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abdominal pain not related to menses, heavy menstrual bleeding, irregular vaginal bleeding and bleeding after
intercourse. Masses will often be noted on the pelvic exam.
Assessment: Differential Diagnosis of Chronic Pelvic Pain
Endometriosis Dysmenorrhea Mittelschmerz IBS
Age of onset
Early 30s but may be With first menstrual May occur at any time May occur at any time in
seen as early as late cycles, usually age after the start of life cycle.
teens. 12-14. menses.
Subjective: Symptoms
New or gradual onset Pain (cramps), usually Mid-cycle pain days Symptoms wax and
of menstrual pain. May start and end with 12-16 of menstrual cycle wane. Pain-cycles
start 7-10 days prior to menstruation. Crampy (count the first day of lasting weeks to months.
menstrual cycle, deep pain, usually radiating bleeding as day #1). Colicky pain associated
dyspareunia - worse to sacrum, vagina and Gradual onset of crampy with a feeling of rectal
during menses, sacral inner thigh area. lower pelvic pain which fullness. Pain improves
backache with menses. Ranges from mild to peaks in 24-36 hours. with bowel movement
Pain often radiates to severe. Often unilateral. Pain is and flatus. Alternating
inner thighs. Menses occasionally sudden in constipation and
may be heavier. onset. Some light stressors. “Bloating”
vaginal bleeding may frequent complaint.
occur.
Objective: Signs
Abd exam may elicite Physical exam will be May have diffuse mild Diffuse tenderness on
mild tenderness. WNL unless patient is abd tenderness. abd exam, greater in
Palpation of uterus and menstruating - Patient Enlarged, tender ovary LLQ. Often note
ovaries often very will have significant may be present or excessive discomfort
painful. Occasionally discomfort with exam ovaries may be WNL with rectal exam. Exam
may feel modules during menses but no Afebrile, WBC count otherwise nonspecific.
behind the uterus, will abnormalities of uterus WNL.
not have fever or or overies shoudl be
elevated WBC count. found. Afebrile, nml
WBC.
Plan: Treatment
NSAIDs for pain. Start As per Endometriosis. For acute pain: Toradol Metamucil or other
with first pain, even if 30-60 mg IM narcotic bulk-forming agent =
mild initially. Motrin 800 as needed. For chronic cornerstone of therapy
mg tid or Naprosyn 500 treatment NSAIDs and - take on a regular
mg bid. 24 hour dosing OCPs as per basis. Increase fluid
of NSAID important. endometriosis. intake. Identify, avoid
For acute relief - Toradol food triggers.
30-60 mg IM. Relaxation techniques
Occasional use of mild may be effective.
narcotic OK (Tylenol #3). Increase aerobic
Oral Contraceptive or exercise. Warm baths.
Depo-Provera will bring
relief to many but may
not be effective for 3
months. Start ASAP.