PHARMACIST ASSESSMENT – DYSMENORRHEA
Patient
Name:
HSN:
Address:
DOB:
Telephone:
☐ Lactating
Medical History ☐ Liver dysfunction ☐ Renal dysfunction (CrCl
)
Drug History/ Drug allergies:
Patient History
History of gynecological disorders other than typical dysmenorrhea symptoms (ex: endometriosis, ovarian cysts,
fibroids), inflammatory bowel disease, or irritable bowel syndrome?
☐ Yes  Refer to MD
History of IUD insertion within last six months?
☐ No  Continue ☐ Yes  Refer to MD
Is the patient trying to conceive or possibly pregnant?
☐ No  Continue ☐ Yes  Refer to MD
At what age did the symptoms first appear?
☐ 6 months - 1 year after menarche up to age 25 → Continue
☐ Onset immediately at menarch, after age 25, or after at least 2 years of painless periods → Refer to MD
(possible pelvic abnormality)
Previously diagnosed with dysmenorrhea by a physician?
☐ Yes ☐ No
Does the patient have a history of, or risk factors for, cardiovascular or cerebrovascular disease? (see full
guidelines for definitions of risk factors and CVD)
☐ No  Continue ☐ Yes  Prefer treatment options other than NSAIDs (particularly avoid diclofenac and
celecoxib). Refer to MD if NSAID deemed necessary.
Has any pharmacologic or non-pharmacologic treatment been used for symptoms?
☐ No ☐ Yes  What was tried?
What was the effect?
Review of Symptoms
Pain accompanied by a fever?
☐ No → Continue ☐ Yes → Refer to MD (possible infection)
Any rectal pain or bleeding ?
☐ No → Continue ☐ Yes → Refer to MD
Atypical gynaecological symptoms present? (pain during sexual intercourse, excessive bleeding during menstrual
period, intermenstrual bleeding, post-coital bleeding, vaginal discharge)
☐ No → Continue ☐ Yes → Refer to MD
Pain occurs in ovulatory cycles?
☐ Yes → Continue ☐ No → Refer to MD (pain onset premenstrually or lasting throughout the cycle
often found with endometriosis)
Symptoms consistent with the diagnosis of dysmenorrhea?
☐ cramps in lower abdomen, pelvis
☐ accompanied by other symptoms of prostaglandin excess (nausea, vomiting, diarrhea, backache, thigh
pain, headache, dizziness)
☐ pain starts shortly before onset of menstruation
☐ Yes → Proceed to treatment ☐ No → Consider other conditions / refer to MD
Treatment
☐ Non-pharmacologic treatment recommended:
☐ OTC medication recommended:
☐ Prescribe three day supply of prescription strength NSAID X three months. Options include:
☐ Ibuprofen: 600 to 800 mg three times daily when required. Maximum 3200 mg /day.
☐ Mefenamic acid: 500mg initially at onset of bleeding and symptoms, followed by 250mg every 6
hours for 3-5 days
☐ Naproxen base: 500mg initially, followed by 250mg every 6 to 8 hours, when required. Maximum
1.25g/day
☐ Other NSAID: (loading dose followed by usual recommended dose for 3-5 days)
Prescription Issued for minor ailment
Rationale for prescribing:
Rx: (Name, strength)
Quantity (may prescribe quantity for 3-5 days of treatment and up to three cycles, plus one refill):
Dosage Directions:
pseudoDIN: 00951095
Counseling
☐ Instructions on non-pharmacologic measures
☐ Expect relief of symptoms within 30 to 60 minutes; if no response after 3 cycles or symptoms worsen,
contact your pharmacist or MD
Follow-up scheduled in 2 to 3 days (date):
☐ In pharmacy ☐ Telephone (number:
)
☐ Symptoms resolved – advise continuing therapy as needed monthly. Contact MD for authorization of refills
past initial 3 months or refer patient to MD
☐ Symptoms improved but still bothersome --> Continue treatment for 3 months; if still a concern, consider
trial of a different NSAID (MAXIMUM two trials) or refer patient to MD.
☐ No effect or symptoms worsening --> Refer to MD
Prescribing Pharmacist:
Name:
Pharmacy:
Tel:
Signature:
Fax:
Email:
Date: