Aquifer Family Medicine 32 Discussion Aquifer Family Medicine 32 Discussion • Discuss the questions that would be important to include when interviewing a patie

Aquifer Family Medicine 32 Discussion

Aquifer Family Medicine 32 Discussion

• Discuss the questions that would be important to include when interviewing a patient with this issue.
• Describe the clinical findings that may be present in a patient with this issue.
• Are there any diagnostic studies that should be ordered on this patient? Why?
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.

The student should be able to:

Describe the risk factors for dysmenorrhea. Describe normal and abnormal physical examination findings on a pelvic exam. Discuss an appropriate differential diagnosis for a patient with dysmenorrhea. Describe the treatment of dysmenorrhea. Define menorrhagia. Discuss the evaluation of a patient with possible premenstrual syndrome (PMS). List the treatment options for a patient with premenstrual syndrome. Describe the use and insertion for the progestin only intrauterine device (IUD) in a patient with dysmenorrhea.


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. 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. Aquifer Family Medicine 32 Discussion

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.


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.

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). Cisgender refers to a person whose sex assigned at birth, based on genitalia, matches their current gender identity.

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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.

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?” Aquifer Family Medicine 32 Discussion

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