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The physical examination should include components that are relevant to the patient’s complaint and with the patient’s history in mind. Thyroid palpation and an abdominal assessment are appropriate for all individuals with complaints of painful menstruation. A pelvic examination and bimanual exam are appropriate tests for sexually active individuals (Osavande & Mehulic, 2014). Adolescents that are not sexually active with histories consistent with primary dysmenorrhea do not need to have a pelvic examination (Osavande & Mehulic, 2014). Laboratory tests may be used pending the relevance determined by the provider. Laboratory tests may include: pregnancy test, CBC, thyroid function tests, vaginal and endocervical swabs, erythrocyte sedimentation rate, and urinalysis (Osayande & Mehulic, 2014). Additional tests may be ordered as necessary.
Diagnosis and Differentials
Without more information, the initial diagnosis in this case would be unspecified dysmenorrhea (ICD-10: N94.6). Further information and evaluations may be needed to rule out secondary causes of dysmenorrhea, if clinical findings are suspicious for secondary dysmenorrhea. Differential diagnoses may be: primary dysmenorrhea, endometriosis, pelvic inflammatory disease, fibroids, or uterine cancer (Hackley & Kriebs, 2017).
Therapies
Pharmacological therapies for primary dysmenorrhea include NSAIDs or oral contraceptives (Osavande & Mehulic, 2014). Strong evidence supports the use of NSAIDs as the first line treatment for primary dysmenorrhea (Osavande & Mehulic, 2014). The choice of NSAID should be made on an individual basis, though over-the-counter ibuprofen, Aleve, or Midol are popular and effective choices (Osavande & Mehulic, 2014). The decision to use oral contraceptives should be made by the patient after thorough education and risks are explained to the patient.
The most effective non-pharmacological therapy used to treat primary dysmenorrhea is the topical application of heat (Osavande & Mehulic, 2014). Some dietary supplements, such as omega 3 fatty acids and B vitamins, have shown mixed effectiveness for controlling menstrual pain (Osavande & Mehulic, 2014). Lifestyle modifications can also assist in decreasing painful menstruation. Some evidence suggests low fat or vegetarian diets can decrease intensity and duration of menstrual cramps (Alsaleem, 2018). Obesity and smoking are other factors that can be modified to improve menstrual cramps, through weight loss and smoking cessation, respectfully (Hackley & Kriebs, 2017). Stress reduction techniques may also improve symptoms in stressed individuals (Osavande & Mehulic, 2014).
Follow-Up
If symptoms of primary dysmenorrhea improve with the pharmacological adjustments and non-pharmacological interventions, Osavande and Mehulic (2014) recommend continuing treatment and reassessing every six months. If symptoms are not relieved, the patient should return to the clinic for further evaluation after menstruation.  
References
Alsaleem M. A. (2018). Dysmenorrhea, associated symptoms, and management among students at King Khalid University, Saudi Arabia: An exploratory study. Journal of Family Medicine and Primary Care, 7(4), 769-774. https://dx.doi.org/10.4103%2Fjfmpc.jfmpc_113_18
Hackley, B. & Kriebs, J. (2017). Primary care of women. Burlington, MA: Jones & Bartlett Learning.
Osayande, A. & Mehulic, S. (2014). Diagnosis and initial management of dysmenorrhea. American Family Physician, 89(5), 341-346. Retrieved from https://www.aafp.org/afp/2014/0301/p341.html
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