Family Medicine 32: 33-year-old with painful cyclesUser: Ralph MarreroEmail: [email protected]: March 30, 2022 10:44 PM

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 gynecologicalproblems.Summarize the key features of a patient presenting with dysmenorrhea, capturing the information essential for differentiatingbetween 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 differentiatingbetween 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.Recognize “don’t miss” conditions that may present with PMS.Demonstrate active listening skills and empathy for patients.Demonstrate the ability to elicit and attend to patients’ specific concerns.

Knowledge

Primary Dysmenorrhea Definition, Prevalence, and Risk Factors

Primary dysmenorrhea is defined as the onset of painful menses without pelvic pathology. Secondary dysmenorrhea is defined aspainful menses secondary to some additional pathology.Primary dysmenorrhea is associated with increasing amounts of prostaglandins. The actual prevalence is unknown but rangesfrom 45% to 97% including teens and older adults. Ten to fifteen percent of people with a uterus feel their symptoms are severeand 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 symptomsof 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 decreasedblood flow.Risk Factors for Primary Dysmenorrhea

Mood disorders such as depression or anxiety have been associated with dysmenorrhea, especially in adolescents. This maybe a complex association as other factors may be comorbid with the mood disorder diagnosis, and the cause and effect isnot 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 associatedwith ovulatory cycles. Classically, an adolescent will start experiencing dysmenorrhea one or two years after menarche. Thisis the time it takes naturally for an adolescent to develop regular ovulatory cycles. The earlier the onset of menarche themore likely dysmenorrhea may occur.

This means that a detailed history regarding the nature of menses during adolescence and after children is important. It will alsobe 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 contraceptivepills may also be helpful as a second-line choice. NSAIDs inhibit the production and release of prostaglandins but have long-termside effects, and oral contraceptives inhibit ovulation, reduce endometrial proliferation, and mimic the lower prostaglandin phaseof 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.

Gender

People who are born with a uterus may identify as female or male. We can therefore identify this population as "female assignedat birth," meaning they had a sex assigned at birth as female based on the genitalia seen, or “person with a uterus” to

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acknowledge the biologic presence of a uterus in someone who may identify as anything other than female in their life. Pleasenote that transgender men should not be excluded in this consideration, for which calling periods “cycles” and utilizingterminology of a person with a uterus or exam of the pelvis is more appropriate than “gynecologic.” See below for additionalgender Teaching Points.

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, werecommend asking early in a visit either how they would like to be addressed and/or what pronouns they use. Common answersare 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 moreinclusively 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 asfemale.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 genderidentity.Non-binary, gender-nonconforming, and gender-expansive are all terms some patients use to identify their gender as on aspectrum rather than binary.Sexual orientation refers to the gender that people have sex with. This can be different from romantic orientation as people can beromantically and sexually attracted to different genders or vary based on the person or their own identity. It is also important toconsider the anatomy of partners, as a “male” partner may have a uterus and not a penis, and a “female” partner may have apenis. 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 wouldwant to use he/him pronouns, despite talking about problems related to a uterus. You should not assume based on physicalappearance what organs a patient may or may not have, in the same way, that you cannot know without asking if someone hashad a hysterectomy.

Questioning About Reproductive History

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

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 isalso mostly flat, not round as you see in some pictures. A normal uterus may be mildly tender on exam just prior to or duringmenses. A normal uterus can be tilted anteriorly (anteverted or anteflexed), midline, or tilted posteriorly (retroverted orretroflexed). An anteflexed or retroflexed uterus may be difficult to assess for size because of its position. The uterus should besmooth in contour around the entire surface area. Serosal fibroids or large mucosal fibroids may cause a "knobby" feel to theuterus.The uterus should be mobile. The uterus is held in the pelvis by a series of ligaments on each side. With endometriosis, the uterusmay 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 theovaries 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 normalcolumnar glands are covered by squamous epithelium. They are merely inclusion cysts that may come and go and are of noclinical significance. While looking at the cervix white discharge can also normally be seen coming from the os or in the vagina. Ifthere 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 nosymptoms like itching, burning, or foul-smelling discharge. It is normal to have physiologic clear to white vaginal discharge. Thevolume of discharge may get so heavy that it requires a pad for comfort; the volume may change during the course of a menstrualcycle.

Menorrhagia

Menorrhagia is very difficult to define precisely and is only one of the terms associated with abnormal uterine bleeding. Theabsolute criterion for menorrhagia is blood loss of more than 80 milliliters. Some providers try to use pad or tampon count.

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However, there is variability in the absorption of different pads and how much blood one has on the pad prior to changing. Askingabout 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.

Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria

Premenstrual syndrome (PMS) is characterized by physical and behavioral symptoms occurring in the luteal phase of the normalmenstrual 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 healthdiagnosis.The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, oranxiety 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 onculture and social norms. It may be helpful to get the perspective of other close contacts of the patient.

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 miscarriageor 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 withthis process is important. Evidence is growing that marijuana can have detrimental effects on the fetus, even though it ismore widely accepted. We recommend a sensitive approach to help patients with addiction cut down on substances whenthey are ready. Primary care treatment options for opioid use may include buprenorphine which can lower withdrawalsymptoms in the neonate.

3. Immunizations: Check for live-attenuated immunizations that must be given prior to pregnancy, such as MMR andchickenpox. Guidelines suggest giving Tdap during the third trimester of each pregnancy, influenza if indicated by the timeof year, and testing for rubella immunity if there is not clear evidence of vaccination with the MMR vaccine. SARS-CoV2vaccines should be considered given the higher risk of complications if one who is pregnant develops COVID-19. There isemerging 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.

Safety and Mental Health

Premenstrual syndrome or premenstrual dysphoric disorder may coexist with additional Axis 1 and Axis 2 mental healthdiagnoses. 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) isimportant.

Management

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 ofmenses, 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 efficaciouswhen taken cyclically starting a day or two prior to the onset of menses and continuing into the first days of menses. Studies havenoted 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 areeffective. Hormonal implants, inserts, intrauterine devices, patches, and rings may also be considered. Some people will prefer toavoid hormonal options if possible. Other treatments shown to be effective include acupressure, acupuncture, and superficialneedling. Medicinal plant remedies may include fennel, vitamin E, chamomile and thyme, but other side effects should beconsidered.A pregnancy test should be performed in an adolescent or anyone with a uterus who is sexually active with someone who has apenis. Other testing should be added if the patient has any type of dysfunctional uterine bleeding or pelvic pain outside of thetypical pattern. For instance, consideration of polycystic ovary syndrome may be considered for irregular menstruation.

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Treatment for Leiomyomas and Associated Symptoms

A Progesterone-releasing intrauterine device (IUD) is an effective option for reducing menstrual blood flow in those withmenorrhagia secondary to fibroids. Another advantage is that it can be left in for five to seven years (potentially longer but not yetwidely accepted). There are potential complications, particularly during the procedure to place the device, but after appropriatelydiscussing these with a patient it is a viable option. In studies, the progesterone-releasing IUD (levonorgestrel-releasingintrauterine system) has clearly demonstrated decreased menstrual flow in those with fibroids. In one smaller study, the devicedecreased overall uterine volume. However, it does not decrease the size of individual fibroids already in the uterus. Throughdecreasing uterine volume and endometrial atrophy, the progesterone-releasing IUD can also decrease dysmenorrhea. In peoplewho hope to maintain fertility for the future yet control their symptoms now, this is one of the best options with the fewest sideeffects. Irregular vaginal bleeding, especially initially, is a common side effect of the progesterone-releasing IUD. Other potentialside 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 withimmediate treatment if any infection is found. Good patient instructions to monitor for foul-smelling discharge and signs ofsystemic infection or perforation are key.Acupuncture has been used for many pain conditions. Some studies demonstrate effectiveness for dysmenorrhea without uterinepathology when compared to sham or placebo treatments. In further studies, acupuncture improves the quality of life but may beassociated 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 inthe past. Oral contraceptive pills (OCPs) have been proven effective when used for dysmenorrhea related to anovulation onlywithout a structural problem, especially in a patient who needs birth control. In those with isolated dysmenorrhea, small trialshave demonstrated benefit. However, a meta-analysis of these found insufficient evidence that oral combined hormonal pills areeffective for dysmenorrhea alone. The confusion is that OCPs are often used in structural problems of the uterus that cause bothmenorrhagia and dysmenorrhea. In leiomyoma and adenomyosis, OCPs decrease blood loss and may decrease dysmenorrhea bythinning the endometrial lining. OCPs are commonly known to patients and providers making them often the initial step inmanagement. In adolescents, they have the additional benefit of regulated menses. However, other options that are not oral, suchas the vaginal ring and the hormonal patch, are worth considering. These may cause less nausea and vomiting as they bypass thegastrointestinal system altogether. All types of combined hormonal contraceptives have a slightly increased risk of venousthromboembolism, highest in the first year of use. For this reason, these types are not recommended in smokers older than 35years. Specific side effects with the patch may be site dermatitis in as many as 20% of users. The vaginal ring has risks ofleukorrhea and vaginitis in approximately 5% of patients; the other types do not. None of these worsen cervical dysplasia or havebeen 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 mayinclude weight gain, irregular menses for weeks to months, and potential mood changes. However, there is no risk of venousthromboembolism and this can be used in a smoker older than 35. This is a great choice for transgender men as it can helpdecrease periods without additional estrogen or a traumatizing procedure.Hysterectomy is the definitive surgical option for those with secondary dysmenorrhea and those with menorrhagia who nolonger desire to bear children. In a meta-analysis, surgery has been proven to reduce bleeding more at one year than any othermedical treatment. However, medical treatments may have less morbidity depending on the exact etiology of menorrhagia. Somesurgeons will offer hysterectomy to a person with a uterus 14 to 16 weeks in size or greater whether or not the patient hassymptoms. Any leiomyoma that is growing rapidly, regardless of the rest of the uterine exam, may be an indication forhysterectomy. For a patient who has failed other management, hysterectomy may be an option. Myomectomy, in which theclinician removes the leiomyoma but not the entire uterus, is another surgical option. Consideration of a patient's futurereproductive plans are important in distinguishing these two options. Other procedural options for dysmenorrhea unrelated touterine pathology include presacral neurectomy and uterine nerve ablation, both via laparoscopy, though there is insufficientevidence 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 thosewho are not planning any children in the near future, this may be a viable option for birth control. An advantage of the copper IUDis that it has no hormones. However, in people using this, there is an increased risk of dysmenorrhea and menorrhagia just fromthe 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, considerationof future fertility is imperative. Some consider this a relative contraindication. Post-procedure, the patient usually has pelvic painfor at least 24 hours, sometimes lasting up to 14 days. "Post-embolization syndrome" is a group of signs and symptoms thatinclude pain, cramping, vomiting, fatigue, and sometimes fever and leukocytosis. Other complications from the procedure toconsider as you counsel this patient are potential ovarian failure (up to 3% in women younger than 45), infection, necrosis offibroids, and vaginal discharge, and bleeding for up to two weeks. This treatment is usually reserved for those who cannot tolerateother hormonal treatments or who do not want those treatments for other reasons. This procedure is usually performed by aninterventional radiologist. It is not an option for dysmenorrhea alone or for menorrhagia without uterine fibroids.

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 someirregular bleeding at the beginning for up to six months. Some women will stop bleeding altogether, and others continue havingperiods with less bleeding. The IUD is just taken out if the patient decides to try to get pregnant again. If, after five years, theydecide they do not want to get pregnant, it can be replaced at the same visit for another five years.Progestin Implants

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These are put under the skin and last for three years. They can cause unpredictable spotting and can also be removed earlier ifdesired.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 thefourth week, during which time the person has a period. This option contains ethinyl estradiol in addition to a progestin. Cautionshould be used to ensure proper placement for absorption and consideration of the amount of subcutaneous tissue in the area ofplacement.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 afterstopping 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.

Premenstrual Syndrome Treatment

Danazol is an androgenic medication with progesterone effects. It lowers estrogen and inhibits ovulation. However, its multipleandrogenic 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, theiranti-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 notalways effective for premenstrual syndrome, they are a good place to start. It would be appropriate to try this in a person alsoneeding birth control. One study demonstrates potential improved effectiveness by decreasing the placebo pills to four days fromseven. Additionally, pills can be taken for sequential cycles, skipping the placebo week, to reduce the frequency of menstruationand, theoretically, the rate of PMS/PMDD.Selective serotonin reuptake inhibitors (SSRI) during menses are an effective treatment of PMS, especially if severe moodsymptoms predominate. There are three effective regimens for SSRI use. One regimen is continuous daily treatment. Another isintermittent treatment, which is just as effective as a daily treatment for decreasing both psychological and physical symptomsduring menses. There are two types of intermittent treatment. One method is to start therapy 14 days prior to menses (lutealphase of cycle) and continue until menses starts. The second method is to start on the first day a patient has symptoms andcontinue until the start of menses or three days later. Many randomized trials have used fluoxetine and sertraline. Venlafaxine canbe used as well. Lower doses are effective. If one medication does not work, another in the same class should be tried prior toconsidering the treatment a failure. Follow-up should occur after two to four cycles. Intermittent treatment is associated withfewer 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 breasttenderness. In studies, the effectiveness for treating these symptoms is inconsistent. It has anti-androgenic effects but offers lesscontrol than hormonal options. If this were to be tried on a patient, the dosing would be during the luteal phase. One must becautious 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 useantidepressants. 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 phasemay be effective for mild symptoms. Relaxation therapy has also been studied and shown some efficacy. These are all worthdiscussing with patients, although true efficacy is not proven.

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 arerare with appropriate technique. If a patient were to get pregnant, they have a higher risk of an ectopic pregnancy and this is anemergency. Patients may also experience vasovagal symptoms with placement. They should also be reminded that it is noteffective 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 toibuprofen. 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 experienceirregular bleeding. Some partners can feel the string. After the patient's next period, she should come back to have the stringchecked 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 ensureit stays inside the uterus but to use caution that it is not inadvertently removed. The strings can be trimmed at follow-up visits ifneeded.The patient should return to the clinic for any fever associated with lower abdominal pain, with or without abnormal vaginal

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discharge. These signs would be concerning for uterine infection.

Studies

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 deficiencyanemia is common in patients of reproductive age, affecting between 21% and 67% of those with menorrhagia. It can add to thefatigue a person feels. This type of anemia is responsive to therapy, which initially is oral iron supplementation, and couldprogress 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 oramount. 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 acknowledgedthat 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 intracavitaryissues. 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 anintravaginal portion, and all should be advised of this in advance. This could be uncomfortable and can cause psychologicaldistress if the patient does not realize this will be done or if they have a history of trauma, particularly sexual trauma. Thecombination of abdominal and vaginal ultrasounds allow for reliable measurements and anatomy of the cervix, uterus, andovaries. Ultrasound is acceptable at the initial evaluation whenever the physician thinks the patient has secondary dysmenorrheabased 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 overlapwith menstrual disorders, making the diagnosis easy to miss unless you are looking for it. Thyroid disorders can also affect thefrequency of menses and should be considered if other causes of abnormal bleeding are excluded. Hypothyroidism is common inpeople of reproductive age, particularly those assigned female at birth. The American College of Obstetrics and Gynecology hasnot recommended this test for all initially without compelling history. However, guidelines from the United Kingdom dorecommend thyroid testing.Computed tomography (CT) scans have been studied but these do not give a well-defined look at pelvic pathology and are notroutinely 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 ofadenomyosis and locations of leiomyomas. MRI is able to more accurately assess changes in tumor volume preoperatively. Attimes it can provide better analysis of ovarian masses as well. MRI is expensive and time-consuming, factors that must bebalanced with how useful the information obtained will be. MRI is not used as an initial study for secondary dysmenorrhea ormenorrhagia.Testing for von Willebrand disease should be considered in any person with menorrhagia and other potential episodes of heavybleeding, 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 andGynecology recommends testing for von Willebrand for any women with severe menorrhagia, meta-analyses do not demonstratethis to be cost-effective in initial assessment. The one exception is when menorrhagia occurs in an adolescent. Bleeding disordersmore commonly present as menorrhagia from the beginning of menses rather than starting 15 years after menarche. Ifconsidering starting OCPs in an adolescent, one should order the von Willebrand prior to initiation, as it may affect the results.

Clinical Reasoning

Differential of Secondary Dysmenorrhea / Menorrhagia

More Common Diagnoses:

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Adenomyosis

Epidemiology: Occurs more frequently in parous than nonparous people. Adenomyosis actually can befound in any person with a uterus from adolescence to menopause.

Pathophysiology: This is not completely understood. One theory is endometrial invagination but has notbeen completely proven. It is hypothesized that estrogen and progesterone play a role only becausehormones can be treatment options.

Presentation: 60% of women complain of menorrhagia. The uterus is typically enlarged and diffuselyboggy, but symmetric and should still be mobile. There may be some urinary or gastrointestinalsymptoms secondary to size and mass effect on the bladder and rectum.

Diagnosis: Ultrasound may demonstrate a heterogeneously boggy uterus. MRI is more specific fordiagnosis.

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 uterineartery embolization or hysterectomy may be performed in those no longer desiring biological children.

Chronic pelvicinflammatorydisease (PID)

Epidemiology: The exact incidence and prevalence is unknown.

Pathophysiology: PID can have a subclinical smoldering course that is considered chronic. Thesepatients can have significant morbidities to include infertility and pain in the lower abdomen. Many ofthese 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 isseen in one-third of patients with chronic pelvic inflammatory disease, especially subclinical diseasethat isn't treated early.

Management: As with acute PID, workup should include testing for sexually transmitted infections andtreatment covering chlamydia and gonorrhea if suspected or diagnosed.

Endometriosis

Epidemiology: Endometriosis is a disorder that affects people of reproductive age with a uterus. Themost common age affected is 25 to 35 years old. The exact prevalence in the general population isunknown. 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. Theseinclude 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 ordysmenorrhea, 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 withleiomyoma. On physical exam, these patients have pain in the pain cul-de-sac, immobile andretroflexed uterus, nodules on the uterosacral ligaments, or just pain with uterine motion.

Management: Symptoms may be controlled with methods similar to those for menorrhagia. Hormonalcontraceptives may alleviate symptoms. Hysterectomy and uterine artery embolization are less likely tobe effective as the tissue is outside of the uterus.

Uterineleiomyomas

(commonlycalled fibroids)

Epidemiology: Fibroids are the most common benign tumors of the uterus. Decreased risk of developingfibroids has been noted with oral contraceptive use, increasing parity, and smoking. Increased risk isknown with early menarche, family history of fibroids, and increased alcohol use. Although moreresearch 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 ascompared to other racial demographic groups. Disparities also exist in the type of care that womenreceive for their fibroids; for example, studies have shown that Caucasian women are more likely to beoffered a laparoscopic procedure as compared to African American and Hispanic women with the samehousehold income, indicating systemic disparities in care.

Pathophysiology: These are made of normal myometrial cells. They can occur within the cavity andunder 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 nosymptoms at all. Work loss and quality of life can be issues. The physical exam typically has anenlarged uterus that is freely mobile. The uterus may feel "knobby" from an irregular contour, andoccasionally 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 amongthe options.

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Cervicalstenosis

Cervical stenosis can be congenital or acquired. With congenital stenosis, an adolescent will havesignificant dysmenorrhea, which is not as responsive to nonsteroidal anti-inflammatory medications aswould be expected. The menstrual flow will also be minimal. Acquired stenosis may be related tocryotherapy or LEEP procedures (performed for concerns of cervical cancer on Pap tests and colposcopybiopsies). This causes dysmenorrhea as the uterus is distended with blood. On exam, the uterus will feeldiffusely enlarged.

Endometrialadenocarcinomaor endometrialhyperplasia

Endometrial adenocarcinoma (cancer) may occur under age 40 (2%–14% of cases) but is less likely in thisage group. It does present with irregular bleeding, more often as postmenopausal bleeding. It may or maynot cause dysmenorrhea. Endometrial hyperplasia is a non-malignant process that can mimic endometrialadenocarcinoma. It generally occurs in the perimenopausal or menopausal period. It is due to unopposedestrogen.

Inflammatorybowel disease

Inflammatory bowel disease can often be misdiagnosed as a gynecologic problem since constipation anddiarrhea are associated with premenstrual syndrome as well. Additionally, when a person has bloody stoolsduring her menses, the clinical diagnosis can be more confusing. However, when there is pain withdefecation 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 bowelsyndrome

Irritable bowel syndrome may cause crampy pain prior to and during menses, but will also occur at othertimes 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 bodybut is commonly in the abdomen. It is a rare type of cancer and therefore less likely.

Ovarian cystsOvarian cysts commonly cause recurrent and chronic pelvic pain. This type of pain is more likely to occurmid-cycle, although the patient may have pain associated with menses. This location of this pain istypically in one of the lower quadrants and not as much midline. Ovarian cysts may come and go related toovulation.

Mood disordersor adjustmentdisorders

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 painresponse.

Uterine polypsUterine polyps may be associated with abnormal bleeding—specifically intermenstrual or postcoitalbleeding—but there will also be menorrhagia. Polyps do not typically present with dysmenorrhea, but thismay occur later.

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