What to do for severe menstrual cramps, nausea, and potential early period in a patient trying to conceive?

Immediate Emergency Evaluation Required

This patient needs urgent medical evaluation in an emergency department or urgent care setting immediately to rule out ectopic pregnancy, spontaneous abortion, or pelvic inflammatory disease (PID), as severe cramping, nausea, near-syncope, and early bleeding in a woman trying to conceive are red flags for potentially life-threatening conditions. 1

Critical Differential Diagnoses to Exclude

Ectopic Pregnancy (Highest Priority)

• Early bleeding with severe cramping in a woman attempting conception must be evaluated for ectopic pregnancy, which can present with vaginal bleeding 5 days before expected menses, severe unilateral or generalized pelvic pain, nausea, and near-syncope from internal bleeding 1
• Obtain immediate quantitative β-hCG, transvaginal ultrasound, and hemoglobin/hematocrit 1
• Ectopic pregnancy can be life-threatening if rupture occurs, leading to hemorrhagic shock 1

Spontaneous Abortion (Threatened or Incomplete)

• Severe cramping with early bleeding may represent threatened or incomplete abortion, particularly given the patient's attempts to conceive 1
• β-hCG testing is essential to confirm or exclude pregnancy 1
• If pregnancy is confirmed with severe cramping and bleeding, ultrasound assessment of intrauterine pregnancy viability is mandatory 1

Pelvic Inflammatory Disease

• Severe pelvic pain with nausea and systemic symptoms (near-syncope) warrants evaluation for PID, especially if sexually active 1
• Look for fever >38.3°C (101°F), cervical motion tenderness, adnexal tenderness, abnormal vaginal discharge, and elevated inflammatory markers 1
• PID requires immediate empiric antibiotic treatment to prevent long-term sequelae including infertility, which is particularly concerning in a patient trying to conceive 1

Emergency Department Evaluation

Immediate Testing Required

• Quantitative β-hCG to confirm or exclude pregnancy 1
• Complete blood count to assess for anemia from bleeding 1
• Transvaginal ultrasound if β-hCG positive to locate pregnancy and assess viability 1
• Pelvic examination to assess for cervical motion tenderness, adnexal masses, and discharge 1
• Consider STI testing (gonorrhea/chlamydia) if PID suspected 1

Warning Signs Requiring Immediate Action

• Hemodynamic instability (hypotension, tachycardia, near-syncope) suggests possible ruptured ectopic pregnancy or severe hemorrhage requiring immediate resuscitation 1
• Fever with severe pelvic pain suggests PID or septic abortion, requiring immediate antibiotics 1
• Unilateral severe pain with positive pregnancy test strongly suggests ectopic pregnancy 1

If Life-Threatening Conditions Are Excluded

Primary Dysmenorrhea Management (Only After Ruling Out Above)

• If pregnancy test is negative, ultrasound is normal, and examination shows no signs of PID, severe dysmenorrhea can be treated with NSAIDs 2, 3, 4, 5
• Ibuprofen 400 mg every 4-6 hours is the first-line treatment for dysmenorrhea, starting at the earliest onset of pain 2, 4, 5
• Maximum daily dose is 3200 mg, though doses above 400 mg every 4-6 hours show no additional benefit for pain relief 2
• Administer with food or milk to reduce gastrointestinal side effects 2

Severe Symptoms Requiring Further Investigation

• Nausea, vomiting, and near-syncope are concerning symptoms that exceed typical primary dysmenorrhea and warrant investigation for secondary causes even if initial workup is negative 3, 4, 5
• Consider endometriosis or adenomyosis if symptoms persist despite NSAID therapy, particularly in a patient with fertility concerns 3, 4
• Referral to gynecology is appropriate if symptoms do not respond to NSAIDs within 2-3 cycles or if secondary dysmenorrhea is suspected 4

Critical Pitfall to Avoid

Do not assume this is simple dysmenorrhea without first excluding pregnancy-related complications and PID. The combination of attempting conception, early bleeding, severe pain, nausea, and near-syncope creates a high-risk scenario that demands immediate evaluation before attributing symptoms to primary dysmenorrhea 1, 3, 4.