Week 2 Case Discussion

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?”

“I have been having some problems the past year or so with cramps during my period. I am not used to it and am missing two or three days of work every month because of it.”

“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?”

“Sometimes I have diarrhea as well, but that is only for one day at the beginning. But for the entire time I have my period I am just so exhausted.”

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. Lower income

· D. Menarche late in adolescence

· 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 20% to 90%. Ten to fifteen percent of assigned females feel their symptoms are severe and have to miss school or work. Dysmenorrhea usually occurs hours to a day prior to the onset of menses and lasts up to 72 hours.

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. Week 2 Case Discussion

· There is also an association between tobacco use and dysmenorrhea.

· Females who have more children are noted to have a decreased incidence of primary dysmenorrhea.

· Additionally, females who report 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 females 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.

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.

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. See below for additional gender Teaching Points.

 

You continue asking about her gynecologic history.

“Can you tell me about your menstrual cycles?”

“I get my period every 29 days, and it lasts six to seven days. The first day is light, but the cramping starts. Then on the second and third days I am miserable with cramping pain, and one of those days I have diarrhea. Other than that, the rest of it is manageable.”

“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?”

“Oh, just with my husband.”

“Do you feel safe at home?”

“What do you mean?”

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

“Oh no, but thank you for asking. My sister was a victim of sexual abuse and her doctors never asked her.”

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

“I just had a boyfriend in high school, but we didn’t have sex. Then I met my husband.”

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

“Oh, I’m not sure what that means—I’m a woman and have intercourse with my husband.”

“Have you ever been pregnant?”

“I have two kids, aged eight and six. We conceived both times within a few months without difficulty, but I was never pregnant other than those two times.”

“How did the pregnancies go?”

“The pregnancies were fine. I didn’t need a C-section or anything—the deliveries went off without any problems.”

“How have your periods changed over the years?”

“Well, I started my period in eighth grade, I must have been 13. I had no problems with cramping or diarrhea until after my first child. Then I had minor cramping, but nothing like this. After my second child I felt better while I was breastfeeding but then the cramping started again. My periods have always been regular, but I guess now they last a day or two longer than before.”

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

“I tried heating pads and that seems to help some when I put it on my lower stomach. Sometimes I try Midol or Pamprin from the drug store, and I have tried acetaminophen, but nothing regular because it did not seem to help.”

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

“I don’t have any pain on any other days of the month, except those couple days during my period.”

Do you and your partner use birth control?”

“Yes, we use condoms mostly. I tried the pill once but I had vomiting with it and stopped after a week. I actually ended up trying three different types and had vomiting with all three.”

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

“No.”

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). Week 2 Case Discussion

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 periods who do not identify as female.

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

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

Gender Expression refers to the patient’s presentation as male, female or nonbinary, 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 than romantic orientation as people can be romantically and sexually attracted to different genders, or vary based on the person or their own identity.

For example, if a patient with a gynecological 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. For that purpose, we may refer to “people with a uterus” in this case to be more inclusive. Week 2 Case Discussion

TEACHING POINT

Questioning about Pregnancy 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?” Week 2 Case Discussion

 

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.

Pulmonary: Her lungs are clear to auscultation bilaterally.

Cardiovascular: Regular rate and rhythm without any murmur.

Abdominal: Normal bowel sounds. Nontender 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.”

 

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?”

She explains that she uses one super tampon every two to three hours on days two through five of her period. Sometimes she has to wear a pad in addition to the tampon as she bleeds so much it overflows. On the days that she has the worst cramping she also passes some clots. This is much heavier than what she experienced prior to her pregnancies.

“Have you ever had a sexually transmitted infection?”

“No.”

“Have you ever had an abnormal Pap test?”

“No.”

You look in the electronic medical record and see that her last Papanicolaou (Pap) test was one year ago and the results showed a normal Pap with a negative HPV, which means she is not due for another Pap test until four years from now. (Per guidelines, females over 30 who are co-tested for HPV and have a normal Pap test should have this repeated every five years). If she were age 21-30, HPV testing would not be performed for a normal Pap test, and it would be repeated every three years. Week 2 Case Discussion

“Do you feel pain when you have intercourse?”

“At times, but it is rare. I think that is when I have some dryness though. Maybe I also get it when my husband is deeper as well. I had not thought about it much until now.”

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

“Sometimes I gain water weight but I thought that was normal. My family says I get grumpy too but I don’t notice that. I do have to go to bed early during the first few days of my period.”

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

“I will have times when I have to urinate frequently but it is never painful. I did have a bladder infection once, but I have never had anything like that again. I never have trouble with bowel movements. I am very regular. I try to eat fiber every day.”

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.

 

Once you and the nurse 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 and the nurse 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, and you gently insert the speculum at an angle to allow for maximum comfort and then readjust 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. Week 2 Case Discussion

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 nontender 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.”

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. Week 2 Case Discussion

· Metrorrhagia is irregular frequent bleeding but it doesn’t have to be heavy.

· Menometrorrhagia that is irregular frequent and heavy bleeding.

TEACHING POINT

Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria

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 disorder.

The patient must have one of the following: marked mood lability, irritability or anger, depressed mood or feeling hopeless, or anxiety and edginess. Week 2 Case Discussion

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.

 

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

· E. Endometriosis

· F. Fibroids

· G. Inflammatory bowel disease

· H. Irritable bowel syndrome

· I. Leiomyosarcoma

· J. Mental health concerns

· K. Ovarian cysts

· L. Uterine polyps

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. Week 2 Case Discussion

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.

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. Some people will prefer to avoid hormonal options if possible.

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. Week 2 Case Discussion

 

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 of 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. Week 2 Case Discussion

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. Week 2 Case Discussion

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. Week 2 Case Discussion

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.

 

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. Week 2 Case Discussion

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 10  3 /μL (8.0 cells x10  9 /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.

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?”

“I took it three times a day like you said. At first I felt nauseated but then I remembered to eat with it so that was better. Sometimes I would forget the dose in the middle of the day while I was at work, but I took it as scheduled the majority of the time.”

“Did it make your pain any better?

“The pain is a little 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?”

“I guess the pain used to be eight or nine on bad days when I saw you last time. Now it is about a three every day of my period except for those two really bad days where it is a five or six.”

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

“Yes we did. We don’t want any right now but I am not sure about two or three years from now. And since the medication worked but not as well as I had hoped, I am interested in talking about one of the other options you brought up last time.” Week 2 Case Discussion

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. Depo-Provera

· E. Hysterectomy

· F. Progesterone-releasing intrauterine device

· G. Uterine artery embolization

SUBMIT

Answer Comment

The correct answer is E.

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.