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Old 11-04-2012
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Arrow Gyrus Daily Questions; Obstetrics & Gynecology #7

A 15-year-old female is brought to your office complaining of severe dysmenorrhea that has become progressively worse since the onset of menses. Menarche occurred at age 13. The pain is located predominantly on the right side, lasts for the duration of the menstrual fl ow, and at its worst is associated with nausea and vomiting. She has had to miss school with every menstrual period for the past year. She has tried nonsteroidal medications, which initially helped but no longer relieve the pain significantly. The next step in management is:
A Take the maximal dose of nonsteroidal medications and see if pain is improved
B Refer her to psychiatry since this may just be a ploy to get out of school
C Start combined oral contraceptive hormone pills
D Obtain a pelvic ultrasound
E Perform a laparoscopy to evaluate for endometriosis
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Old 11-04-2012
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D Obtain a pelvic ultrasound
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Old 11-20-2012
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Quote:
Originally Posted by Novobiocin View Post
D Obtain a pelvic ultrasound
You are thinking about what? Novo
I will pick ans--C Start combined oral contraceptive hormone pills
Cuz the diagnosis is Primary dysmenorrhea which is not controlled by NSAID so, next treatment is trying COC
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Old 11-20-2012
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D obtain pelvic usg. to look for the cause. then u can start with ocp's to regulate her menses.
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Old 11-20-2012
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thinking of endometriosis , ..........OC pills trial or USG ......

i think C...........
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Old 11-20-2012
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Quote:
Originally Posted by heartbeat View Post
You are thinking about what? Novo
I will pick ans--C Start combined oral contraceptive hormone pills
Cuz the diagnosis is Primary dysmenorrhea which is not controlled by NSAID so, next treatment is trying COC
Although her presentation points more towards primary dysmenorrhea (OC pills would be the right answer)
What is atypical about her pain is that it is localized to right side which made me think to rule out a secondary cause like endometriosis (most common site is ovary-chocolate cyst).
Management remains the same for both-OC Pills, so it really doesn't matter but I would rather know what I am dealing with.

Bottomline: In order to diagnose Primary dysmenorrhea you should rule out a pelvic pathology.
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Old 11-20-2012
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D Obtain a pelvic ultrasound
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Old 11-20-2012
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The reasons which are make me think of Primary dysmenorrhea and not endometriomas are:
1- lower abd pain
2- last for the duration of menstrual flow
3- nausea and vomiting
4- tried nonsteroidal medications, which initially helped
5- not mentioned that there is adnexal mass

In my opinion they are asking about the second line treatment if first line failed and not to check for previous miss diagnosis
plz correct me if i am wrong
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Old 11-21-2012
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Quote:
Originally Posted by heartbeat View Post
The reasons which are make me think of Primary dysmenorrhea and not endometriomas are:
1- lower abd pain
2- last for the duration of menstrual flow
3- nausea and vomiting
4- tried nonsteroidal medications, which initially helped
5- not mentioned that there is adnexal mass

In my opinion they are asking about the second line treatment if first line failed and not to check for previous miss diagnosis
plz correct me if i am wrong
I agree with you here. There are more points in favor of Primary dysmenorrhea especially the pattern/timing of the pain with associated nausea and vomiting.
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Old 11-26-2012
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so what would be the correct option then?? i thought it should be D to rule out endometrioma or some anatomical problem like rudimentary horn...unilateral is the clue to investigate further before starting ocps
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Old 11-27-2012
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Answer D
The answer is DThe significant factors in this patient’s history are the progression of her symptoms, the severity, and the localized nature of the pain.

Primary dysmenorrhea may besevere, but is usually diffuse throughout the pelvis and does not become progressively worse over time.

The history in this patient suggests secondary dysmenorrhea, possibly an obstructive müllerian anomaly.For this reason the next step should be a pelvic ultrasound. Combined hormonal contraceptives would be the next step if the pain did not localize and there was no significant progression of pain
symptoms with each menses. She is already on NSAIDs, so increasing the amount would not be beneficial given the severity of the symptoms. A laparoscopy would not be appropriate at this point without first performing an ultrasound and maximizing medical therapy. Although sometimes pelvic pain can be attributed to psychiatric causes, it is rare, and the patient should have all structural abnormalitiesinvestigated and optimal medical therapy tried first.
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