How should a 14-year-old female with recent menarche presenting with sudden severe abdominal pain be evaluated and managed?

Evaluation and Management of Sudden Severe Abdominal Pain in a 14-Year-Old Girl After Starting Period

This 14-year-old girl requires immediate ultrasound evaluation to rule out ovarian torsion, which is a gynecologic emergency that can cause permanent infertility if diagnosis is delayed. 1

Immediate Diagnostic Workup

Essential First Steps

• Obtain urine or serum β-hCG immediately to rule out pregnancy-related complications, even in young adolescents, as a negative test essentially rules out ectopic pregnancy 1, 2
• Perform transvaginal AND transabdominal pelvic ultrasound with Doppler urgently in the Emergency Department as the first-line imaging modality 1, 3
• Do NOT start with CT imaging in this reproductive-aged female, as it exposes the patient to unnecessary radiation when gynecologic causes are most likely 3

Critical Red Flags to Assess

• Severity and pattern of pain: Ovarian torsion typically presents as severe, constant pain that may fluctuate in intensity but rarely completely resolves without intervention 1
• Timing relative to menses: Menstruation can precipitate acute angioedema episodes in certain conditions, and severe abdominal pain during menses warrants consideration of multiple diagnoses 4
• Presence of fever: Fever suggests tubo-ovarian abscess rather than ovarian torsion 1

Key Ultrasound Findings to Identify

For Ovarian Torsion (Most Time-Sensitive Diagnosis)

• Unilaterally enlarged ovary (>4 cm or volume >20 cm³) 1
• Peripheral follicles (found in up to 74% of cases) 1
• Abnormal or absent venous flow (100% sensitivity, 97% specificity) 1
• Whirlpool sign (twisted vascular pedicle with 90% sensitivity in confirmed cases) 1
• CRITICAL PITFALL: Normal arterial blood flow does NOT rule out ovarian torsion, as torsion can be intermittent or partial, and venous flow abnormalities are more sensitive 1

For Other Gynecologic Emergencies

• Tubo-ovarian abscess: 93% sensitivity and 98% specificity on pelvic ultrasound 3
• Hematometrocolpos: Consider in patients with amenorrhea and abdominal pain, as imperforate hymen can cause retrograde menstruation 5

Management Algorithm Based on Ultrasound Findings

If Ovarian Torsion Suspected

• Obtain urgent gynecologic consultation for immediate laparoscopic detorsion 1
• Proceed with surgery even if the ovary appears necrotic, as intraoperative visual assessment is highly inaccurate—only 18-20% of ovaries that appear necrotic are actually necrotic on pathological examination 1
• Time is critical: Early detection is essential to prevent adnexal necrosis and infertility 1

If Ultrasound is Inconclusive but Clinical Suspicion Remains High

• Order MRI pelvis without and with IV contrast (80-85% sensitivity for torsion, showing enlarged ovary with stromal edema and absent/diminished enhancement) 1, 3
• Consider CT abdomen/pelvis with IV contrast as second-line (74-95% sensitivity, 80-90% specificity), showing asymmetrically enlarged ovary, twisted pedicle, and abnormal/absent ovarian enhancement 1

If Pelvic Inflammatory Disease Suspected

• Initiate empiric broad-spectrum antibiotics immediately when minimum criteria are met (uterine + adnexal + cervical motion tenderness), covering N. gonorrhoeae, C. trachomatis, gram-negative bacteria, anaerobes, and streptococci 2
• Do NOT delay antibiotics waiting for culture results, as this can cause permanent reproductive damage 2
• Obtain cervical cultures for gonorrhea/chlamydia to guide partner treatment 2

Rare but Important Differential Diagnoses in Adolescents

• Hematometra with uterine anomalies: Consider in postmenarchal girls with acute abdomen, as diagnosis may require MRI and can be missed on initial laparoscopy 6, 5
• Isolated fallopian tube torsion: Rare but reported in 13-year-old girls, requiring high index of suspicion to salvage adnexal structures 7

Critical Pitfalls to Avoid

• Never dismiss severe pain during menses as "just cramps": Diagnosis of abdominal angioedema during menses is very difficult, and severe abdominal pain (visual analog scale >5) with ascites or intestinal edema requires specific evaluation 4
• Do not require multiple criteria before acting: In suspected PID, requiring two or more findings reduces sensitivity and misses cases that can cause permanent reproductive damage 2
• Do not use CT as first-line: Ultrasound provides equivalent or superior diagnostic accuracy for gynecologic causes without radiation exposure 3, 2
• Do not assume normal arterial flow rules out torsion: Venous flow abnormalities are more sensitive 1