Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Dysmenorrhea, Primary
DYSMENORRHEA, PRIMARY
Painful menstruation without demonstrable pelvic disease. Occurs 1 to 3 years after menarche when ovulation is established.
I. Etiology
A. Recent data demonstrate that prostaglandins, which are released during the breakdown of the endometrium, are higher in dysmenorrheic females. The prostaglandins act as pain mediators and stimulate uterine contractility.
B. Dysmenorrhea is not usually associated with the onset of menses, although some adolescents experience discomfort with the first cycles (generally anovulatory).
II. Incidence
A. An estimated 75% of all adolescent girls complain of one or more symptoms of dysmenorrhea, and an estimated 18% of young women have severe enough symptoms to interfere with normal activities.
B. Most common gynecologic complaint in this age group
C. Leading cause of short-term school absenteeism in females
III. Subjective data
A. Onset of one or more of the following symptoms during or prior to menstruation. Pain usually starts within 1 to 4 hours of onset of menses but can occur 1 to 2 days prior to menses. Symptoms persist for 24 to 48 hours following beginning of menstrual flow, or less frequently for 2 to 4 days.
1. Premenstrual tension, including irritability or emotional lability, headache
2. Abdominal cramps
3. Nausea, vomiting, anorexia
4. Constipation, diarrhea
5. Weight gain
6. Fluid retention, bloating (3 to 5 lb in the 4 to 7 days prior to onset of menses)
7. Syncope
8. Vaginal discomfort
9. Suprapubic pain radiating to back and thighs
B. Pertinent subjective data to obtain
1. Detailed menstrual history
a. Age at menarche
b. Regularity of menses
c. Amount of flow
d. Duration of menses
e. Onset of cramping in relation to menarche
2. Location and description of pain
3. When pain or cramping occur
4. How long pain lasts
5. Any premenstrual symptoms (e.g., bloating, irritability)
6. Mittelschmerz
7. Expectations of menses; history of mother or sisters with dysmenorrhea
8. Absences from school because of dysmenorrhea: How often and how many days? Does she miss other activities (e.g., parties, sports events)?
9. Treatments used and effectiveness
10. Adolescent’s understanding of the menstrual cycle
11. Adolescent’s relationship with mother
12. Sexual activity: Some adolescents will use a complaint of dysmenorrhea as an entry to the health care system when they either want, or want to discuss, birth control.
13. Note: A detailed menstrual history should be obtained from every adolescent female presenting for routine health care. Discussion should include questions about discomfort relating to menses.
IV. Objective data
A. Weight, height, blood pressure
B. Mild cramps on first day: Complete physical examination, including inspection of external genitalia for hymenal abnormalities, is appropriate for 13to 16-year-old age group who are not sexually active.
C. Moderate to severe cramps: Complete physical examination, including pelvic exam; if unable to complete pelvic exam, rectoabdominal exam should be done to rule out pelvic pathology. Include careful palpation of uterosacral ligaments for tenderness or nodules (suggestive of endometriosis).
D. Include pelvic exam, Pap smear, and cultures for adolescents who are sexually active.
E. Pelvic ultrasound to rule out uterine or vaginal anomalies (will not detect endometriosis)
V. Assessment
A. Diagnosis of primary dysmenorrhea can be made by history typical for primary dysmenorrhea and negative findings on physical examination.
B. Differential diagnosis: Secondary dysmenorrhea; Atypical history and positive findings on physical examination; adnexal tenderness and masses or nodules of uterosacral ligaments; pain increased over time
VI. Plan
A. The goals of treatment are to allay anxiety and provide symptomatic relief of pain.
B. Reassurance
1. Simple explanation of the menstrual process and anatomy
2. The pain is not “in her head” as may have been suggested.
3. Pain can be managed: no need to anticipate pain every month.
C. Pharmacologic management: Begin with the simplest treatment, and progress to stronger medications as needed. Use one of the following:
1. Aspirin: 300 to 600 mg every 4 hours as needed or
2. Anaprox: 550 mg stat, followed by 275 mg every 6 hours or 550 mg bid (maximum dose 1,375 mg/24 hours)
or
3. Orudis: 25 to 50 mg every 6 to 8 hours; may increase dosage to 75 mg every 6 to 8 hours (maximum dose 300 mg/24 hours)
or
4. Motrin: 400 mg every 4 to 6 hours; increase to 600 or 800 mg every 6 to 8 hours if necessary (maximum dose 3,200 mg/24 hours)
or
5. Ponstel: 500 mg initially, then 250 mg every 6 hours as needed for pain; do not exceed 1 week of therapy.
6. Note: For severe dysmenorrhea associated with vomiting, one of the above medications may be started 1 to 2 days prior to menses if not sexually active.
7. Birth control pills—if NSAIDs and antiprostaglandins ineffective or child sexually active. Choice of oral contraceptive should be based on smoking history, past medical history, and family history. Low-dose estrogen preparations may not be appropriate to support bone health.
a. Pelvic examination and Pap smear prior to starting treatment
b. Indicated for severe dysmenorrhea associated with vomiting and with unsatisfactory response to analgesics and antiprostaglandins
c. Use for 3 months, discontinue for 3 to 6 months, and resume for another 3 months. Patient will usually continue to have relief for 1 to 2 months between use of birth control pills because of anovulation. If cramps recur, try antiprostaglandin before starting birth control pills again.
d. Use of birth control pills helps distinguish organic pathology. If cramps become worse while patient is on birth control pills, refer for laparoscopy to rule out endometriosis.
8. Compazine: 5 mg every 4 hours at onset of menses to control vomiting
D. Local measures. Heating pad on abdomen
VII. Education
A. Dysmenorrhea is not abnormal. It does not mean that there is any physical abnormality or disease present, nor is it a psychosomatic illness.
B. Dysmenorrhea is an indication that ovulation is occurring. Stress the positive future aspects of motherhood.
C. Dysmenorrhea may be more severe during times of stress.
D. If fluid retention or bloating is a problem, decrease salt intake for 10 days before menses.
E. Continue with regular routine as much as possible. Some discomfort may persist once on medication, but if pain is under control, do not forego activities.
F. Increased exercise (e.g., jogging, bicycling, ice skating) on a regular basis has been of value in decreasing menstrual pain. Competitive athletes have fewer ovulatory cycles and therefore less dysmenorrhea.
G. Showers, baths, and shampoos during menses will not increase discomfort or cause cramps.
H. Medication
1. Aspirin taken with a cup of coffee or tea may be quite effective. The caffeine potentiates the effects of aspirin.
2. Take antiprostaglandins with food to minimize gastrointestinal side effects.
3. Continue antiprostaglandins for 2 to 3 days only.
4. Do not use medication longer than necessary.
5. NSAIDs prevent cramps and treat pain. Dysmenorrhea treatment is most effective if treatment is initiated at onset of menstrual shedding or before, if possible.
6. After 1 to 2 years on a birth control pill regimen of 3 months on and 3 months off, cramps often improve spontaneously.
7. Do not prescribe antiprostaglandins for anyone with a history of allergy to aspirin or any NSAID.
8. When on the birth control pill, flow will be lighter.
9. Give mother and child complete information on birth control pill, and have them read booklet that comes with prescription packet.
10. Stress importance of calling the office immediately if there are any questions regarding side effects.
11. Take all medication as directed. Do not take more than prescribed.
VIII. Follow-up
A. Have patient call after next menstrual period to report effectiveness of treatment.
B. Return visit in 3 to 4 months to evaluate effectiveness of medication and to maintain encouragement and support
C. Follow-up visit every 3 months while on birth control pills with a complete physical
IX. Complications
A. Vomiting causing inability to retain medication
B. Psychological stress
X. Consultation/referral
A. Questionable or abnormal findings on physical examination or history
B. Severe dysmenorrhea prior to institution of pharmacologic therapy
C. No response to prescribed treatment
D. Inability to retain medication because of vomiting