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Case History

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Image not available. A 15-year-old girl attends with her mother asking for treatment for her painful periods. She has to take at least one day a month off school because of the pain and is concerned about how this will affect her examination results. She is not yet sexually active.

What specific areas should you explore in the history?

Is a pelvic examination indicated?

What first-line treatments would you recommend?

What non-pharmacological treatments exist?

Is surgery ever indicated?

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Background

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Image not available. Dysmenorrhoea is defined as painful menstrual cramps and has been traditionally sub divided into primary (without any pathology) and secondary dysmenorrhoea (due to other pathology). It is very common, with estimates of prevalence ranging from 20% to 90%.1 Most adolescents self-medicate rather than consult a doctor; however, dysmenorrhoea is the most common cause of recurrent school absenteeism in teenage girls. It is important, therefore, that it is identified and treated early.

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What specific areas should you explore in the history?

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Pain with menstruation will usually commence within a year of menarche, thus if it starts beyond this period it should alert to the possibility of other pathology (such as endometriosis or adenomyosis).2 Therefore, age at menarche and age at which dysmenorrhoea began should be elicited. An attempt should be made to understand the bleeding pattern, as initial anovulatory cycles are often more irregular, heavier and more painful and this may improve as cycles become ovulatory and more regular. Associated symptoms may include radiation of pain to the back or thighs, nausea, vomiting or diarrhoea. However, cyclical rectal bleeding or other bowel symptoms may point to a diagnosis of rectal endometriosis or irritable bowel syndrome. The pain usually starts no more than a few hours before the onset of menstruation and settles after the first 24–36 hours. More prolonged pain or pain of a non-cyclical nature should raise the suspicion of other pathology. Dysmenorrhoea usually improves after childbirth and if parity is controlled for there is no relationship with age.3 However, depression and anxiety, disruption of social networks and smoking are all associated factors.1 As many of the initial treatments are available over the counter, what treatments have been tried and whether or not they were successful at all should be established.

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Is a pelvic examination indicated?

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As long as nothing in the history suggests another pathology, there is no need for a pelvic examination prior to commencing empirical treatment, especially in girls who are not yet sexually active. Abnormal vaginal discharge or risk of sexually transmitted infections should prompt internal examination and appropriate swabs.

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What first-line treatments would you recommend?

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Dysmenorrhoea is thought to be due to increased prostaglandin production by the endometrium which causes stronger and more irregular uterine contractions, reducing uterine blood flow and causing painful, transient ischaemia. Prostaglandins are also ...

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