Adolescent dysmenorrhea (<18 years)

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Adolescent dysmenorrhea (<18 years)

Pelvic exam

Consider adjunctive therapies

Affects ADLs, sports or school?

Possible secondary dysmenorrhea, consider gynecology consult, off pathway

Effective symptom resolution?

Treat appropriately

Start hormonal therapy with OCPs (may also use other hormonal methods if preferred by the patient)

Effective symptom resolution?

Continue therapy

Consider gynecology consult

Start NSAID (start with a loading dose at the onset of menses and continue a scheduled doese untill the first 1-2 days of the menstrual cycle or the duration of pain)

Adjunctive therapies

  • Acupuncture
  • Heating pad/hotwater bottle/chemical adhesive pad (e.g. Thermacare™)
  • Exercise
  • Dietary changes (low fat-vegetarian diet)
  • Behavioral interventions (mindfulness, coping strategies, biofeedback, etc.)
  • Vitamin B1 (100 mg daily)
  • Vitamin E (500 units daily)
  • Magnesium supplementation

Ultrasound Pelvis

Consult gynecology for diagnostic laparoscopy (consider levonorgestrel IUD at the time of the laparoscopy)

Treat appropriately

Inclusion Criteria
  • Recurrent, crampy lower abdominal pain that occurs during menstruation
Exclusion Criteria
  • History of abdominal/pelvic surgery
  • Immunocompromised or oncologic history
  • Other complex medical history

Sexually active or severe symptoms?

Concern for PID?

Detailed history including HEADSS exam

Urine Pregnancy, Urine

Pelvic exam


Common symptoms (typically begins with onset bleeding or < 24 hr before onset of menses)

  • Crampy lower abdominal/pelvic pain
  • Low back pain
  • Nausea/vomiting/diarrhea
  • Headache
  • Fatigue
  • Dizziness

NSAIDs for dysmenorrhea

  • First line (propionic acid class)
  • Ibuprofen
  • Naproxen
  • Second line (fenamate class)
  • Mefenamic acid

Does the patient have another source that could explain the dysmenorrhea?

  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Psychogenic disorders
  • Endometriosis
  • Adenomyosis
  • Ovarian cysts
  • Intrauterine/pelvic adhesions
  • Pelvic inflammatory disease
  • Imperforate/incomplete hymenal fenestration
  • Cervical stenosis
  • Intrauterine contraceptive device (IUD)