What history taking and physical exam should be done for a 27-year-old active duty female with severe menstrual cramping?

Evaluation of Severe Menstrual Cramping in a 27-Year-Old Active Duty Female

For a 27-year-old active duty female with severe menstrual cramping, obtain a focused menstrual and reproductive history, assess for Female Athlete Triad components, and perform a targeted physical examination including vital signs, BMI, and pelvic exam to differentiate primary from secondary dysmenorrhea.

History Taking

Menstrual History

• Document menstrual cycle characteristics: cycle length (normal 23-35 days), duration of bleeding, and regularity using a menstrual chart for at least 6 months 1
• Characterize the pain: onset timing relative to menses (primary dysmenorrhea typically begins with bleeding onset and lasts 48-72 hours), severity, location, and duration 2, 3
• Assess impact on function: specifically ask about interference with military duties, physical training, and academic activities, as 66% of female military cadets report menstrual symptoms interfering with physical activities 4
• Screen for menstrual irregularities: oligomenorrhea (>35 days between cycles), amenorrhea (>6 months without bleeding), or polymenorrhea (<23 days) 1

Female Athlete Triad Screening (Critical for Active Duty Personnel)

• History of menstrual disturbances: delayed menarche, irregular cycles, or amenorrhea—these are significant risk factors for stress fractures in athletes and military personnel 1
• History of stress fractures or recurrent non-healing injuries 1
• Eating and weight history: history of dieting, critical comments about weight from superiors, pressure to lose weight 1
• Energy availability assessment: ask about dietary intake relative to exercise demands, as low energy availability causes exercise-associated menstrual disturbances 1
• Psychological factors: screen for depression, perfectionism, obsessiveness 1

Reproductive and Sexual Health History

• Sexual practices and contraception use: current methods, consistency of use, and any contraindications to hormonal contraceptives 1
• History of sexually transmitted infections or pelvic inflammatory disease 1
• Pregnancy history: gravidity, parity, outcomes 1
• Trauma history: ask about unwanted sexual activity or sexual assault using trauma-informed approach, as this predisposes to chronic pelvic pain and dysmenorrhea 1
• Infertility concerns: inability to conceive after 12 months of unprotected intercourse (or 6 months if >35 years) 1

Associated Symptoms

• Physical symptoms: headache, lethargy, sleep disturbances, body pains, nausea, vomiting, diarrhea, constipation 3
• Psychological symptoms: anxiety, depression, irritability, mood disturbances 3
• Heavy bleeding: assess for menorrhagia, which may indicate secondary causes 5
• Signs of secondary dysmenorrhea: dyspareunia, non-cyclic pelvic pain, abnormal vaginal discharge 1

Medical and Surgical History

• Past gynecologic conditions: endometriosis, uterine fibroids, ovarian cysts, cervical procedures 1
• Previous surgeries: particularly pelvic or abdominal 1
• Thyroid disorders or other endocrine conditions 1
• Current medications: especially those affecting coagulation or hormones 1

Military-Specific Concerns

• Difficulties with menstrual hygiene management: obtaining, changing, and disposing of menstrual materials during field exercises or deployments, as 62.6% of female cadets report difficulties changing materials 4
• Impact on duty performance: missed training days, reduced physical performance 4

Physical Examination

Vital Signs and General Assessment

• Vital signs: blood pressure, heart rate, respiratory rate to assess for severe bleeding complications 6
• Height, weight, and BMI calculation: assess for eating disorders or Female Athlete Triad 1
• Waist-to-hip ratio: truncal obesity (WHR >0.9) may suggest polycystic ovary syndrome 1

Targeted Physical Examination

• Thyroid examination: assess for enlargement, nodules, or tenderness to identify thyroid disease 1
• Skin examination: look for hirsutism (male escutcheon pattern), acne, or signs of androgen excess suggesting PCOS 1
• Breast examination: assess for galactorrhea (may indicate hyperprolactinemia) 1
• Abdominal examination: palpate for masses, organomegaly, or tenderness 1

Pelvic Examination

• External genitalia: assess for abnormalities, lesions, or discharge 1
• Speculum examination: evaluate cervix for ectropion, discharge, or lesions; obtain cervical cancer screening if due 1
• Bimanual examination: assess uterine size, shape, position, mobility; check for adnexal masses or tenderness; palpate for cul-de-sac nodularity suggesting endometriosis 1
• Digital rectal examination: if indicated to assess for posterior cul-de-sac pathology 1

Initial Laboratory Assessment (If Indicated)

When to Order Labs

• If heavy bleeding is present: complete blood count to assess for anemia (hemoglobin, hematocrit), coagulation studies 1, 5
• If menstrual irregularities are present: thyroid function tests, prolactin level, follicle-stimulating hormone/luteinizing hormone (day 3-6 of cycle), progesterone (mid-luteal phase), testosterone, DHEAS 1
• If PCOS is suspected: fasting glucose and insulin 1

Clinical Pitfalls to Avoid

• Do not assume primary dysmenorrhea without excluding secondary causes: perform pelvic examination if patient has risk factors for secondary dysmenorrhea (dyspareunia, non-cyclic pain, abnormal bleeding) 2
• Do not overlook Female Athlete Triad: active duty personnel are at high risk, and 90% of peak bone mass is attained by age 18, making early intervention critical 1
• Do not dismiss functional impact: menstrual symptoms significantly affect military performance, with over 90% of female cadets reporting menstrual changes in rigorous training environments 4
• Use trauma-informed approach: avoid approaching from behind during thyroid exam, provide patient control during examination, and explicitly ask permission before sensitive exams 1
• Consider pregnancy: perform pregnancy test if any doubt exists, especially before prescribing NSAIDs or hormonal contraceptives 1