CE ARTICLE

A case study and comprehensive differential diagnosis and care

plan for the three Ds of women’s health: Primary dysmenorrhea,
secondary dysmenorrhea, and dyspareunia
Wendy Stoelting-Gettelfinger, PhD, JD, APN, NP-C (Assistant Clinical Professor)
Indiana University School of Nursing, Bloomington, Indiana

Keywords
Women’s health; young adult women; sexual
health; human papilloma virus (HPV);
menorrhagia; patient education; primary care.
Correspondence
Dr. Wendy Stoelting-Gettelfinger, PhD, JD, APN,
NP-C, Indiana University, Department of
Nursing, 1033 E 3rd St. Rm 441, Sycamore Hall,
Bloomington, IN 47405.
Tel: 317-501-4161;
Fax: 812-855-6978;
E-mail: wstoelti@indiana.edu
Received: December 2008;
accepted: July 2009
doi: 10.1111/j.1745-7599.2010.00544.x
Disclosures
The author reports no conflicts of interest and
no inducements were made by any commercial
entity to submit this article.
Abstract
Purpose: To provide a case study for the discussion, diagnosis, manage-
ment, and comprehensive plan of care for primary dysmenorrhea, secondary
dysmenorrhea, and dyspareunia for the advanced practice registered nurse
(APRN) working in primary care.
Data sources: Selected text, research, clinical articles, and personal commu-
nication with expert APRNs.
Conclusions: Three of the most commonly presenting women’s health related
conditions include primary dysmenorrhea, secondary dysmenorrhea, and dys-
pareunia. These conditions can present a challenge in developing an accurate
differential diagnosis and appropriate plan of care. This article presents the
reader with a detailed case study that provides an analysis of each potential dif-
ferential diagnosis with rationale. A recommended diagnostic and therapeutic
plan of care is included for the reader’s review.
Implications for practice: If left untreated, primary dysmenorrhea, sec-
ondary dysmenorrhea, and dyspareunia can result in pain, suffering, and im-
paired fertility and sexual function. Patients frequently experience symptoms
for months to years prior to accurate diagnosis.

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fore menses begin, with the worst pain experienced on

Case study
Ms. S is a 20-year-old healthy female with a 2-year his-
tory of dysmenorrhea with onset of symptoms at age 18,
4 years after menarche. Past medical history included
a diagnosis of human papillomavirus (HPV) at age 19.
The patient’s primary presenting symptoms included a
4-month history of severe painful menstrual cramps
accompanied by painful intercourse. Severe menstrual
cramping and pain began 4 months ago when oral contra-
ceptives (OCs) were changed; the pain was so severe that
she reported several instances of absence from work. Pa-
tient takes naproxen 550 mg daily when cramps and pain
begin with no relief. Painful cramping starts 5–7 days be-
the first day of flow; the pain disappears completely by
the third day of flow. Ms. S is gravida 0; last normal men-
strual period (LMP) began 6 days ago at her office visit.
Her physical exam was unremarkable with the exception
of a dry vaginal vault. She had been treated conserva-
tively by her primary care physician with OCs and non-
steroidal anti-inflammatory drugs (NSAIDs) for her dys-
menorrhea with no relief. Her surgical history included
abdominal surgery as an infant to enclose the bladder
inside the pelvic cavity with no subsequent problems.
She also reported painful intercourse (dyspareunia) and
vaginal dryness with penile thrusting for the past 4
months about 1 week before onset of her period. Patient

Journal of the American Academy of Nurse Practitioners 22 (2010) 513–522 

C 2010 The Author 513
Journal compilation 
C 2010 American Academy of Nurse Practitioners
The 3 Common Ds in Women’s Health
reported an abnormal Papanicolau (Pap) smear 1 year
prior to office visit. Patient requested human immuno-
deficiency virus (HIV) testing because she had never been
previously tested. No history of sexually transmitted in-
fections other than HPV. Patient reported no change in
vaginal discharge with no itching, burning, or malodor.
Patient reported having unprotected sexual intercourse
with two partners during her lifetime.
Objective findings included Pap and pelvic annual
exam with results of atypical squamous cells of unde-
termined significance (ASCUS)-HPV high-risk HPV in the
previous year. Colposcopy at that time revealed no atyp-
ical cells. Pelvic exam performed 4 months earlier with
negative Neisseria gonorrhoeae (GC) and chlamydia cul-
tures.
Medications:
r Low-dose OC: 30 ethinyl estradiol/0.15 desogestrel
one tablet by mouth (PO) every day.
r Naproxen 550 mg daily as needed for menstrual pain.
Overview
This article presents a case study and comprehensive
analysis with rationale of the potential differential diag-
noses and care plan for the advanced practice registered
nurse (APRN) in the primary care setting. Three of the
most commonly presenting women’s health-related con-
ditions in a family-based practice include primary dys-
menorrhea, secondary dysmenorrhea, and dyspareunia.
Although these conditions occur commonly, they can
present a challenge in developing an accurate differential
diagnosis and appropriate plan of care. A sample diagnos-
tic and comprehensive treatment plan are also included.
Differential diagnosis
The differential diagnoses for dysmenorrhea in a
young, otherwise health female include primary and
secondary dysmenorrhea, endometriosis, adenomyosis,
pelvic inflammatory disease (PID), cervical stenosis, fi-
broids, ovarian cyst, and endometrial polyps. Each pos-
sibility will be considered below.
Primary dysmenorrhea
This diagnosis is likely in probability but the APRN must
rule out pelvic pathology for definitive diagnosis. The dif-
ferential diagnosis for primary dysmenorrhea or painful
menstruation with no pathologic cause includes ruling
out other conditions such as membranous dysmenor-
rhea and secondary or pathological dysmenorrhea caused
514
W. Stoelting-Gettelfinger
by endometriosis, adenomyosis, PID, cervical stenosis, fi-
broids, ovarian cyst, and endometrial polyps (Decherney,
Nathan, Goodwin, & Laufer, 2007; French, 2005). Pri-
mary dysmenorrhea is generally associated with ovu-
latory cycles with the mechanism of pain attributed
to prostaglandin activity (Morrow & Naumberg, 2009).
Generally, it is believed that ovulation becomes associ-
ated with menstrual cycles 2–4 years after menarche in
most women, which is consistent with Ms. S’s history
(Zhang et al., 2008). Therefore, the diagnosis of primary
dysmenorrhea is suggested by the onset of symptoms
that coincide with the history of ovulation (Morrow &
Naumberg). Primary dysmenorrhea generally does not
occur at menarche, but generally occurs later in adoles-
cence (Decherney et al. Morrow & Naumberg).
Ms. S’s symptoms of menstrual cramping and pain did
not begin until age 18, which is consistent with the out-
side window for the onset of primary dysmenorrhea. It
is also important to note that “the prevalence of primary
dysmenorrhea peaks in the second and third decades of
life and decreases in frequency with advancing age as
the prevalence of secondary dysmenorrhea increases”
(Morrow & Naumberg, 2009, p. 19.) However, as many
as 14%–26% of adolescents miss school or work as a
result of primary dysmenorrhea pain (Decherney et al.,
2007; French, 2005; Wolf & Schumann, 1999). Ms. S’s
symptoms of missing work and school on the first day
of menses is also consistent with a diagnosis of primary
dysmenorrhea. Primary dysmenorrhea pain generally oc-
curs on the first day of menses when the menstrual
flow begins, but it may not be present until the sec-
ond day of flow (French; Morrow & Naumberg; Wolf &
Schumann). In addition, nausea, vomiting, diarrhea, and
headache may occur. In Ms. S’s case, the symptoms of
vomiting, diarrhea, or headache are missing. One distinc-
tion concerning primary dysmenorrhea is that symptoms
associated with endometriosis (discussed below) are not
present (Morrow & Naumberg). Ms. S’s menstrual pain
and cramping are somewhat consistent with primary dys-
menorrhea, but she also has symptoms consistent with
endometriosis, making a diagnosis of secondary dysmen-
orrhea a strong possibility.
Primary dysmenorrhea can be misdiagnosed as sec-
ondary dysmenorrhea because of endometriosis. How-
ever, the timing and onset of symptoms are helpful
in differentiating primary and secondary dysmenor-
rhea (Decherney et al., 2007; Youngkin & Davis,
2004). Secondary dysmenorrhea because of endometrio-
sis may cause pain that usually begins 1–2 weeks be-
fore menses with peak pain 1–2 days before menses
that is relieved by the onset of menstrual flow (Dech-
erney et al.; Morrow & Naumberg, 2009; Youngkin &
Davis). In Ms. S’s case, her symptoms are somewhat
W. Stoelting-Gettelfinger
a mix of primary dysmenorrhea-related pain and sec-
ondary dysmenorrhea/endometriosis-related pain. Ms.
S’s menstrual cramping pain generally begins 5–7 days
in advance of her period that is somewhat consis-
tent with secondary dysmenorrhea from endometrio-
sis. Endometriosis-related pain generally is relieved by
the onset of flow (Decherney et al.). In contrast, Ms.
S’s menstrual pain is worse on her first day of flow,
but does not subside until day 3 of her menstrual
flow.
Another symptom Ms. S is experiencing that is un-
related to primary dysmenorrhea is dyspareunia. Dys-
pareunia that occurs with deep thrusting during inter-
course is more often associated with endometriosis. Ms.
S’s dyspareunia that begins about 1 week before her pe-
riod and ends with its onset is somewhat consistent with
secondary dysmenorrhea/endometriosis. Because of Ms.
S’s age, onset of her symptoms, and mother’s history of
menstrual-related pain, it is likely that Ms. S has primary
dysmenorrhea, but it is important to rule out other pelvic
abnormalities such as endometriosis. Ms. S’s pain is not
relieved by her current dose of naproxen, another factor
that could possibly indicate that her dysmenorrhea may
not be related to primary dysmenorrhea prostaglandin
activity. However, Ms. S. has been taking a substandard
dose of naproxen 550 mg once daily. Before determining
that naproxen is ineffective, a therapeutic trial at an ac-
curate dose should be prescribed at 550 mg twice or even
three times daily (Abramowicz & Zucotti, 2007).
In addition, Ms. S has not tried any different types
of NSAIDs or antiprostaglandins other than naproxen
to treat her pain. Ms. S only takes naproxen when she
starts to experience pain. It is very possible that she will
respond well to a therapeutic dose of naproxen or an-
other NSAID such as ibuprofen (Abramowicz & Zucotti,
2007). Many women find one NSAID to be more effec-
tive than another, and tend to try various products before
settling on a single effective medication and dosage (Mor-
row & Naumberg, 2009). In addition, taking NSAIDs con-
sistently before the onset of pain has been shown to be
effective with some patients (Dawood & Khan-Dawood,
2007). Some patients with primary dysmenorrhea do not
get pain relief with medication. “It is estimated that as
many as 10%–25% of women do not respond to NSAIDs
or choose not to use them because of their related side
effects” (Morrow & Naumberg, p. 24). However, a recent
Cochrane Intervention Review found that NSAIDs pro-
vide effective relief for dysmenorrhea-related pain and
appeared to be more effective than paracetamol. How-
ever, the comprehensive review of over seven databases
did not demonstrate that any particular NSAID was safer
or worked better than others (Marjoribanks, Proctor,
Farquhar, & Derks, 2010). In addition, NSAIDs are
The 3 Common Ds in Women’s Health
known to cause adverse effects, including upset stomach,
headache, and sleepiness (Abramowicz & Zucotti).
Another factor to consider is the fact that Ms. S’s dys-
menorrhea has not been relieved by taking OCs. In fact,
she reported that her cramps have been “worse” since
her prescription was changed from one she had taken
for the past 18 months to an OC that has a slightly
higher level of estrogen 4 months ago. OCs, particularly
those with higher estrogen content, have been shown
to prevent pain in most patients with primary dysmen-
orrhea who do not obtain relief with antiprostaglandins
(Decherney et al., 2007). One Cochrane Review con-
cluded that there is insufficient evidence from random-
ized control led trials to support the contention that
low- and medium-dose estrogen OCs were effective in
treating women with primary dysmenorrhea. In addi-
tion, this Cochrane Review demonstrated no difference
between OC preparations (Wong, Farquhar, Roberts, &
Proctor, 2009). Despite the lack of randomized control
led trial data, nonsystematic reviews claim that OCs are
up to 90% effective in the treatment of dysmenorrhea
(Morrow & Naumberg, 2009; Smith, 2007). OCs pre-
vent ovulation and alter endometrium formation that
results in decreased prostaglandin activity and resultant
pain. Because Ms. S has not experienced any pain re-
lief by taking OCs, it is important to rule out other pelvic
abnormalities.
Secondary dysmenorrhea
This is likely in probability but the APRN must deter-
mine the source of pelvic pathology to make this diag-
nosis. The differential diagnosis for secondary dysmenor-
rhea includes endometriosis, adenomyosis, leiomyomas,
intrauterine devices, PID, adhesions, cervical stenosis,
ovarian cyst, and endometrial polyps. Each differential di-
agnosis will be analyzed for probability below.
Endometriosis. This is likely in probability but cannot
be confirmed without direct visualization of implants. En-
dometriosis should be considered in the differential di-
agnosis of virtually all pelvic disease because of its var-
ied presentations. Endometriosis is the growth of cells
similar to those that form the inside of the uterus (en-
dometrial cells), but in a location outside of the uterus.
Endometrial cells are the same cells that are shed each
month during menstruation. The cells of endometrio-
sis attach themselves to tissue outside the uterus and
are called endometriosis implants (Milingos et al., 2006).
The implants are most commonly found on the ovaries,
the fallopian tubes, outer surfaces of the uterus or in-
testines, and on the surface lining of the pelvic cav-
ity. Endometriosis should be considered in any patient
of reproductive age complaining of pain or infertility
515
The 3 Common Ds in Women’s Health
(Decherney et al., 2007; French, 2005). Endometrio-
sis is common among women of reproductive age and
its clinical findings vary greatly depending upon the
size, number, and extent of implants. Endometriosis is
estimated to affect over 1 million women (estimates
range from 3% to 18% of women) in the United States
(French; Milingos et al.). Infertility, dysmenorrhea, and
dyspareunia are the main presenting symptoms associ-
ated with endometriosis (Decherney et al.). Ms. S’s con-
cerns include dysmenorrhea and dyspareunia; however,
she has never attempted to get pregnant, so her fer-
tility is unknown. Endometriosis is likely in probability
based only on Ms. S’s history and timing of her symp-
toms but a definitive diagnosis cannot be made with-
out further diagnostic testing (Decherney et al.; Milingos
et al.).
Endometriosis is characterized by pain that begins 1–2
weeks before menses that reaches a peak 1–2 days be-
fore that is relieved at the onset of menstrual flow or
shortly thereafter (Decherney et al., 2007). Ms. S re-
ported cramping menstrual pain that begins 5 to 7 days
before her period begins with excruciating pain on her
first day of menses that disappears by the third day of her
flow. Ms. S’s symptoms are somewhat consistent with
secondary dysmenorrhea from endometriosis; however,
Ms. S’s pain is not relieved by the onset of her flow. In-
stead, Ms. S’s pain is at its worst on the first day of her
menstrual flow that is consistent with a diagnosis of pri-
mary dysmenorrhea. Endometriosis is also characterized
by pain during sexual intercourse or findings of adnexal
tenderness or mass or cul-de-sac nodularity. Ms. S re-
ported pain during sexual intercourse that begins about 1
week before her period begins and stops after her period
begins, which is consistent with endometriosis-related
pain. However, Ms. S’s pelvic exam did not reveal any ad-
nexal tenderness or cul-de-sac nodularity. Based on Ms.
S’s history and physical exam, it is likely that she has en-
dometriosis but such a diagnosis cannot be confirmed and
Ms. S’s symptoms should first be treated to see if they re-
solve before considering invasive diagnostic procedures
(Decherney et al.; Milingos et al., 2006).
Adenomyosis. This is unlikely in probability. Adeno-
myosis is a condition where the tissue that lines the
uterus (endometrium) grows within the uterus’ muscu-
lar outer walls. Adenomyosis generally occurs in women
late in their childbearing years after they have born chil-
dren (Decherney et al., 2007; V. L. Katz, 2007). Adeno-
myosis is characterized by excessive menstrual bleeding
that is heavy or prolonged, severe cramping or sharp,
knife-like pain during menstruation, dysmenorrhea that
lasts throughout a woman’s period worsens with age,
painful intercourse, menorrhagia, passing blood clots
during menstrual period, and a uterus that is symmetri-
516
W. Stoelting-Gettelfinger
cally double or triple normal size (Decherney et al.; V. L.
Katz). In this case, Ms. S is only 22 years of age, making a
diagnosis of adenomyosis unlikely. In addition, her uterus
was small in size upon physical exam. Although Ms. S has
dyspareunia and dysmenorrhea, she is not experiencing
any other symptoms associated with adenomyosis. There-
fore, a diagnosis of adenomyosis is unlikely.
Leiomyomas. Possible, but not likely in probability.
Uterine leiomyomas are benign tumors composed of
smooth muscle and fibrous connective tissue. They are
also referred to as fibromyomas, fibromas, fibroleiomy-
omas, fibroids, or simply myomas (Hildreth, Cassio, &
Glass, 2009; Van Voorhis, 2009). They can occur singly
but often are multiple, with variations in size. In addi-
tion, leiomyomas are more common in African-American
than in white women (Hildreth et al.). The etiology of
leiomyomas is not fully understood, but it is suspected
that they are monoclonal tumors resulting from somatic
mutations of one single neoplastic cell. It is also thought
that estrogens, progesterone, and human growth hor-
mone play an important role in the regulation of the
tumor growth (Hildreth et al.; Van Voorhis). Symptoms
occur only in 35%–50% of affected patients, with the
number one symptom reported being abnormal, exces-
sive uterine bleeding or menorrhagia. Leiomyomas may
also cause acute pain that may be characterized as dys-
menorrhea or dyspareunia. Other symptoms include uri-
nary frequency, urinary retention, ureteral obstruction,
and hydronephrosis (Hildreth et al.; Van Voorhis). In this
case, while Ms. S’s periods have been slightly heavier for
the past 4 months, they are not excessively heavy. In ad-
dition, Ms. S’s pain is only acute for the first day of her
menses and she is not experiencing any urinary symp-
toms. Ms. S’s dyspareunia is only experienced for about
1 week before her period and disappears after her period
begins. Based on Ms. S’s history and physical exam, a di-
agnosis of leiomyomas is possible but not likely.
PID/infection. Possible but not likely in probability.
PID infection and inflammation develop in the pelvic or-
gans, including the uterus, fallopian tubes, and ovaries.
PID is a general term for acute, subacute, recurrent,
or chronic infection of the oviducts, ovaries, and adja-
cent tissues. Most PID infections result from the bacte-
rial agents N. gonorrhoeae (GC) and Chlamydia trachomatis,
but they can even be viral or parasitic (Decherney et al.,
2007). Mycoplasma genitalium can also be an important and
frequent cause of female lower genital tract infections. It
is important to note that infections with M. genitalium and
C. trachomatis are often asymptomatic, with no significant
differences between the bacteria in terms of symptoms
(Falk, Fredlund, & Jensen, 2005). In this case, PID is pos-
sible, but not likely considering all differential diagnoses
because Ms. S has no prior history of PID, no previous
W. Stoelting-Gettelfinger
sexually transmitted infections (STIs) other than HPV,
and no change in her vaginal discharge. However, PID
must always be considered because it frequently presents
with bilateral/diffuse lower abdominal or pelvic pain.
Ms. S does not have any fever, nausea, or vomit-
ing. PID is generally characterized by the onset of lower
abdominal and pelvic pain, vaginal discharge, abdom-
inal, uterine, adnexal, and cervical motion tenderness
in addition to one or more of the following: tempera-
ture above 101◦ F, leukocyte count greater than 10,0000,
gram-negative intracellular diplococci in cervical secre-
tions, purulent material, and an elevated erythrocyte sed-
imentation rate (Decherney et al., 2007). Ms. S. has none
of the symptoms generally associated with PID. Diagnosis
of PID is generally confirmed by adnexal tenderness and
chandelier sign, neither of which was found on examina-
tion. In addition, Ms. S does not have bilateral or diffuse
pelvic pain. Ms. S’s negative STI tests for N. gonorrhoeae
and C. trachomatis 4 months ago in addition to her history
of a monogamous sexual relationship for the past 2 years
also decreases the likelihood of a diagnosis of PID.
Adhesions. Possible but only somewhat likely in prob-
ability. An adhesion is a band of scar tissue that binds
two parts of tissue together that should remain separate.
Adhesions develop when the body’s repair mechanisms
respond to any tissue disturbance, such as surgery, in-
fection, trauma, or radiation. Abdominal adhesions are
a common complication of surgery, occurring in up to
93% of people who undergo abdominal or pelvic surgery
so they should always be considered in a postsurgical pa-
tient. However, abdominal adhesions also occur in 10.4%
of people who have never had surgery (Hammoud, Gago,
& Diamond, 2004). Ms. S’s surgery occurred when she
was an infant, and her pain did not begin until nearly
18 years later. Adhesions typically begin to form within
the first few days after surgery, but they may not produce
symptoms for months or even years (Hammoud et al.).
Pain with intercourse caused by pelvic adhesions is a po-
tential sign of pelvic adhesions. In addition, endometrio-
sis can cause adhesions that cause tissues and organs to
become stuck together. Pain from adhesions can be re-
lieved by removing the adhesions through laparoscopic
resection, ablation, or surgery. Most commonly, adhe-
sions cause pain by pulling nerves, either within an organ
tied down by an adhesion or within the adhesion itself
(Hammoud et al.). Because Ms. S’s dyspareunia is peri-
odic in nature and occurs only a week before her period
and ceases with menstrual flow, abdominal adhesions are
possible, but not a likely cause of her pain.
Cervical stenosis. This is unlikely in probability. Cervi-
cal stenosis is a narrowing of the cervical opening. Cervi-
cal stenosis can lead to obstruction of menstrual flow and
dysmenorrhea in premenopausal women. Cervical steno-
The 3 Common Ds in Women’s Health
sis may be congenital, inflammatory, neoplastic, or surgi-
cal in origin and may be partially or completely occlusive.
Many cases of cervical stenosis follow surgical manipula-
tion of the cervix (Decherney et al., 2007; Youngkin &
Davis, 2004). In Ms. S’s case, she has not experienced
any change in her menstrual flow other than it has been
slightly heavier for the past 4 months. Her periods have
not changed in their duration and her cervix was pink
with a small round os upon physical examination. The
swab and brush were inserted with ease to obtain spec-
imens. Ms. S has never had any cervical surgeries, abla-
tions, cervical or uterine cancer, or radiation therapy fre-
quently associated with cervical stenosis. Based upon her
history and physical exam, cervical stenosis is an unlikely
cause of Ms. S’s dysmenorrhea.
Ovarian cyst. Unlikely in probability. Ovarian enlarge-
ment by a benign mass or cyst can cause twisting of the
ovary and tube to cause acute, severe abdominal pain
that may be accompanied by nausea and vomiting. Ms. S
has no nausea, vomiting, or severe abdominal pain. Most
significantly, her abdomen was soft, and nontender with
no adenexal tenderness; the ovaries were smooth and al-
mond like in size upon palpation without adenexal ten-
derness. However, ovarian cysts should be considered be-
cause they can cause pain if they twist the ovary causing
intermittent pain (Tierney, McPhee, & Papadakis, 2007).
Ms. S’s pain is related to the onset of her menses and sub-
sides by the third day of her menstrual flow. In addition,
Ms. S has been on OCs for the past 2 years and has taken
them continuously, which reduce her chances of experi-
encing an ovarian cyst. Ms. S has no history of menstrual
irregularities with menstrual cycles that occur at 28-day
intervals. Ovarian cysts often present with menstrual ir-
regularities (Decherney et al., 2007; Youngkin & Davis,
2004). Ms. S’s history is not consistent with an ovarian
cyst, making it unlikely in probability.
Endometrial polyps. This is very unlikely in proba-
bility. Endometrial polyps consist of areas in the uterus
where the lining (endometrium) becomes overgrown
and forms a mass (polyp). Uterine polyps may attach
to the interior of the uterus by a large base or a thin
stalk and range in size from a few millimeters to sev-
eral centimeters. Although endometrial polyps can hap-
pen at any time, uterine polyps most commonly oc-
cur in women in their 40s and 50s. Many women
with uterine polyps are asymptomatic, but generally,
these women experience one or more of the follow-
ing: irregular menstrual bleeding, such as bleeding vary-
ing amounts at frequent but unpredictable intervals,
bleeding between menstrual periods, excessively heavy
menstrual periods (Decherney et al., 2007; Dreisler,
Sorensen, Ibsen, & Lose, 2009). In Ms. S’s case, her age
makes her an unlikely candidate for endometrial polyps.
517
The 3 Common Ds in Women’s Health
In addition, she does not have irregular menstrual bleed-
ing, bleeding between periods, or excessive flow. Based
upon Ms. S’s history, a diagnosis of endometrial polyps is
very unlikely.
Membranous dysmenorrhea. Highly unlikely in
probability. The diagnosis of membranous dysmenorrhea
includes primary dysmenorrhea and secondary dysmen-
orrhea. Membranous dysmenorrhea is rare; it causes in-
tense cramping pain because of passage or shedding of
a cast of the endometrium as a single entity through an
undilated cervix (Decherney et al., 2007). In Ms. S’s case,
there have been no changes in her menstrual flow. Ms. S
reported no clotting or tissue in her menstrual flow that
might indicate membranous dysmenorrhea. In Ms. S’s
case, a diagnosis of membranous dysmenorrhea should
be considered a “zebra” among the “horses” of more com-
monly occurring differential diagnoses making it highly
unlikely.
Dyspareunia secondary to inadequate lubrication
This is very likely in probability. Inadequate lubrica-
tion remains one of the primary causes of dyspareunia
(DeCherney et al., 2007). The vagina produces lubrica-
tion during sexual arousal, but many women experi-
ence inadequate lubrication related to low estrogen states
such as postpartum and menopausal stages, lack of sex-
ual arousal or foreplay, and certain medications that in-
hibit arousal and production of lubrication (DeCherney
et al.). Although a drop in estrogen can occur at any age,
Ms. S’s inadequate lubrication is unlikely to be associated
with a low estrogen state. She is 20 years old, not postpar-
tum, has regular periods, and is not menopausal with no
decreased vaginal elasticity associated with aging. While
the two medications that Ms. S is taking at their current
doses are not generally associated with inadequate lubri-
cation, Ms. S’s complaints of vaginal dryness for the past
4 months in addition to her pelvic exam that revealed a
dry vaginal vault supports a diagnosis of dyspareunia sec-
ondary to inadequate lubrication. Based on Ms. S’s his-
tory, a diagnosis of dyspareunia secondary to inadequate
lubrication is very likely in probability.
Dyspareunia secondary to endometriosis. Likely
in probability but cannot be confirmed. The differen-
tial diagnosis for dyspareunia includes inadequate lu-
brication, low estrogen states such as postpartum and
menopausal stages, intact hymen, tender episiotomy scar,
decreased elasticity associated with aging, Bartholin’s
gland abscess or lesions, clitoral irritation, clitoral in-
fection, vaginal infections, sensitivity reactions, atrophic
reactions, endometriosis, PID, and ectopic pregnancy
(Decherney et al., 2007). Ms. S has been sexually ac-
tive for several years and does not have an intact hymen.
518
W. Stoelting-Gettelfinger
She had no lesions, abscesses, lesions, clitoral irritation,
or infection upon physical exam, nor has she used any
new soaps or products that might be associated with a
sensitivity reaction. Ms. S’s dyspareunia could be caused
by PID, but her history and symptoms make a diagnosis
of PID unlikely. Ms. S’s LMP was approximately 6 days
ago, making an ectopic pregnancy highly unlikely; how-
ever, the symptoms of pain upon deep penetration by her
partner are consistent with endometriosis. In addition,
Ms. S’s pain begins approximately 1 week before her pe-
riod when her potential endometrial implants would be
enlarged and disappears when her flow begins. Ms. S’s
history and symptoms are consistent with dyspareunia
caused by lack of lubrication or endometriosis.
Assessment/diagnosis
1. Primary dysmenorrhea—If, after ruling out all
other pathological causes for dysmenorrhea and
without a definitive diagnosis of endometriosis, pri-
mary dysmenorrhea would be the likely diagnosis
for Ms. S. given the normal pelvic exam. The pres-
ence of menstrual pain that is most acute on the
first day of menses and is not relieved by the on-
set of flow, plus a history of maternal menstrual
pain supports a diagnosis of primary dysmenorrhea
(Decherney et al., 2007).
2. Secondary dysmenorrhea because of
endometriosis—Cannot make a definitive diag-
nosis without direct visualization of endometrial
implants; however, based on Ms. S’s symptoms
this diagnosis remains likely in probability (Dech-
erney et al., 2007; Youngkin & Davis, 2004). The
presence of premenstrual cramping pain for 5–
7 days coupled with dyspareunia that occurs with
deep penile thrusting 1 week before menses and
disappears upon menses supports a diagnosis of
secondary dysmenorrhea due to endometriosis.
3. Dyspareunia secondary to inadequate
lubrication—Inadequate lubrication is one of
the primary causes of dyspareunia (Decherney
et al., 2007). Ms. S’s complaints of vaginal dryness
in addition to her pelvic exam that revealed a dry
vaginal vault supports a diagnosis of dyspareunia
secondary to inadequate lubrication.
4. Dyspareunia secondary to endometriosis—
Ms. S’s concerns of dyspareunia with deep penile
thrusting that occurs 1 week before menses and is
relieved by the onset of menses are consistent with
dyspareunia secondary to endometriosis. However,
further diagnostic testing including laparoscopy or
laparotomy because of previous pelvic surgery is
W. Stoelting-Gettelfinger
required for a confirmatory diagnosis (Decherney
et al., 2007; Youngkin & Davis, 2004).
5. At Risk for cervical dysplasia because of pre-
vious HPV infection—HPV lab results pending.
Ms. S’s history of HPV infection as indicated by her
ASCUS high-risk Pap smear 1 year ago places her
at risk for cervical dysplasia. Although Ms. S’s col-
poscopy revealed no cervical dysplasia and pending
the results of Ms. S’s HPV test results, Ms. S contin-
ues to be at risk for cervical dysplasia.
6. At risk for HIV because of unprotected sex—
HIV labs pending. Any sexually active person that
is having unprotected sex and not using condoms is
at risk for contracting HIV. Ms. S has had two sex-
ual partners, one of whom infected her with HPV.
She is not aware of how many sexual partners that
her first partner had or if he practiced safe sex by
wearing condoms. Ms. S’s sexual history places her
at risk for HIV.
7. At risk for GC and chlamydia—GC and chlamy-
dia cultures pending. Although Ms. S’s history
places her at very low risk of GC and chlamydia, she
is a sexually active collegiate who does not practice
safe sex and this places her at risk for contracting
all STIs including GC and chlamydia.
Diagnostic plan
1. Refer to specialist for laparoscopy or laparotomy
after 4–6 months of the therapeutic regimen (dis-
cussed below) if no relief from dysmenorrhea or
dyspareunia is obtained to determine the pres-
ence of endometrial implants or other patholog-
ical causes for pain, including pelvic adhesions.
Because of Ms. S’s previous abdominal surgery, la-
paroscopy may not be feasible even though it is less
invasive than a laparotomy. Ms. S’s menstrual pain
is debilitating and is affecting her daily life. If her
symptoms are not improved by the therapies im-
plemented below, further diagnostic testing is rec-
ommended. The use of other ancillary diagnostic
studies such as ultrasound, x-ray, and computed
tomographic scans are of little use in diagnosing
endometriosis. CA-125 (cancer antigen) is cost ef-
fective and is often elevated in women with en-
dometriosis, but it can be elevated by many other
pelvic diseases and is not specific to endometriosis
(Decherney et al., 2007). The reference standard
test for diagnosis and staging of endometriosis is
laparoscopy or laparotomy with biopsy. It should
be considered when first-line therapies are ineffec-
tive and dysmenorrhea causes functional impair-
ment (French, 2005). In addition, laparoscopy or
The 3 Common Ds in Women’s Health
laparotomy will allow for treatment by ablation or
removal of any endometrial implants or adhesions
or other pathologies if present.
2. In adolescents such as Ms. S who are 20 years of
age or younger, low-grade squamous intraepithe-
lial lesions (LSIL) or ASCUS detected by screening
should be monitored with repeated cytology every
12 months. If high-grade squamous intraepithelial
lesions (HSIL) or atypical squamous cells, cannot
exclude HSIL (ASC-H) is detected, Ms. S should be
referred to colposcopy for biopsy. If, at this first
12-month follow-up the cytology is normal or if
LSIL or ASCUS is detected, continued monitor-
ing is recommended. Routine screening should re-
sume if cytology is normal at the second 12-month
follow-up (at 24 months). If cytology shows LSIL,
ASCUS, ASC-H, or HSIL, referral for colposcopy
is warranted (American Society for Colposcopy
and Cervical Pathology [ASCCP], 2007; Bris-
mar, Johansson, Borjesson, Arbyn, & Andersson,
2009; Moscicki, 2008; Widdice & Mosciki, 2008).
Therapeutic plan
Primary dysmenorrhea or secondary dysmenor-
rhea/endometriosis. Treat empirically with hormonal
therapy/OC to delay Ms. S’s periods.
Regardless if Ms. S’s dysmenorrhea is primary or sec-
ondary to endometriosis, treatment with OCs is rec-
ommended to delay her periods and therefore limit
her dysmenorrhea symptoms related to menstruation.
There are several OC options to delay her periods
and limit her dysmenorrhea related to menstrual flow.
Any monophasic OC containing 20–35 micrograms of
estrogen (ethinyl estradiol) can be used to delay a
woman’s menstrual cycle. OCs prevent ovulation and
reduce prostaglandin production if Ms. S’s dysmenor-
rhea is truly primary in nature. In addition, monopha-
sic OCs disrupt or interrupt the cycles of stimulation
and bleeding of endometriotic tissue if her dysmenor-
rhea is secondary to endometriosis (Lehne, 2007). The
continuous exposure to combination OCs can result in
decidual changes in the endometrial glands and has
been shown to be effective in decreasing dysmenor-
rhea and even retarding the progression of endometriosis
(Decherney et al., 2007). If a generic monophasic pill is
prescribed, Ms. S. should take active pills from two pill
packs for 6 weeks in a row and then take inactive pills
during week 7. If she experiences no unpredictable bleed-
ing or side effects during this cycle, she would then take
active pills for 9 weeks consecutively in the next cycle
and 12 weeks in the following cycle to eventually limit
her periods to four times yearly. Using generic OCs may
519
The 3 Common Ds in Women’s Health
provide the most cost-effective method for limiting Ms.
S’s periods, but this requires the patient to use multiple
pill packs and discard inactive pills.
Another option currently on the market is the OC Sea-
sonale, a 91-day extended-cycle pack containing 84 con-
secutive active then 7 inert tablets that are started on day
1 of the menstrual cycle or on first Sunday after onset
of menses. Seasonale contains 0.03 ethinyl estradiol with
0.15 levonorgestrel (Lehne, 2007). Because Seasonale
provides 84 consecutive days of active pills, it will limit
Ms. S to having approximately four (4) periods per year
instead of twelve (12) to reduce the number of first men-
strual flow days, when Ms. S is most acutely affected.
Prepackaged extended pill packs provide a convenient
method for patients to keep track of their pills and do not
require discarding inactive pills. However, such prepack-
aged pill packs may cost more depending upon individual
insurance coverage.
A third option is the OC Seasonique, which provides
a pill pack with 84 days of pills containing ethinyl estra-
diol/levonorgestrel (0.03/0.15) followed by 7 days of pills
containing ethinyl estradiol at (0.01/0), a very low dose
of estrogen. The use of low-dose estrogen pills instead of
inactive pills during week 13 could limit uncomfortable
symptoms associated with a hormone-free interval such
as lighter periods and less bloating (Epocrates, 2009). An-
other option available that could delay Ms. S’s periods for
up to 12 months is Lybrel. Lybrel is a low-dose extended-
use contraceptive that contains low doses of progesterone
and estrogen (Tarascon Pocket Pharmacopoeia, 2007).
Lybrel is designed to be taken daily for a period of 12
months with no hormone-free intervals and no periods
for 1 year. Approximately 50% of women that take ly-
brel experience no periods at the end of one year’s treat-
ment. Approximately, 4 of 10 women experience spot-
ting or bleeding that requires wearing protective pads
(Epocrates). Each of these treatment options should be
discussed with Ms. S so that she can choose the option
that is best for her.
Analgesic therapy
Naproxen 550 mg PO should be taken with food twice
daily or three times daily beginning 3 days before the end
of active pill pack and discontinued when cramping sub-
sides after menses.
Because Ms. S took a substandard dose of naproxen
with no relief in the past, a trial of naproxen prescribed
at the appropriate therapeutic dose should first be used
to determine if pain relief can be obtained. Naproxen 550
mg taken twice daily or even three times daily for the
management of more severe pain has been shown to be
effective in the treatment of dysmenorrhea. “The main-
520
W. Stoelting-Gettelfinger
stay of pharmacologic treatment of primary dysmenor-
rhea spans across the several classes of prostaglandin
synthetase inhibitors, including aspirins, fenamates, and
nonsteroidal anti-inflammatory medications (NSAIDs)”
(Morrow & Naumberg, 2009, p. 24). Prostaglandin in-
hibitors such as naproxen have been shown to decrease
the intensity of symptoms associated with high levels of
endometrial prostaglandins. “Their effectiveness results
from cyclooxygenase inhibition and a subsequent de-
crease in prostaglandin production, leading to diminished
concentration of prostaglandins in endometrial fluid and
decreased uterine tone” (Morrow & Naumberg, p. 24).
Approximately 70% of women experience moderate to
complete relief of dysmenorrhea-related symptoms with
the use of prostaglandin inhibitors prescribed and taken
at appropriate dosages; however, individual trials show
wide variations in range (Morrow & Naumberg; Owen,
2004).
Analgesic alternative therapy
Ibuprofen 400 mg PO can be taken with food every 4–
6 hours beginning 3 days before end of active pill pack
and discontinued when cramping subsides after menses.
If Ms. S achieves no relief with a therapeutic dose of
naproxen, changing her to a different NSAID such as
ibuprofen may be effective in relieving her menstrual
discomfort. Ibuprofen is an NSAID/antiprostaglandin
that works by blocking prostaglandin synthesis and
metabolism. Antiprostaglandins such as ibuprofen must
be taken before pain is established because they are
much less effective after the onset of pain (Decherney
et al., 2007). In addition, Ms. S states that her mother’s
menstrual cramps are relieved by ibuprofen. Utilizing
a patient-centered approach to care, if Ms. S is more
comfortable taking a medication that effectively man-
ages dysmenorrhea for her mother, then such a choice
is reasonable in selecting equivalent treatment options.
Ibuprofen is an NSAID that is available over the counter
that has been extremely effective in reducing menstrual
prostaglandin and relieving dysmenorrhea (Decherney
et al.). Ibuprofen is also fairly inexpensive. Ibuprofen
should be tried and evaluated for relief before potentially
changing to a prescription type medication such as cele-
coxib (Celebrex), a COX-2 inhibitor, or stronger analgesic
such as codeine (Daniels, Gitton, Wenchun, Stricker,
& Barton, 2008). In addition, NSAIDs such as ibupro-
fen are appropriate sole therapy for women with mild
menstrual pain associated with minimal endometriosis
(Abramowicz & Zucotti, 2007). Because Ms. S has se-
vere dysmenorrhea, adding NSAID therapy plus OCs
will work synergistically to improve dysmenorrhea
(Decherney et al.).
W. Stoelting-Gettelfinger
Adjuvant therapy
The application of low-level topical heat therapy has
been shown to be as effective as ibuprofen in treating dys-
menorrhea. However, the practicality of applying contin-
uous low-level heat during the activities of daily living
such as attending class and working may be somewhat
impractical (Akin et al., 2001; Decherney et al., 2007;
Morrow & Naumberg, 2009).
Diets low in fat and meat products have been shown
to decrease serum sex-binding globulin and decrease
the duration and intensity of dysmenorrhea (Decherney
et al., 2007; Morrow & Naumberg, 2009). Low-fat veg-
etarian diets have been associated with increased serum
sex hormone binding globulin concentration and reduc-
tions in body weight, dysmenorrhea duration and inten-
sity, and premenstrual symptom duration. The decreased
dysmenorrheal symptom effects might be mediated by di-
etary influences on estrogen activity (Barnard, Sciallie,
Hurlock, & Bertron, 2000).
Dyspareunia secondary to inadequate lubrication
The application of personal lubricants can decrease dys-
pareunia by decreasing the friction of penile entry. Be-
cause Ms. S reported experiencing vaginal dryness for the
past 4 months at the onset of her painful intercourse, ap-
plication of a personal lubricant to the vaginal opening
may decrease the dyspareunia that Ms. S is experienc-
ing (A. Katz, 2007). In addition, taking sufficient time for
foreplay before sex allows time for a woman’s body to
produce natural lubricants that can facilitate penile en-
try and reduce friction (Goldstein, Pukall, & Goldstein,
2009).
Dyspareunia secondary to endometriosis
Changing sexual positions can alleviate dyspareunia
for many individuals that experience pain during inter-
course. Ms. S indicated that she and her partner were
willing to try different positions to relieve discomfort. If
a woman utilizes the top position, she has more control
over the depth of penetration and may decrease dyspare-
unia (Goldstein et al., 2009).
At risk for cervical dysplasia because of previous
HPV infection
Gardasil vaccine protects against the four major strains
of HPV that cause the majority of cervical cancers and
genital warts (Herrero, 2009). In uninfected women, Gar-
dasil can cause a 70% reduction in cervical cancers and
a 90% reduction in genital warts. In Ms. S’s case, even
though she has had an HPV infection, she may still get
The 3 Common Ds in Women’s Health
some benefit from the vaccine because we do not know
to which specific strains of virus she was previously ex-
posed. For example, if Ms. S was not exposed to HPV 16
that is associated with over 50% of cervical cancers, she
would still benefit from taking Gardasil (Herrero). Ide-
ally females should receive vaccination for HPV before
they become sexually active. In this case, Ms. S is sexu-
ally active and has been previously diagnosed with HPV.
Therefore, it would be extremely important to explain to
her that she would receive less benefit from taking the
vaccine because she has previously been diagnosed with
HPV and may have already contracted an HPV type tar-
geted by the vaccine. However, few sexually active young
women are infected with all HPV types covered by the
vaccine, so Ms. S could still get protection against the
types she has not contracted (Centers for Disease Con-
trol and Prevention [CDC], 2009). The 2008 updates on
Gardasil from the Advisory Committee on Immuniza-
tion Practices (ACIP) demonstrate efficacy was seen in
the subset of 16- to 26-year-old women who were poly-
merase chain reaction (PCR)-negative and seropositive at
baseline. However, no efficacy (positive or negative) was
seen in the subset of women PCR positive and seroposi-
tive at baseline (Haupt, 2008). The related costs and po-
tential benefits of the Gardasil series should be explained
in detail to Ms. S so that she can make an informed deci-
sion related to efficacy and cost.
Follow-up plan
1. Review GC and chlamydia results with patient.
2. After going over results with patient and answering
any of her questions, treat for any GC or chlamydia
infection if detected.
3. If positive for GC, explain to patient that all sexual
contacts must be notified and treated. Answer any
questions and address any concerns that the patient
might have.
4. Rescreen for C. trachomatis and GC 4–6 weeks af-
ter completion of therapy if GC and/or chlamydia
cultures come back positive (Uphold & Graham,
2003).
5. Schedule appointment to go over HIV test results.
6. Schedule appropriate counseling/referrals, addi-
tional testing, and treatment if HIV results are pos-
itive.
7. Go over HPV test results with patient in 1 week.
Answer any questions and address any patient con-
cerns at that time.
8. Follow Step 2 for the diagnostic plan as outlined
above. Although this patient has had a previous
colposcopy, explain the procedure and address any
concerns that she may have if the procedure is in-
dicated (ASCCP, 2007; Widdice & Mosciki, 2008).
521
The 3 Common Ds in Women’s Health
9. If HPV results are negative, re-check after first pe-
riod on selected OC regime to evaluate the effec-
tiveness of treatment regimen in alleviating men-
strual pain and dyspareunia.
10. Provide Gardasil immunization series upon pa-
tient’s decision at 0-, 2-, and 6-month intervals.
11. If no relief is obtained from treatment regimen, ex-
plore other pain control options and discuss referral
to specialist for further diagnostic testing.
Conclusion
In conclusion, three of the most commonly present-
ing women’s health-related conditions in a family-based
practice include primary dysmenorrhea, secondary dys-
menorrhea, and dyspareunia. Although these conditions
occur commonly, the development of a comprehensive
plan of care and accurate differential diagnoses remains
an interesting challenge for the APRN.
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