• Intermittent diarrhea
• Dyspareunia
• Enlarged, mobile, non-tender uterus
• Symptoms severe enough to cause her to miss work

References

Reid RL. Premenstrual Dysphoric Disorder (Formerly Premenstrual Syndrome). In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc.; January 23, 2017.

DIFFERENTIAL DIAGNOSIS 1

CLINICAL REASONING

Dr. Barnett then asks you to list the top items on your differential diagnosis for Ms. Tomlin’s dysmenorrhea based on the key findings from her history and physical exam.

Question

From the following, select the top four diagnoses on your differential.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Adenomyosis
• B. Cervical stenosis
• C. Chronic pelvic inflammatory disease
• D. Endometrial cancer/Endometrial hyperplasia
• E. Endometriosis
• F. Fibroids
• G. Inflammatory bowel disease
• H. Irritable bowel syndrome
• I. Leiomyosarcoma
• J. Mental health concerns
• K. Ovarian cysts
• L. Uterine polyps

SUBMIT

Answer Comment

The correct answers are A, C, E. F.

Most Likely / Important Diagnoses

A panel of experts selected the following as the most likely diagnoses at this point: adenomyosis (A), chronic pelvic inflammatory disease (C), endometriosis (E), fibroids (F). More about these conditions below.

TEACHING POINT

Differential of Secondary Dysmenorrhea / Menorrhagia

More Common Diagnoses:

Adenomyosis	Epidemiology: Occurs more frequently in parous than nonparous people. Adenomyosis actually can be found in any person with a uterus from adolescence to menopause. Pathophysiology: This is not completely understood. One theory is endometrial invagination but has not been completely proven. It is hypothesized that estrogen and progesterone play a role only because hormones can be treatment options. Presentation: 60% of women complain of menorrhagia. The uterus is typically enlarged and diffusely boggy, but symmetric and should still be mobile. There may be some urinary or gastrointestinal symptoms secondary to size and mass effect on the bladder and rectum. Diagnosis: Ultrasound may demonstrate a heterogeneously boggy uterus. MRI is more specific for diagnosis. Management: There is not currently any surgical method to remove the discrete areas affected. Hormonal contraception may help with symptoms in those who desire future pregnancy, while uterine artery embolization or hysterectomy may be performed in those no longer desiring biological children.
Chronic pelvic inflammatory disease (PID)	Epidemiology: The exact incidence and prevalence is unknown. Pathophysiology: PID can have a subclinical smoldering course that is considered chronic. These patients can have significant morbidities to include infertility and pain in the lower abdomen. Many of these cases will have plasma cells on endometrial biopsy. Presentation: The cardinal symptom is lower abdominal pain, usually unrelated to menses. However, pain that occurs just prior to or during menses is highly suggestive of dysmenorrhea. Menorrhagia is seen in one-third of patients with chronic pelvic inflammatory disease, especially subclinical disease that isn’t treated early. Management: As with acute PID, workup should include testing for sexually transmitted infections and treatment covering chlamydia and gonorrhea if suspected or diagnosed.
Endometriosis	Epidemiology: Endometriosis is a disorder that affects people of reproductive age with a uterus. The most common age affected is 25 to 35 years old. The exact prevalence in the general population is unknown. Risk factors include nulliparity, early menarche or late menopause, short menstrual cycles, and long menses. There may be protective factors that decrease the likelihood of endometriosis. These include multiparity, lactating, and late menarche. Pathophysiology: Endometrial glands in areas other than the uterus. Presentation: Symptoms include dyspareunia, bowel or bladder symptoms that cycle with menses, fatigue, abnormal vaginal bleeding, and some effects on fertility. Pain, either chronic pelvic pain or dysmenorrhea, occurs in 75% of patients with endometriosis and is the most common symptom. Dyspareunia is a differentiating clinical factor: it is common in those with endometriosis; it is rare with leiomyoma. On physical exam, these patients have pain in the pain cul-de-sac, immobile and retroflexed uterus, nodules on the uterosacral ligaments, or just pain with uterine motion. Management: Symptoms may be controlled with methods similar to those for menorrhagia. Hormonal contraceptives may alleviate symptoms. Hysterectomy and uterine artery embolization are less likely to be effective as the tissue is outside of the uterus.
Uterine leiomyomas (commonly called fibroids)	Epidemiology: Fibroids are the most common benign tumors of the uterus. Decreased risk of developing fibroids has been noted with oral contraceptive use, increasing parity, and smoking. Increased risk is known with early menarche, family history of fibroids, and increased alcohol use. Although more research needs to be done exploring the causes of fibroids that include a more racially diverse pool, there seems to be a disproportionately high rate of fibroid development in African American women as compared to other racial demographic groups. Disparities also exist in the type of care that women receive for their fibroids; for example, studies have shown that Caucasian women are more likely to be offered a laparoscopic procedure as compared to African American and Hispanic women with the same household income, indicating systemic disparities in care. Pathophysiology: These are made of normal myometrial cells. They can occur within the cavity and under the endometrium (submucosal), within the myometrium (intramural), on the serosal surface (serosal), or in the cervix. Presentation: Common symptoms of fibroids include pain, pressure, and changes in menstruation. Other related signs may be miscarriages, infertility, or an enlarged uterus, and some may have no symptoms at all. Work loss and quality of life can be issues. The physical exam typically has an enlarged uterus that is freely mobile. The uterus may feel “knobby” from an irregular contour, and occasionally be minimally tender on exam. Management: NSAIDS, combined oral contraceptive pills, levonorgestrel-releasing IUDs, depo-medroxyprogesterone, and a variety of surgical options (e.g., hysterectomy, myomectomy) are among the options.

Less Common Diagnoses:

Cervical stenosis	Cervical stenosis can be congenital or acquired. With congenital stenosis, an adolescent will have significant dysmenorrhea, which is not as responsive to nonsteroidal anti-inflammatory medications as would be expected. The menstrual flow will also be minimal. Acquired stenosis may be related to cryotherapy or LEEP procedures (performed for concerns of cervical cancer on Pap tests and colposcopy biopsies). This causes dysmenorrhea as the uterus is distended with blood. On exam, the uterus will feel diffusely enlarged.
Endometrial adenocarcinoma or endometrial hyperplasia	Endometrial adenocarcinoma (cancer) may occur under age 40 (2%–14% of cases) but is less likely in this age group. It does present with irregular bleeding, more often as postmenopausal bleeding. It may or may not cause dysmenorrhea. Endometrial hyperplasia is a non-malignant process that can mimic endometrial adenocarcinoma. It generally occurs in the perimenopausal or menopausal period. It is due to unopposed estrogen.
Inflammatory bowel disease	Inflammatory bowel disease can often be misdiagnosed as a gynecologic problem since constipation and diarrhea are associated with premenstrual syndrome as well. Additionally, when a person has bloody stools during her menses, the clinical diagnosis can be more confusing. However, when there is pain with defecation and bloody stools occur at times other than during menses this diagnosis becomes clearer. Abnormal vaginal bleeding is not a typical symptom of inflammatory bowel disease.
Irritable bowel syndrome	Irritable bowel syndrome may cause crampy pain prior to and during menses, but will also occur at other times during the month. This pain is often associated with diarrhea and/or constipation.
Leiomyosarcoma	Leiomyosarcoma is an abnormal variant of a smooth muscle tumor that can occur anywhere in the body but is commonly in the abdomen. It is a rare type of cancer and therefore less likely.
Ovarian cysts	Ovarian cysts commonly cause recurrent and chronic pelvic pain. This type of pain is more likely to occur mid-cycle, although the patient may have pain associated with menses. This location of this pain is typically in one of the lower quadrants and not as much midline. Ovarian cysts may come and go related to ovulation.
Mood disorders or adjustment disorders	Mood disorders or adjustment disorders can be exacerbated by, but do not typically cause dysmenorrhea. Dysmenorrhea is a real pain syndrome. If you treat a concurrent mood disorder it can improve the pain response.
Uterine polyps	Uterine polyps may be associated with abnormal bleeding—specifically intermenstrual or postcoital bleeding—but there will also be menorrhagia. Polyps do not typically present with dysmenorrhea, but this may occur later.

References

ACOG. The American College of Obstetricians and Gynecologists. 2021. Uterine Fibroids. Accessed April 6, 2021.

Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428-41.

De La Cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 2017;95(2):100-7.

Eltoukhi HM, Modi MN, Weston M, Armstrong AY, Stewart EA. The health disparities of uterine fibroid tumors for African American women: a public health issue. Am J Obstet Gynecol. 2014;210(3):194-9.

Fadhlaoui A, Ben Hassouna J, Khrouf M, Zhioua F, Chaker A. Endometrial adenocarcinoma in a 27-year-old woman. Clin Med Insights Case Rep. 2010;3:31-9.

Ferrero S, Abbamonte LH, Giordano M, Parisi M, Ragni N, Remorgida V. Uterine myomas, dyspareunia, and sexual function. Fertil Steril. 2006;86(5):1504-10.

Hay PE, Kerry SR, Normansell R, et al. Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study. Sex Transm Infect. 2016;92(1):63-6.

Huyck KL, Panhuysen CI, Cuenco KT, et al. The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters. Am J Obstet Gynecol. 2008;198(2):168.e1-168.e1689.

Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762-78.

Levgur M. Diagnosis of adenomyosis: a review. J Reprod Med. 2007;52(3):177-93.

Lippman SA, Warner M, Samuels S, Olive D, Vercellini P, Eskenazi B. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril. 2003;80(6):1488-94.

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-8.

Savaris RF, Fuhrich DG, Maissiat J, Duarte RV, Ross J. Antibiotic therapy for pelvic inflammatory disease. Cochrane Database of Systematic Reviews. 2020, Issue 8. Art. No.: CD010285.

Vannuccini S, Petraglia F. Recent advances in understanding and managing adenomyosis. F1000Res. 2019;8:F1000 Faculty Rev-283. Published 2019 Mar 13.

DIFFERENTIAL DIAGNOSIS 2

CLINICAL REASONING

You feel that it is likely Ann Tomlin has fibroids. It is possible she has adenomyosis, since her uterus is symmetrically shaped, or all of her fibroids could be intramural. Her sexual and reproductive history makes chronic pelvic inflammatory disease less likely. Endometriosis could be the diagnosis as well. Since endometriosis is often diagnosed with surgery, it is reasonable to empirically treat for fibroids initially. Then on subsequent visits, if the symptoms are not improved, a consult to gynecology for surgical consideration will be warranted.

TEACHING POINT

Primary Dysmenorrhea: Presentation and Treatment

In a family physician’s office, primary dysmenorrhea in an adolescent is a common diagnosis.

In a person with a uterus who is under 20 and not sexually active with the classic history of suprapubic pain the first two days of menses, non-steroidal anti-inflammatory medications can be started without a pelvic exam.

Ibuprofen is the gold-standard anti-inflammatory, but many other anti-inflammatories have also been proven equally efficacious when taken cyclically starting a day or two prior to the onset of menses and continuing into the first days of menses. Studies have noted improvement with diclofenac, vaginal sildenafil, celecoxib, and naproxen.

Choice of the specific anti-inflammatory to use should be based on cost and side effects the patient experiences. If anti-inflammatories are not effective, combination birth control pills (monophasic or triphasic) with medium-dose estrogen are effective. Hormonal implants, inserts, intrauterine devices, patches, and rings may also be considered. Some people will prefer to avoid hormonal options if possible. Other treatments shown to be effective include acupressure, acupuncture, and superficial needling. Medicinal plant remedies may include fennel, vitamin E, chamomile and thyme, but other side effects should be considered.

A pregnancy test should be performed in an adolescent or anyone with a uterus who is sexually active with someone who has a penis. Other testing should be added if the patient has any type of dysfunctional uterine bleeding or pelvic pain outside of the typical pattern. For instance, consideration of polycystic ovary syndrome may be considered for irregular menstruation.

References

Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762-78.

Sharghi M, Mansurkhani SM, Larky DA, et al. An update and systematic review on the treatment of primary dysmenorrhea. JBRA Assist Reprod. 2019;23(1):51-7. Published 2019 Jan 31.

Smorgick N, As-Sanie S. Pelvic Pain in Adolescents. Semin Reprod Med. 2018;36(2):116-22.

DIAGNOSTIC TESTING

TESTING

Dr. Barnett agrees with you that Ms. Tomlin most likely has leiomyoma (fibroids) or could have adenomyosis. “Let’s talk about what studies should be conducted at this point to rule out other medical conditions and to confirm our diagnosis. Then, we can discuss our recommendations with Ms. Tomlin.”

Question

What labs and radiology studies would you like to order now? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Complete blood count
• B. Computed tomography (CT) scan
• C. Human chorionic gonadotropin
• D. Magnetic resonance imaging (MRI)
• E. Pelvic ultrasound
• F. Thyroid-stimulating hormone
• G. Von Willebrand testing

SUBMIT

Answer Comment

The correct answers are A, C, E, F. For more instruction on the laboratory and radiologic workup of secondary dysmenorrhea/menorrhagia, see the Teaching Point below.

TEACHING POINT

Evaluation of Differential of Secondary Dysmenorrhea / Menorrhagia

A complete blood count is always a consideration when a person seems to be bleeding more heavily than usual. Iron deficiency anemia is common in patients of reproductive age, affecting between 21% and 67% of those with menorrhagia. It can add to the fatigue a person feels. This type of anemia is responsive to therapy, which initially is oral iron supplementation, and could progress to iron infusions if indicated.

A pregnancy test should be done on every person with a uterus of reproductive age with any changes in bleeding pattern or amount. Ectopic pregnancy can present with irregular bleeding and is life-threatening. Additionally, unusual forms of pregnancy—such as molar pregnancies—can cause heavy bleeding, abdominal pain, and uterine enlargement. Although it is acknowledged that pregnancy most commonly causes amenorrhea, these are diagnoses not to be missed.

Ultrasound is the study of choice for pelvic pathology. The sensitivity is 60% and specificity is 93% for detecting intracavitary issues. The sensitivity for detecting intramural pathology is also high, but not as high as it is for detecting intracavitary issues. Ultrasound has a high positive predictive value for detecting adenomyosis as well. It does not require any radiation to the ovaries (CT scans will), no intravenous dyes are needed, and it is generally painless for the patient. The pelvic ultrasound does require an intravaginal portion, and all should be advised of this in advance. This could be uncomfortable and can cause psychological distress if the patient does not realize this will be done or if they have a history of trauma, particularly sexual trauma. The combination of abdominal and vaginal ultrasounds allow for reliable measurements and anatomy of the cervix, uterus, and ovaries. Ultrasound is acceptable at the initial evaluation whenever the physician thinks the patient has secondary dysmenorrhea based on clinical history and physical exam.

Thyroid disorders are easy to check for and easy to treat. The fatigue and bowel symptoms of thyroid disease may also overlap with menstrual disorders, making the diagnosis easy to miss unless you are looking for it. Thyroid disorders can also affect the frequency of menses and should be considered if other causes of abnormal bleeding are excluded. Hypothyroidism is common in people of reproductive age, particularly those assigned female at birth. The American College of Obstetrics and Gynecology has not recommended this test for all initially without compelling history. However, guidelines from the United Kingdom do recommend thyroid testing.

Computed tomography (CT) scans have been studied but these do not give a well-defined look at pelvic pathology and are not routinely used for gynecologic problems. They may be used at the end of a work-up for pelvic pain, but usually to look for other, non-gynecologic abdominal causes.

Magnetic resonance imaging (MRI) is being used more often in diagnosing gynecologic pathology. It can give a better diagnosis of adenomyosis and locations of leiomyomas. MRI is able to more accurately assess changes in tumor volume preoperatively. At times it can provide better analysis of ovarian masses as well. MRI is expensive and time-consuming, factors that must be balanced with how useful the information obtained will be. MRI is not used as an initial study for secondary dysmenorrhea or menorrhagia.

Testing for von Willebrand disease should be considered in any person with menorrhagia and other potential episodes of heavy bleeding, such as postpartum hemorrhage. In the initial workup of isolated dysmenorrhea, this is not recommended. However, when dysmenorrhea is present with menorrhagia it should be considered. Even though the American College of Obstetrics and Gynecology recommends testing for von Willebrand for any women with severe menorrhagia, meta-analyses do not demonstrate this to be cost-effective in initial assessment. The one exception is when menorrhagia occurs in an adolescent. Bleeding disorders more commonly present as menorrhagia from the beginning of menses rather than starting 15 years after menarche. If considering starting OCPs in an adolescent, one should order the von Willebrand prior to initiation, as it may affect the results.

References

Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A. Treatment of menorrhagia. Am Fam Physician. 2007;75(12):1813-9.

James A, Matchar DB, Myers ER. Testing for von Willebrand disease in women with menorrhagia: a systematic review. Obstet Gynecol. 2004;104(2):381-8.

Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol. 2009;201(1):107.e1-107.e1076.

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-8.

Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004;54(502):359-63.

INITIAL PLAN

CARE DISCUSSION

Dr. Barnett explains dysmenorrhea to Ms. Tomlin.

You and Dr. Barnett go back in the exam room and he explains the diagnosis to Ms. Tomlin, adding, “I was wondering if you could tell me how much this affects your life?”

“I think my periods are pretty heavy, but right now,” she clarifies, “it is the pain that is most bothersome. When I have to miss work or have trouble caring for my children it makes me feel incredibly guilty. If I could just get the pain under control, I would feel better.”

When Dr. Barnett inquires if she is planning on having any more children, Ms. Tomlin indicates that she has not discussed that with her husband. Dr. Barnett suggests that if she considers getting pregnant again he would like to see her for a preconception appointment.

Dr. Barnett recommends Ms. Tomlin take ibuprofen to decrease the effect of prostaglandins, and hence decrease cramping. Ms. Tomlin wonders, “Isn’t ibuprofen a lot like Midol, which I took before and it didn’t really help?”

“Some types of Midol contain NSAIDs, like ibuprofen. Other types of Midol contain acetaminophen,” Dr. Barnett explains, “but I think the Midol may not have helped because you did not take it regularly. I’d like you to take the ibuprofen regularly when you have your periods. Does this sound like something you would like to try?” Ms. Tomlin agrees to try it.

“There is also the option of taking birth control pills to decrease the cramping,” Dr. Barnett begins, but Ms. Tomlin interjects that she does not want to use hormones since they’ve made her vomit in the past.

Dr. Barnett explains that he would also like to get some bloodwork and order a pelvic ultrasound to look at her uterus more closely. Ms. Tomlin leaves with the plan to return after two periods so she can see if the ibuprofen has helped with her symptoms.

TEACHING POINT

Preconception Counseling

Never lose a chance to bring up preconception considerations.

1. Vitamin supplementation: Daily supplementation with 400 to 800 micrograms of folic acid is recommended, as many pregnancies are unplanned. This lowers the risk for neural tube defects by over 70%. Patients with a history of miscarriage or fetuses affected by neural tube defects should be counseled to take a higher dose.
2. Substance use: Substances such as alcohol, tobacco, caffeine, or other substances (marijuana, opioids, stimulants, etc.) should be discontinued and/or cut back as much as possible. Having shared decision making and readiness to assist with this process is important. Evidence is growing that marijuana can have detrimental effects on the fetus, even though it is more widely accepted. We recommend a sensitive approach to help patients with addiction cut down on substances when they are ready. Primary care treatment options for opioid use may include buprenorphine which can lower withdrawal symptoms in the neonate.
3. Immunizations: Check for live-attenuated immunizations that must be given prior to pregnancy, such as MMR and chickenpox. Guidelines suggest giving Tdap during the third trimester of each pregnancy, influenza if indicated by the time of year, and testing for rubella immunity if there is not clear evidence of vaccination with the MMR vaccine. SARS-CoV2 vaccines should be considered given the higher risk of complications if one who is pregnant develops COVID-19. There is emerging data demonstrating the safety of the mRNA vaccines in pregnancy.
4. Chronic conditions: Get any chronic medical problems—such diabetes, depression, asthma/COPD, or thyroid disorders—under control prior to pregnancy.

References

ACOG. The American College of Obstetricians and Gynecologists. 2021. Marijuana and Pregnancy. Accessed April 6, 2021.

Carl J, Hill DA. Preconception counseling: make it part of the annual exam. J Fam Pract. 2009;58(6):307-14.

CDC. Centers for Disease Control and Prevention. Routine Measles, Mumps, and Rubella Vaccination. Reviewed January 26, 2021. Accessed April 6, 2021.

Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons [published online ahead of print, 2021 Apr 21]. N Engl J Med. 2021;10.1056/NEJMoa2104983.

RETURN VISIT AND LAB RESULTS

TESTING

You review the results of the lab studies.

Two months later, you see Ms. Tomlin is on the schedule and ask to see her. Dr. Barnett replies, “That is a great idea! Continuity is one of the keys to therapeutic relationships in family medicine.”

He tells you that he spoke with Ms. Tomlin after her ultrasound result came back. She seemed to understand the results over the phone but was waiting for two full menstrual cycles to follow up about treatment.

You take a few minutes to review the results of the studies you requested at Ms. Tomlin’s last visit.

STUDIES

Thyroid-stimulating hormone: 2.5 μIU/mL (2.5 mIU/L)

Human chorionic gonadotropin: (HCG) negative

complete blood count:

• White blood cell count 8.0 cells x 10³/μL (8.0 cells x10⁹/L)
• Hemoglobin 11.5 g/dL (115 g/L)
• Hematocrit 35% (0.35)
• Platelets 250,000/mm³ (250 x10⁹/L)
• Pelvic ultrasound: Three fibroids in the uterus. One serosal measuring 2 x 2.5 x 1.5 cm. The other two intramural, measuring 3 x 2 x 2.6 cm and 4.3 x 5.2 x 4.5 cm. Ovaries: normal in size and appearance without cysts. No pelvic free fluid.

See the associated reference ranges in conventional and SI units.

THERAPEUTIC OPTIONS

CARE DISCUSSION

You ask Ms. Tomlin how she is feeling during her return visit.

You greet Ms. Tomlin and start by asking her how she is doing, remembering that open-ended questions are the best method to start the interview. She replies, “Well, I have had two periods since the last time I was here. The cramping is better, but I still had to miss work one day last month because the diarrhea and cramping were so bad.”

You then begin to ask more direct questions.

“How have you been doing with the ibuprofen?”

“Did it make your pain any better?

You follow up to get more specific: “On a scale from one to ten, can you tell me what your pain was like prior to the medication and now that you have used it for two months?”

“Did you and your husband have a chance to talk about having more children?”

Question

Considering Ms. Tomlin’s history, which is the best treatment option at this time for her diagnosis? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

• A. Acupuncture
• B. Combined hormonal birth control (pills, patch, Nuva-ring)
• C. Copper intrauterine device
• D. Hysterectomy
• E. Injectable Medroxyprogesterone
• F. Progesterone-releasing intrauterine device
• G. Uterine artery embolization

SUBMIT

Answer Comment

The correct answer is F.

Ms. Tomlin’s desire to have children in a couple of years weighs heavily in the decision of the best treatment option for her. For instance, an IUD can be removed earlier if she desires children sooner. Since she has had prior side effects with hormones, the IUD would be the most appropriate hormonal option. The copper IUD, on the other hand, can cause more cramping and is not approved for menorrhagia.

TEACHING POINT

Treatment for Leiomyomas and Associated Symptoms

A Progesterone-releasing intrauterine device (IUD) is an effective option for reducing menstrual blood flow in those with menorrhagia secondary to fibroids. Another advantage is that it can be left in for five to seven years (potentially longer but not yet widely accepted). There are potential complications, particularly during the procedure to place the device, but after appropriately discussing these with a patient it is a viable option. In studies, the progesterone-releasing IUD (levonorgestrel-releasing intrauterine system) has clearly demonstrated decreased menstrual flow in those with fibroids. In one smaller study, the device decreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Through decreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In people who hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with the fewest side effects. Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potential side effects are lower abdominal pain and breast tenderness. The risk of uterine perforation is more likely at the time of insertion. The risk of infection is within the first 20 days of insertion. Routine STI testing may be performed prior to or during insertion with immediate treatment if any infection is found. Good patient instructions to monitor for foul-smelling discharge and signs of systemic infection or perforation are key.

Acupuncture has been used for many pain conditions. Some studies demonstrate effectiveness for dysmenorrhea without uterine pathology when compared to sham or placebo treatments. In further studies, acupuncture improves the quality of life but may be associated with higher health costs for the patient.

Combined hormonal contraceptives would be an effective option if the patient has not experienced side effects from these in the past. Oral contraceptive pills (OCPs) have been proven effective when used for dysmenorrhea related to anovulation only without a structural problem, especially in a patient who needs birth control. In those with isolated dysmenorrhea, small trials have demonstrated benefit. However, a meta-analysis of these found insufficient evidence that oral combined hormonal pills are effective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause both menorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and may decrease dysmenorrhea by thinning the endometrial lining. OCPs are commonly known to patients and providers making them often the initial step in management. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, such as the vaginal ring and the hormonal patch, are worth considering. These may cause less nausea and vomiting as they bypass the gastrointestinal system altogether. All types of combined hormonal contraceptives have a slightly increased risk of venous thromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35 years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The vaginal ring has risks of leukorrhea and vaginitis in approximately 5% of patients; the other types do not. None of these worsen cervical dysplasia or have been proven to increase the risk of breast cancer.

Injectable medroxyprogesterone is another potential treatment for leiomyomas and the symptoms associated with them. However, recent literature does demonstrate that there is bone density loss after several years of use. Other side effects may include weight gain, irregular menses for weeks to months, and potential mood changes. However, there is no risk of venous thromboembolism and this can be used in a smoker older than 35. This is a great choice for transgender men as it can help decrease periods without additional estrogen or a traumatizing procedure.

Hysterectomy is the definitive surgical option for those with secondary dysmenorrhea and those with menorrhagia who no longer desire to bear children. In a meta-analysis, surgery has been proven to reduce bleeding more at one year than any other medical treatment. However, medical treatments may have less morbidity depending on the exact etiology of menorrhagia. Some surgeons will offer hysterectomy to a person with a uterus 14 to 16 weeks in size or greater whether or not the patient has symptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication for hysterectomy. For a patient who has failed other management, hysterectomy may be an option. Myomectomy, in which the clinician removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient’s future reproductive plans are important in distinguishing these two options. Other procedural options for dysmenorrhea unrelated to uterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy, though there is insufficient evidence to recommend those in most cases.

The copper IUD is another effective form of birth control. This device may stay inside the uterus for up to 10 years. For those who are not planning any children in the near future, this may be a viable option for birth control. An advantage of the copper IUD is that it has no hormones. However, in people using this, there is an increased risk of dysmenorrhea and menorrhagia just from the IUD. It is not a treatment for leiomyomas at all. In this case, it could potentially make the symptoms worse.

Since all patients undergoing uterine artery embolization must understand the potential for urgent hysterectomy, consideration of future fertility is imperative. Some consider this a relative contraindication. Post-procedure, the patient usually has pelvic pain for at least 24 hours, sometimes lasting up to 14 days. “Post-embolization syndrome” is a group of signs and symptoms that include pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure to consider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis of fibroids, and vaginal discharge, and bleeding for up to two weeks. This treatment is usually reserved for those who cannot tolerate other hormonal treatments or who do not want those treatments for other reasons. This procedure is usually performed by an interventional radiologist. It is not an option for dysmenorrhea alone or for menorrhagia without uterine fibroids.

References

Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A. Treatment of menorrhagia. Am Fam Physician. 2007;75(12):1813-9.

Fisher WA, Black A. Contraception in Canada: a review of method choices, characteristics, adherence and approaches to counseling. CMAJ. 2007;176(7):953-61.

Grigorieva V, Chen-Mok M, Tarasova M, Mikhailov A. Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas. Fertil Steril. 2003;79(5):1194-8.

Magalhães J, Aldrighi JM, de Lima GR. Uterine volume and menstrual patterns in users of the levonorgestrel-releasing intrauterine system with idiopathic menorrhagia or menorrhagia due to leiomyomas. Contraception. 2007;75(3):193-8.

Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855. Published 2006 Apr 19.

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-8.

Proctor ML, Latthe PM, Farquhar CM, Khan KS, Johnson NP. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2005;(4):CD001896. Published 2005 Oct 19.

Proctor ML, Roberts H, Farquhar CM. Combined oral contraceptive pill (OCP) as treatment for primary dysmenorrhoea. Cochrane Database Syst Rev. 2001;(4):CD002120.

Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guidelines. Uterine fibroid embolization (UFE). Number 150, October 2004. Int J Gynaecol Obstet. 2005;89(3):305-18.

DISCUSSING TREATMENT

TEACHING

You discuss Ms. Tomlin with Dr. Barnett.

You report to Dr. Barnett that the scheduled ibuprofen is working but not as well as Ms. Tomlin would like, concluding, “I think she has secondary dysmenorrhea due to leiomyomas. Since she is still planning to have children her best options are combined hormonal contraceptives or the progesterone-releasing IUD.”

You and Dr. Barnett return to discuss these options with Ms. Tomlin. You start, “I think it would be helpful to consider some type of hormonal treatment for your symptoms. I remember you told us that you had trouble taking the birth control pill in the past. The good news is you have a lot of other options to choose from.”

Ms. Tomlin interjects, “I don’t think I want to try any other pills. I’m really nervous about having a reaction like I had before with pills. How do these other treatments work?”

You explain how other hormonal therapies are used and pull up the website http://www.bedsider.org/methods and go over the information on the page.

When you mention the medroxyprogesterone shot, Ms. Tomlin tells you, “I had a friend who used ‘the shot’ and she gained 30 pounds. I definitely don’t want to try that!”

“I understand,” you assure her. “Beyond this, the other options are all procedures or surgeries. I think one of the options I have just given you is best to start. Which would you like to consider?”

Ms. Tomlin asks, “How much does the IUD cost? I am not sure if my insurance covers it.” Dr. Barnett tells her that the typical patient cost is about $845. He advises her to call and see if her insurance covers the actual IUD and the appointment to place it. He also advises her that many insurances cover it for the heavy bleeding she is experiencing.

Ms. Tomlin decides to try the progesterone-releasing IUD. You arrange a follow-up in two weeks to place the IUD. You recommend she takes 600 mg of ibuprofen prior to the appointment to help with cramping.

TEACHING POINT

Hormonal Birth Control Therapies

Progesterone-Only Intrauterine Device (IUD)

The progesterone-only IUD can stay in place for three to seven years, depending on which device is used. There may be some irregular bleeding at the beginning for up to six months. Some women will stop bleeding altogether, and others continue having periods with less bleeding. The IUD is just taken out if the patient decides to try to get pregnant again. If, after five years, they decide they do not want to get pregnant, it can be replaced at the same visit for another five years.

Progestin Implants

These are put under the skin and last for three years. They can cause unpredictable spotting and can also be removed earlier if desired.

Hormone Patch

The patch is left in place for one week, then the person uses a new patch weekly for three weeks. No patch is placed during the fourth week, during which time the person has a period. This option contains ethinyl estradiol in addition to a progestin. Caution should be used to ensure proper placement for absorption and consideration of the amount of subcutaneous tissue in the area of placement.

Medroxyprogesterone Shot

The shot is given every 12 weeks. If a patient on this decides to get pregnant, it may take a little longer to get pregnant after stopping the shots than if they used the IUD. It also has a higher rate of irregular bleeding at the beginning.

Vaginal Ring

The vaginal ring is placed inside the vagina and left for three weeks. It is removed the fourth week to have a period.

RETURN VISIT

CARE DISCUSSION

Ms. Tomlin returns two weeks later for progesterone-releasing IUD placement.

It is two weeks later, and Ms. Tomlin has just arrived for her progesterone-releasing IUD placement. She tells you she is currently having her period. You explain to her that this is fine because it can, in fact, be easier to place the IUD while she is bleeding since the cervix is open a little.

Mrs. Tomlin says, “I have to be honest with you. This last period my mood was uncontrollable. I was crying all of the time and yelling at my children every day. It really bothers me.”

You remember all of the symptoms you considered three months ago at her first visit when you spoke about premenstrual syndrome. You ask her about all of those again: breast soreness, weight gain, bloating, diarrhea and constipation, and fatigue. Ms. Tomlin replies, “It is pretty much like I told you when you asked before. I have fatigue for the first days of my period and that hasn’t changed much. I get diarrhea for about one day now. I do get some bloating, but my breasts never hurt.”

You ask a few more questions:

“I just want to be certain nothing else is going on. Have you had any problem with your appetite or your sleep?”

“How has your energy been; are you enjoying life and having fun?”

“Have you ever thought of hurting yourself?”

TEACHING POINT

Safety and Mental Health

Premenstrual syndrome or premenstrual dysphoric disorder may coexist with additional Axis 1 and Axis 2 mental health diagnoses. Depression, anxiety, bipolar disorder, and additional psychiatric diagnoses should be considered, and if concerned, asking about thoughts or plans to harm oneself or another (suicidal ideation, homicidal ideation, and/or self-harm or intent) is important.

FINALIZING PLAN

CARE DISCUSSION

You explain Ms. Tomlin’s new concern to Dr. Barnett.

In his office, you explain to Dr. Barnett, “It seems as if Ms. Tomlin does have some problems with her mood changing and irritability during her period. No other new problems have come up, but remember she does get some bloating, fatigue, and one day of diarrhea. I wonder if she does have premenstrual syndrome. I asked her some screening questions for depression, and she doesn’t have any issues with sleeping or appetite changes. She is not suicidal and does not have anhedonia.”

Dr. Barnett recommends looking into this more with follow-up.

Question

Which of the following are effective treatments for premenstrual syndrome? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

• A. Danazol
• B. Hysterectomy
• C. Oral contraceptives
• D. Selective serotonin reuptake inhibitors (SSRIs) during menses
• E. Spironolactone
• F. Vitamin B6

SUBMIT

Answer Comment

The correct answers are A, C, D.

TEACHING POINT

Premenstrual Syndrome Treatment

Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multiple androgenic side effects, including weight gain, suppressing high-density lipids, and hirsutism, limit its desirability among patients. GnRH agonists, such as leuprolide, are effective at treating premenstrual syndrome through ovulation inhibition. However, their anti-estrogen effects, including hot flashes and vaginal dryness, make these not as popular.

Oral contraceptives are an effective treatment for dysmenorrhea, anovulation, and in some cases menorrhagia. While not always effective for premenstrual syndrome, they are a good place to start. It would be appropriate to try this in a person also needing birth control. One study demonstrates potential improved effectiveness by decreasing the placebo pills to four days from seven. Additionally, pills can be taken for sequential cycles, skipping the placebo week, to reduce the frequency of menstruation and, theoretically, the rate of PMS/PMDD.

Selective serotonin reuptake inhibitors (SSRI) during menses are an effective treatment of PMS, especially if severe mood symptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another is intermittent treatment, which is just as effective as a daily treatment for decreasing both psychological and physical symptoms during menses. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (luteal phase of cycle) and continue until menses starts. The second method is to start on the first day a patient has symptoms and continue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine can be used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior to considering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated with fewer side effects and lower cost.

Hysterectomy is not effective for premenstrual syndrome as it does not alter hormonal balance in people with a uterus. Oophorectomy, however, is a potential surgical treatment for severe refractory cases in those done with childbearing.

Spironolactone is a diuretic. It has been tested mainly to control symptoms such as bloating, weight gain, and breast tenderness. In studies, the effectiveness for treating these symptoms is inconsistent. It has anti-androgenic effects but offers less control than hormonal options. If this were to be tried on a patient, the dosing would be during the luteal phase. One must be cautious about causing potential electrolyte abnormalities, such as hyperkalemia, with this medication.

Vitamin B6 has inconsistent data regarding effectiveness. It may be effective for mild symptoms or in women reluctant to use antidepressants. Patients should be cautioned about overdosing as this may cause peripheral neurotoxicity.

Other non-drug interventions include regular exercise and low carbohydrate diets. Decreasing carbohydrates in the luteal phase may be effective for mild symptoms. Relaxation therapy has also been studied and shown some efficacy. These are all worth discussing with patients, although true efficacy is not proven.

References

Armour M, Ee CC, Naidoo D, et al. Exercise for dysmenorrhoea. Cochrane Database Syst Rev. 2019;9(9):CD004142. Published 2019 Sep 20.

Cope E. Danazol in the treatment of menorrhagia. Drugs. 1980;19(5):342-8.

Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol. 2004;104(4):845-59.

IUD PLACEMENT

THERAPEUTICS

The two of you and the chaperone enter the exam room. You explain the procedure to Ms. Tomlin. She has no questions and signs the consent form in front of you, Dr. Barnett, and the chaperone.

After Dr. Barnett has inserted the IUD when Ms. Tomlin is sitting again, Dr. Barnett inquires, “Ms. Tomlin, I understand your mood is up and down around your period?”

After her affirmative reply, he tells her, “This type of treatment for your bleeding may also be helpful for those symptoms. We will have to see over the next two or three months. If you do not think things are better, please come back and let’s discuss other options. Think about asking someone close to you about their observations, as sometimes friends and family can provide useful information about your mood that you may not be aware of yourself.”

Ms. Tomlin agrees.

TEACHING POINT

Progesterone-Releasing IUD Placement: Contraindications / Complications

Contraindications: Infection or active gynecologic cancer, allergy to levonorgestrel (uncommon)

Cautions: History of headache or vascular disease, history of perforation with prior IUD placement, allergy to iodine or shellfish (often used to clean the cervix, other methods could be used).

Complications:

During the actual procedure, the patient can have pain or bleeding. There is also a risk of uterine infection or perforation which are rare with appropriate technique. If a patient were to get pregnant, they have a higher risk of an ectopic pregnancy and this is an emergency. Patients may also experience vasovagal symptoms with placement. They should also be reminded that it is not effective for protection from sexually transmitted infections.

After the procedure is done, the patient may have some bleeding or cramping for a few days, but this usually responds to ibuprofen. There may be foul-smelling vaginal discharge from an infection.

Once the IUD is in place, there is a risk the uterus can expel it, or the patient may have pain with intercourse or experience irregular bleeding. Some partners can feel the string. After the patient’s next period, she should come back to have the string checked and make sure it is still in place. It is a good idea for the patient to check for the IUD strings after every menses to ensure it stays inside the uterus but to use caution that it is not inadvertently removed. The strings can be trimmed at follow-up visits if needed.

The patient should return to the clinic for any fever associated with lower abdominal pain, with or without abnormal vaginal discharge. These signs would be concerning for uterine infection.

DEEP DIVEExpert Comment

References

Grimes DA, Lopez LM, Manion C, Schulz KF. Cochrane systematic reviews of IUD trials: lessons learned. Contraception. 2007;75(6 Suppl):S55-S59.

Mansy, AA. Does sublingual misoprostol reduce pain and facilitate IUD insertion in women with no previous vaginal delivery? A randomized controlled trial. Middle East Fertility Society Journal. 2018;23(1):72–6.

Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. Copper Intrauterine Devices for Emergency Contraception. N Engl J Med. 2021;384(4):335-44.

PHONE FOLLOW-UP

HISTORY

You call Ms. Tomlin to see how she is doing.

Three months after Ms. Tomlin had her IUD placed, you ask Dr. Barnett about Ms. Tomlin.

Dr. Barnett replies, “You know, she never returned. I wonder how she is doing. Why don’t you call her and see how the IUD is working.”

You call Ms. Tomlin and ask her how things have been going since the IUD was placed.

“I am so sorry I did not come back,” she starts. “Everything has gone fantastic. I did have a few weeks of bleeding on and off but none since. And I missed one day of work the first month for cramping, but since then, any cramping I’ve had goes away with just one tablet of ibuprofen. I know I should have come back to have the strings checked, but I can feel them fine when I check myself. Almost everything has gone away. I do still get moody and cry sometimes with my period, but it is tolerable. I can deal with the diarrhea, too, for now. This was the best option for me.”

“I am glad that it worked for you. I will let Dr. Barnett know,” you reply.

Dr. Barnett overhears the final part of your conversation. “I guess she is doing well,” he concludes. You comment how much easier it is to care for Ms. Tomlin now that you have seen her a few times and know her. He agrees wholeheartedly.

He asks,

“Is there anything else you think should be done for her this year during her physical?”

Dr. Barnett agrees and you turn your conversation to the next patient.

References

Saslow D, Solomon D, Lawson HW, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. J Low Genit Tract Dis. 2012;16(3):175-204.

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RELEASE NOTES

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July 1, 2021

• Updated Learning Objectives to align them more closely with the STFM National Clerkship Curriculum.

April 6, 2021

January 2, 2020

LEARNING OBJECTIVES

LEARNING OBJECTIVES

The student should be able to:

• Find and apply diagnostic criteria, risk factors, and surveillance strategies for dysmenorrhea.
• Elicit a focused history that includes information about menstrual history, obstetric history, sexuality, and gender identification.
• Describe appropriate components of a complete physical examination depending on symptoms or risk factors for gynecological problems.
• Summarize the key features of a patient presenting with dysmenorrhea, capturing the information essential for differentiating between the common and “don’t miss” etiologies.
• Describe the initial management of common diagnoses that present with dysmenorrhea.
• Summarize the key features of a patient presenting with menorrhagia, capturing the information essential for differentiating between the common and “don’t miss” etiologies.
• Develop a health promotion plan for a patient of any age or gender that addresses preconception counseling.
• Develop a health promotion plan for a patient of any age or gender that addresses family planning.
• Describe the initial management of common and dangerous diagnoses that present with premenstrual syndrome.
• Demonstrate a focused history and physical exam that differentiates the conditions that may present with PMS.
• Demonstrate active listening skills and empathy for patients which allows you to attend to their specific concerns.

QUESTION 1

SAQ

Question

A 13-year-old patient comes to your office for a physical. Her mother is concerned because she complains of menstrual cramps during her period each month. You determine that menarche was earlier that year and her periods have been mostly regular since that time. The pain is in her lower abdomen and is relieved with Ibuprofen and a heat pack. She has no other medical problems and her physical exam is normal.

What best describes this patient’s condition?

• A. Menorrhagia
• B. Premenstrual dysphoric disorder
• C. Premenstrual syndrome
• D. Primary dysmenorrhea
• E. Secondary dysmenorrhea

SUBMIT

QUESTION 2

SAQ

Question

A 13-year-old patient comes to your office for a physical. Her mother is concerned because she complains of menstrual cramps during her period each month. You determine that menarche was earlier that year and her periods have been mostly regular since that time. The pain is in her lower abdomen and is relieved with Ibuprofen and a heat pack. She has no other medical problems and her physical exam is normal.

What is the most appropriate treatment for this patient?

• A. Continue ibuprofen and heat packs; return if worsening
• B. Copper intrauterine device (IUD)
• C. Start a selective serotonin reuptake inhibitor (SSRI)
• D. Start danazol
• E. Start oral contraceptive pills (OCPs)

SUBMIT

QUESTION 3

SAQ

Question

A 23-year-old patient comes to your office complaining of bothersome symptoms the week before her period each month. She reports that she has significant breast tenderness, is very irritable, and eats significantly more than she does at any other time during the month. Her coworkers notice the difference in her mood. The symptoms resolve after her period. She has no other medical problems or significant past medical history. Physical exam is normal.

What is this patient’s most likely diagnosis?

• A. Menometrorrhagia
• B. Premenstrual dysphoric disorder
• C. Premenstrual syndrome
• D. Primary dysmenorrhea
• E. Secondary dysmenorrhea

SUBMIT

QUESTION 4

SAQ

Question

A 23-year-old patient comes to your office complaining of bothersome symptoms the week before her period each month. She reports that she has significant breast tenderness, is very irritable, and eats significantly more than she does at any other time during the month. Her coworkers notice the difference in her mood, and it is beginning to affect her interactions with them. The symptoms resolve after her period. She has no other medical problems or significant past medical history. She is in a stable relationship with a female partner. Physical exam is normal.

What is the most effective treatment for this patient’s condition?

• A. Copper intrauterine device (IUD)
• B. Danazol
• C. Oral contraceptive pills (OCPs)
• D. Selective serotonin reuptake inhibitor (SSRI) treatment
• E. Vitamin B6 supplementation

SUBMIT

QUESTION 5

SAQ

Question

A 29-year-old transmasculine individual, not on hormones presents to your office complaining of very heavy cycles. These started about six months ago. He reports that his cycles were always normal until six months ago when he started passing a significant number of clots each day. His cycles occur in a regular pattern but usually last more than eight days. He reports having to change a super-absorbent pad every two to three hours. He is attracted to women but has never been sexually active. After sensitively asking for permission, you perform a pelvic exam that shows the uterus is small, non-tender, and has a uniform, smooth contour. On physical exam, you note a moderately enlarged thyroid and dry skin.

What is his most likely diagnosis?

• A. Cervical polyp
• B. Chronic pelvic inflammatory disease
• C. Menorrhagia
• D. Metrorrhagia
• E. Uterine leiomyoma

SUBMIT

Thank you for completing Family Medicine 32: 33-year-old female with painful periods.

• Family Medicine 32: 33-year-old female with painful periods
  • Learning Objectives
  • Knowledge
    • Primary Dysmenorrhea Definition, Prevalence, and Risk Factors
    • Gender
    • Gender and Sexual Identity Questions
    • Questioning about Pregnancy History
    • Normal Pelvic Exam Findings
    • Menorrhagia
    • Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria
    • Preconception Counseling
    • Safety and Mental Health
  • Management
    • Primary Dysmenorrhea: Presentation and Treatment
    • Treatment for Leiomyomas and Associated Symptoms
    • Hormonal Birth Control Therapies
    • Premenstrual Syndrome Treatment
    • Progesterone-Releasing IUD Placement: Contraindications / Complications
  • Studies
    • Evaluation of Differential of Secondary Dysmenorrhea / Menorrhagia
  • Clinical Reasoning
    • Differential of Secondary Dysmenorrhea / Menorrhagia
    • More Common Diagnoses:
    • Less Common Diagnoses:
  • References