What is the best course of treatment for a 26-year-old female with a history of miscarriage, experiencing severe lower abdominal cramping during menses, and currently presenting with mild discomfort and intermittent sharp pain in the ovarian region?

Management of Cyclic Pelvic Pain in a Young Woman with History of Miscarriage

This patient requires a systematic diagnostic workup starting with transvaginal ultrasound to evaluate for endometriosis, ovarian cysts, or adenomyosis, combined with immediate initiation of NSAIDs for pain management.

Immediate Pain Management

Initiate scheduled NSAIDs during menstrual cycles, as this patient is currently managing pain inadequately with only herbal teas. 1

• Ibuprofen 400-600 mg every 6 hours with food during menses and for 24 hours post-onset of cramping provides effective analgesia for dysmenorrhea 1
• The FDA label specifies that for dysmenorrhea, ibuprofen should be initiated at the earliest onset of pain at 400 mg every 4 hours as necessary 1
• Maximum daily dose should not exceed 3200 mg 1
• Heat application (hot showers, heating pads) can be continued as adjunctive therapy, as heat reduces cramping pain based on dysmenorrhea studies 2

Diagnostic Workup Priority

Transvaginal ultrasound is the essential first-line imaging study for this clinical presentation. 3

Primary Differential Diagnoses to Evaluate:

Endometriosis is the leading consideration given:

• Severe cyclical pain that intensifies during menses 4
• Pain radiating to lower back 4
• Sharp, stabbing pain with movement localized to right ovarian region 3
• Age-appropriate (reproductive years) 4

Ovarian cysts must be excluded:

• Sharp, intermittent right-sided pain is characteristic 3
• Cysts can cause asymmetric ovarian enlargement and acute pain episodes 3
• Transvaginal ultrasound has superior sensitivity for ovarian pathology 3

Adenomyosis should be considered:

• Presents as chronic pelvic pain in reproductive-age women 4
• Associated with severe menstrual cramping 4

Additional Considerations:

Pelvic inflammatory disease remains in the differential despite remote miscarriage:

• Can manifest with tubal wall thickening or inflammatory changes 3
• History of prior pregnancy loss and pelvic examination 17 months ago provides potential risk 4

Post-miscarriage complications are unlikely given:

• 17-month interval since miscarriage 2
• Documented declining hCG at that time 2
• However, adhesions from prior instrumentation could contribute to chronic pain 4

Diagnostic Algorithm

1. Obtain β-hCG before any imaging to exclude current pregnancy 3

2. Transvaginal ultrasound as first-line imaging:

   • Evaluate ovaries for cysts, masses, or asymmetric enlargement 3
   • Assess uterus for adenomyosis or fibroids 4
   • Look for free fluid, hydrosalpinx, or inflammatory changes 4
   • Examine for endometriomas or other signs of endometriosis 4

3. If ultrasound is inconclusive and pain persists, consider:

   • MRI pelvis for definitive endometriosis evaluation 4
   • Laparoscopy remains gold standard for endometriosis diagnosis if imaging non-diagnostic 4

Critical Red Flags to Exclude

Ovarian torsion must be considered with acute-on-chronic right-sided pain:

• Presents with asymmetrically enlarged ovary with twisted pedicle 3
• Requires urgent surgical intervention 3
• High index of suspicion needed for timely diagnosis 3

Appendicitis should be excluded if pain becomes acute:

• Most common surgical emergency in right lower quadrant 3
• CT has 95% sensitivity and 94% specificity 3

Common Pitfalls to Avoid

Do not assume gynecologic origin without systematic evaluation of gastrointestinal, urologic, and musculoskeletal systems, as chronic abdominal pain has broad differential 4, 5

Avoid repetitive testing once functional diagnosis established: If organic pathology is confidently excluded and functional pain diagnosed, repetitive imaging is not recommended 5

Do not dismiss severity based on current mild symptoms: This patient rates pain 6/10 during menses with significant functional impairment (pain with movement), requiring definitive diagnosis 5, 6

Follow-Up Plan

• Schedule transvaginal ultrasound within 1-2 weeks 3
• Initiate trial of scheduled NSAIDs during next menstrual cycle 1
• If imaging reveals endometriosis or other treatable pathology, refer to gynecology for definitive management 4
• If workup negative for organic disease, consider referral for cognitive therapy and management of functional pain disorder 5