Pediatric emergency medicine trisk 2149 2149

Clinical Assessment
A detailed menstrual history is important to obtain from the patient complaining
of severe menstrual cramps. Information about the timing of her first period
(menarche), regularity of her cycles, duration of menstrual flow, and the amount
of blood flow per period are important to know. The practitioner should ask about
accompanying signs such as nausea, vomiting, dizziness, or diarrhea. Knowing
whether the cramps keep the patient home from school gives a clue to the
adolescent’s ability to function with the dysmenorrhea. Asking about precipitating
factors (physical activity, bowel movement, urination) or relieving factors (rest,
exercise, heat, medications) is important. Symptoms are usually better controlled
with NSAIDs than with acetaminophen.
A physical examination for dysmenorrhea does not routinely include a pelvic
examination unless the provider is concerned about an imperforate hymen,
adnexal masses, or a sexually transmitted infection. Inspection and palpation of
the abdominal wall for masses, and hernias should be performed for all patients.
It is helpful to ask the patient to point to the location of the pain; the provider
should gently palpate this area at the end of the abdominal examination to avoid
exacerbating pain at the start of the examination. Patients should also be asked to
flex and contract the abdominal wall muscles. Increased pain with these
maneuvers suggests a myofascial etiology of the pain (Carnett sign). The back
and the sacroiliac joints should be palpated to evaluate for tenderness and
radiation.
For patients with a history of sexual activity presenting with pelvic pain, a
bimanual examination should be performed to evaluate for PID. Findings of
cervical motion tenderness, adnexal tenderness, or uterine tenderness would be
consistent with a clinical presentation of PID (see section on PID). Patients with
an undiagnosed STI may present with pelvic pain or with irregular or heavy
vaginal bleeding. Endometriosis may also have findings of adnexal, uterine, or
rectovaginal tenderness or nodularity on bimanual or rectal examination, although
these symptoms are more likely to develop after several years and are less likely
to be found among adolescents than adults. It is important to point out that the

initial treatment of endometriosis is the same as for primary dysmenorrhea
(NSAIDs are first line, followed by hormonal medications); surgical intervention
is not indicated unless a patient has failed first-line therapies.
If pelvic anatomy should be further explored, ultrasonography or MRI is an
option to consider. Pelvic ultrasound is an appropriate initial imaging study to
evaluate uterine and ovarian anatomy. Patients and families should be informed
that optimal ultrasound imaging of the pelvis often requires use of both an