Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Dysmenorrhea
N94.6 – Dysmenorrhea, unspecified
I. DEFINITION
a. Primary dysmenorrhea is the occurrence of painful menses usually beginning within several years of menarche and in the absence of any pelvic pathology, but may occur at any time during childbearing years.
B. secondary dysmenorrhea is painful menstruation because of an identifiable pathologic or iatrogenic condition, which may be read- ily identifiable based on the history and findings in a physical examination.
II. ETIOLOGY
DYsMenorrHea 185
a. Primary dysmenorrhea: Caused by prostaglandins produced in the uterine lining and released into the bloodstream as the lining is shed, causing smooth muscle contraction, nausea, and/or diarrhea
B. secondary dysmenorrhea
1. extrauterine causes
a. endometriosis
b. tumors
i. subserosal leiomyomata
ii. Malignancies
iii. Pelvic tumors
c. ovarian cysts
d. Pelvic inflammatory disease
2. intrauterine causes
a. adenomyosis
b. endometriosis
c. intramural leiomyomata
d. Polyps
i. endometrial
ii. Cervical
e. Presence of an iuD
f. Cervical stenosis
g. endometritis
III. HISTORY
a. What the patient may present with
1. regular, recurrent pain that may occur monthly, prior to menses, or with menses
a. abdominal pain
b. Pelvic pain
c. severe backache
2. nausea, diarrhea, or constipation
3. Weakness
4. Dizziness
5. Weight gain
6. Breast tenderness
7. Backache
B. additional information to be elicited by asking the following questions.
1. relationship to menarche
2. When does pain begin?
3. How long does it last?
4. Does anything make it feel better?
5. When was last menstrual period?
6. What was birth control method(s) used?
7. any relationship to intercourse?
8. any vaginal discharge?
9. any fever related to pain?
10. What is menstrual flow like?
11. is this new? is this a change in pattern?
12. sensitivity to aspirin and nonsteroidal anti-inflammatories?
13. History of chronic illness (kidney disease)?
14. Current medications (prescription and otC)?
15. any postcoital bleeding?
16. any home remedies and/or folk remedies tried, use of comple- mentary and alternative therapies?
17. sti history, vaginitis/vaginosis?
IV. PHYSICAL EXAMINATION
a. Vital signs
1. Blood pressure
2. Pulse
3. temperature, if symptoms are present at time of visit
4. Weight
B. Vaginal examination (speculum): cervix, cervical pathology
C. Bimanual examination
V. LABORATORY EXAMINATION
a. Chlamydia as indicated
B. Gonorrhea culture as indicated
C. Wet mount as indicated
VI. DIFFERENTIAL DIAGNOSIS
See Etiology, II.
VII. TREATMENT
a. Medication
1. ibuprofen (Motrin) 400 mg 4 times a day, 200 mg to 400 mg every 4 to 6 hours (maximum 1.2 g/d)
2. Mefenamic acid (Ponstel) 250 mg, two tablets immediately and one every 6 hours
3. naproxen (anaprox) 275 mg, two tablets immediately and one tablet every 6 to 8 hours (no more than five tablets [1.375 g] per day); aleve 200 mg every 8 to 12 hours
4. naprosyn 500 mg every 12 hours or 250 mg every 6 to 8 hours (maximum 1.25 g the first day, then 1.0 g/d)
5. anaprox Ds 550 mg, one every 12 hours
6. aspirin with codeine, one to two tablets every 4 hours as needed
7. lbuprofen (advil) 200 mg, two tablets every 4 to 6 hours (maxi- mum 1.2 g/d) (otC)
8. Flurbiprofen (ansaid) 100 mg orally two or three times a day
9. Meclofenamate (Meclomen) one tablet (100 mg) every 6 hours as needed
10. other otC analogues
11. oral or possibly other hormonal contraceptive (to produce anovu- latory state)
B. other measures
1. reassurance
2. refer to premenstrual syndrome (PMs) guidelines for diet, com- plementary therapy, exercise, and vitamin recommendations
3. Heating pad
VIII. COMPLICATIONS
May occur with failure to recognize presence of entity as described in dif- ferential diagnosis that results in lack of appropriate treatment
IX. CONSULTATION/REFERRAL
a. Diagnosis of secondary dysmenorrhea
B. Failure to improve after treatment as in Treatment, VII
X. FOLLOW-UP
a. Yearly health examination and Pap smear/HPV screening per guidelines
B. secondary dysmenorrhea follow-up as indicated by physician or with consult
See Bibliographies.