What is the workup for a 17-year-old female (f) with dysmenorrhea and abnormal uterine bleeding?

From the Guidelines

For a 17-year-old female with dysmenorrhea and abnormal uterine bleeding, I recommend starting with a thorough history, physical examination, and appropriate laboratory tests, followed by imaging if necessary, as outlined in the ACR Appropriateness Criteria for abnormal uterine bleeding 1. The workup should include:

• A thorough menstrual history
• Physical exam
• Basic laboratory tests including CBC, pregnancy test, and TSH
• Pelvic ultrasound may be warranted if symptoms are severe or if there's concern for structural abnormalities The American College of Radiology suggests that the workup of a woman with abnormal bleeding begins with a thorough history, physical examination, and appropriate laboratory tests, and may include imaging to primarily assess for structural abnormalities 1. According to the American College of Obstetricians and Gynecologists (ACOG), medical treatments for abnormal uterine bleeding associated with ovulatory dysfunction include progestin-only contraception and combined hormonal contraception 1. The most recent and highest quality study, ACR Appropriateness Criteria for abnormal uterine bleeding 1, recommends a thorough workup before initiating treatment, and suggests that combined hormonal contraceptives (CHCs) may be an appropriate treatment option for abnormal uterine bleeding. If CHCs are contraindicated or poorly tolerated, alternatives include progestin-only options like the levonorgestrel IUD or norethindrone acetate 5-10 mg daily. Patients should be counseled about potential side effects including nausea, breast tenderness, and breakthrough bleeding, which typically improve after 2-3 months of therapy. Follow-up should occur after 3 months to assess symptom improvement and medication tolerance.

From the FDA Drug Label

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 workup for a 17-year-old female with dysmenorrhea and abnormal uterine bleeding is not directly addressed in the provided drug labels. Key points:

• The provided drug labels discuss the treatment of dysmenorrhea with ibuprofen, but do not provide a comprehensive workup for abnormal uterine bleeding.
• A thorough workup would likely involve a combination of medical history, physical examination, laboratory tests, and possibly imaging studies to determine the underlying cause of the abnormal uterine bleeding. 2

From the Research

Diagnostic Approach

• The workup for a 17-year-old female with dysmenorrhea and abnormal uterine bleeding should start with a detailed history and physical examination, including a menstrual history and pregnancy test for patients who are sexually active 3.
• A complete gynecological evaluation, including a pelvic examination, may be useful to detect any kind of general disease that can compromise the hormonal reproductive system, but may not be necessary for all patients 4.
• Transvaginal ultrasonography or transrectal ultrasonography may be considered if secondary dysmenorrhea is suspected or if the patient is sexually active 3, 5.

Laboratory Tests

• Hematic β-hCG must be dosed in every fertile woman with abnormal uterine bleeding 4.
• Laboratory tests should be tailored to each patient, and may include tests for coagulopathy, thyroid dysfunction, or other conditions that may be contributing to the abnormal uterine bleeding 6, 7.

Classification and Etiology

• The PALM-COEIN classification system can be used to categorize the etiologies of abnormal uterine bleeding, including structural and non-structural causes 7.
• The most common causes of secondary dysmenorrhea include endometriosis, pelvic anatomic abnormalities, and infection 3, 5.

Management

• The first-line treatment for dysmenorrhea and abnormal uterine bleeding may include combined oral contraceptives, nonsteroidal anti-inflammatory drugs, or other medical therapies 4, 3, 6.
• Surgical procedures may be necessary for patients with structural lesions, such as polyps, fibroids, or malignancy 6, 7.
• Management should be individualized and take into account the patient's desire for current or future fertility 7.