What is the best management approach for a 20-year-old woman with a 6-year history of dysmenorrhea (painful menstruation), recent worsening of symptoms, and significant anxiety despite previous treatments and inconclusive investigations?

From the Guidelines

The most appropriate next step in managing this 20-year-old woman with a 6-year history of dysmenorrhea and significant anxiety is to adopt a multidisciplinary approach, focusing on both the physical and psychological aspects of her condition. This approach should include a combination of medical therapies and lifestyle modifications.

• The patient should be started on a combined hormonal contraceptive, such as a pill containing 30-35 mcg ethinyl estradiol with levonorgestrel or norgestimate, taken continuously for 3-4 months to suppress menstruation and reduce pain, as suggested by 1.
• Scheduled NSAIDs like naproxen 500 mg twice daily or ibuprofen 600 mg every 6 hours during painful episodes should be used to directly inhibit prostaglandin synthesis, which mediates menstrual pain.
• Given her significant anxiety, cognitive behavioral therapy (CBT) specifically targeting pain management and anxiety would be beneficial, as supported by 1 and 1, which emphasize the importance of addressing psychological factors in pain management.
• A referral to a gynecologist for laparoscopic evaluation to rule out endometriosis, which commonly presents with progressive dysmenorrhea, should be considered, as endometriosis is a common cause of chronic pelvic pain and dysmenorrhea, and its diagnosis and treatment can significantly improve quality of life, as noted in 1.
• The patient should also be encouraged to use non-pharmacological approaches such as heat therapy, regular exercise, and relaxation techniques to help manage her symptoms, as these methods can contribute to overall well-being and pain reduction, in line with recommendations from 1 and 1.
• A pelvic ultrasound should be performed if not already done to exclude structural abnormalities, ensuring that any underlying conditions are identified and addressed appropriately. By addressing both the physical and psychological components of her condition through a comprehensive and multidisciplinary approach, the patient's quality of life, pain levels, and anxiety can be significantly improved.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Dysmenorrhea: For the treatment of dysmenorrhea, beginning with the earliest onset of such pain, ibuprofen tablets should be given in a dose of 400 mg every 4 hours as necessary for the relief of pain. The most appropriate next step in her management is to optimize her pain management. Since she has already tried over-the-counter analgesics and oral contraceptives with no significant relief, consider adjusting her dosage or switching to a different medication.

• Ibuprofen is a viable option for treating dysmenorrhea, with a recommended dose of 400 mg every 4 hours as needed. Given her history of dysmenorrhea and lack of response to previous treatments, schedule regular visits with her primary care physician to monitor her symptoms and adjust her treatment plan as necessary 2.

From the Research

Management Approach

The patient's symptoms of dysmenorrhea and anxiety, despite previous treatments and inconclusive investigations, require a comprehensive management approach. The following steps can be considered:

• Schedule regular visits with her primary care physician to monitor her symptoms and adjust treatment as needed 3
• Consider counseling strategies, such as motivational interviewing or the BATHE strategy, to address her anxiety and improve her overall well-being 4
• Continue to explore other treatment options for her dysmenorrhea, such as alternative pain management strategies or referrals to specialist care

Ruling Out Other Conditions

It is essential to rule out other conditions that may be contributing to her symptoms. However, based on the information provided, there is no clear indication for:

• An ultrasound scan of the abdomen, as previous investigations, including ultrasounds and laparoscopy, have been inconclusive
• Prescribing antibiotics, as there is no evidence of infection
• Starting an antipsychotic, as her symptoms do not appear to be related to a psychiatric condition
• Adhesiolysis, as there is no indication of adhesions contributing to her symptoms

Importance of Follow-up

Regular follow-up appointments with her primary care physician are crucial in managing her symptoms and ensuring timely access to care 3. This approach can help identify any changes in her condition and adjust treatment accordingly.