Clinical Assessment A detailed menstrual history is important to obtain from the patient complaining of severe menstrual cramps Information about the timing of her first period (menarche), regularity of her cycles, duration of menstrual flow, and the amount of blood flow per period are important to know The practitioner should ask about accompanying signs such as nausea, vomiting, dizziness, or diarrhea Knowing whether the cramps keep the patient home from school gives a clue to the adolescent’s ability to function with the dysmenorrhea Asking about precipitating factors (physical activity, bowel movement, urination) or relieving factors (rest, exercise, heat, medications) is important Symptoms are usually better controlled with NSAIDs than with acetaminophen A physical examination for dysmenorrhea does not routinely include a pelvic examination unless the provider is concerned about an imperforate hymen, adnexal masses, or a sexually transmitted infection Inspection and palpation of the abdominal wall for masses, and hernias should be performed for all patients It is helpful to ask the patient to point to the location of the pain; the provider should gently palpate this area at the end of the abdominal examination to avoid exacerbating pain at the start of the examination Patients should also be asked to flex and contract the abdominal wall muscles Increased pain with these maneuvers suggests a myofascial etiology of the pain (Carnett sign) The back and the sacroiliac joints should be palpated to evaluate for tenderness and radiation For patients with a history of sexual activity presenting with pelvic pain, a bimanual examination should be performed to evaluate for PID Findings of cervical motion tenderness, adnexal tenderness, or uterine tenderness would be consistent with a clinical presentation of PID (see section on PID) Patients with an undiagnosed STI may present with pelvic pain or with irregular or heavy vaginal bleeding Endometriosis may also have findings of adnexal, uterine, or rectovaginal tenderness or nodularity on bimanual or rectal examination, although these symptoms are more likely to develop after several years and are less likely to be found among adolescents than adults It is important to point out that the initial treatment of endometriosis is the same as for primary dysmenorrhea (NSAIDs are first line, followed by hormonal medications); surgical intervention is not indicated unless a patient has failed first-line therapies If pelvic anatomy should be further explored, ultrasonography or MRI is an option to consider Pelvic ultrasound is an appropriate initial imaging study to evaluate uterine and ovarian anatomy Patients and families should be informed that optimal ultrasound imaging of the pelvis often requires use of both an abdominal probe and a transvaginal probe For patients who cannot tolerate such an examination or if the ultrasound technologists are not skilled in performing a transvaginal imaging, an MRI should be ordered An MRI may be a better modality to evaluate vaginal and bladder lesions Intraperitoneal lesions, however, are difficult to visualize on imaging studies; surgical approaches may be more useful However, surgical evaluation should not be needed for primary dysmenorrhea and is rarely needed for secondary dysmenorrhea as a surgical emergency Notably, when secondary dysmenorrhea due to endometriosis is suspected, surgical evaluation is best performed by a surgeon with expertise in pediatric endometriosis as the appearance in pediatric patients is very subtle and differs from the appearance in adults Management NSAIDs are first-line medications for most adolescents with dysmenorrhea and have both analgesic and anti-inflammatory effects Nonspecific NSAIDs that inhibit both COX-1 and COX-2 (ibuprofen, naproxen, diclofenac potassium, and meclofenamate) and those that are specific for COX-2 (celecoxib, rofecoxib, and valdecoxib), are effective for treating dysmenorrhea; however use of COX-2 inhibitors has been limited by cardiac side effect The patient should be counseled that NSAIDs are most effective when started to days prior to onset of menstrual bleeding If the patient is unable to predict the onset of her period, she should be advised to start the NSAID at the first sign of cramping or bleeding Naproxen (500 mg PO q12h) and ibuprofen (600 to 800 mg PO q6h) are commonly used Failure to respond to one NSAID does not preclude use of another NSAIDs should be avoided in patients with ulcers, gastrointestinal bleeding, renal disease, or clotting disorders In patients where NSAIDs are contraindicated, tramadol may be used It is a centrally acting analgesic agent that binds to μ-opioid receptors and inhibits the reuptake of norepinephrine and serotonin Tramadol is prescribed as 50 to 100 mg by mouth every hours, not to exceed 400 mg/day Use tramadol with caution in patients with a history of seizures Drug dependence is also possible in patients taking tramadol Patients whose pain is not alleviated by NSAIDs should be offered a hormonal method to treat the dysmenorrhea High-quality randomized clinical trials evaluating the effectiveness of oral contraceptives for dysmenorrhea are lacking, though smaller studies have noted response rates up to 80% Combined oral contraceptive pills (OCPs) containing estrogen and progestin are widely used They work by suppressing ovulation, reducing the amount of endometrial proliferation, and reducing endometrial tissue prostaglandin production Patients who report persistent pain during the week of placebo pills may be considered for an extended cycle regimen (e.g., prescribing a 91-day pack rather than the standard 28-day pack) The combined contraceptive transdermal patch (Xulane) or vaginal ring (NuvaRing or Annovera) delivers similar results as OCPs Any patient who is sexually active should be counseled about the value of hormonal medications for birth control as well Before initiating any therapy containing estrogen, the patient should be assessed for any contraindication to estrogen (described in detail under Abnormal Uterine Bleeding section) Patients in whom estrogen is contraindicated or not preferable can try a progestin-only medications The injectable depot medroxyprogesterone (DepoProvera) is particularly effective in suppressing ovulation and alleviating pain from dysmenorrhea and can be administered every 12 weeks Implantable subdermal progestin (Nexplanon) and progestin-releasing IUDs (Mirena) may also be longer-acting alternatives to treat dysmenorrhea Most patients with primary dysmenorrhea will respond to NSAIDs and hormonal medications within months Patients whose menstrual-associated pain continue to be severe despite months of NSAIDs and hormonal management should be assessed for dysmenorrhea secondary to endometriosis or other pelvic pathology A laparoscopy may be performed to evaluate for endometriosis ABNORMAL UTERINE BLEEDING Goals of Treatment The goal for the ED physician is to reduce the patient’s vaginal bleeding in a prompt yet safe manner CLINICAL PEARLS AND PITFALLS The physician should assess for signs for hemodynamic instability, including checking orthostatic vital signs and hemoglobin The differential diagnosis for abnormal uterine bleeding (AUB) should include hematologic disorders, such as von Willebrand disease and other coagulation disorders Assess whether there are any contraindications for administering an estrogen-containing therapy Background AUB refers to irregular, prolonged, or excessive menstrual bleeding unrelated to pregnancy The term AUB has replaced the previous terminology of dysfunctional uterine bleeding The majority of adolescents who present to the ED with AUB will have bleeding related to anovulatory cycles Normal menstrual cycles in an adolescent may range from 21 to 45 days, though the adult menstrual cycle is generally 21 to 35 days Regular ovulatory cycles may not occur until to years after menarche, with the majority of AUB within the first 18 months after menarche being due to anovulatory cycles Bleeding that persists beyond days, recurs at intervals of fewer than 21 days, soaks greater than one pad per hour for more than hours in a row, produces large-sized clots, causes symptomatic anemia, or creates hemodynamic instability, warrants attention Ovulation typically occurs 14 days prior to the onset of menses, and the ovarian follicle forms a corpus luteum (type of functional ovarian cyst) that secretes progesterone and estradiol After ovulation, the progesterone produced by the corpus luteum promotes growth of the endometrial secretory glands and spiral blood vessels, though it also limits the ultimate thickness of the endometrium As the corpus luteum degenerates, circulating levels of estrogen and progesterone fall which lead to endometrial necrosis and menstrual sloughing, which comprises the menstrual blood flow The majority of adolescents who present with AUB experience intervals of anovulation Without ovulation, there is no progesterone secreted by the corpus luteum to promote structural integrity of the endometrium Estrogen levels secreted by the ovarian follicles may fluctuate; when large amounts are secreted, there is greater endometrial proliferation and thus heavier vaginal bleeding Clinical Manifestations History, physical, and laboratory tests help the clinician guide the severity of the patient’s vaginal bleeding Bleeding that has been occurring for days or more, at intervals more frequently than every 21 days, bleeding greater than 80 mL menstrual period, or bleeding large clots that are at least quarter sized, should be evaluated by a healthcare provider for AUB Pertinent history should also include a pregnancy risk assessment (last sexual intercourse, dates of last two menstrual periods, contraceptive use history), presence of sexual activity, or presence of any underlying platelet or bleeding disorder (e.g., thrombocytopenia, von Willebrand disease) The physical examination starts with the measurement of the patient’s vital signs, including checking for orthostatic changes in the pulse and blood pressure Pallor and symptomatic orthostasis are concerning for significant anemia Petechiae, bruising, and mucosal bleeding may indicate a bleeding disorder Signs ... dysmenorrhea as a surgical emergency Notably, when secondary dysmenorrhea due to endometriosis is suspected, surgical evaluation is best performed by a surgeon with expertise in pediatric endometriosis... evaluation is best performed by a surgeon with expertise in pediatric endometriosis as the appearance in pediatric patients is very subtle and differs from the appearance in adults Management NSAIDs are