1. Pelvic Pain – Dysmenorrhea and Endometriosis

2. Case 1
A 20 y.o. woman presents to her gynecologist with a 4 year history of increasing lower abdominal pain with her menses. The pain begins on the first day of her menses and lasts 2-3 days. She also complains of lower back pain and nausea. Menarche occurred at the age of 13 and her menses occur every 28 days and last 5 days. Physical and pelvic exam are normal.

3. Case 1
How is dysmenorrhea diagnosed? How is it distinguished from other types of pelvic pain?
What is the pathophysiology of dysmenorrhea?
What are reasonable approaches to treatment?

4. Dysmenorrhea
Dysmenorrhea – severe, painful cramping sensation in the lower abdomen often accompanied by other symptoms – sweating, tachycardia, headaches, n/v, diarrhea, tremulousness, all occurring just before or during menses
- Primary: no obvious pathologic condition, onset < 20 years old
- Secondary: associated with pelvic conditions or pathology

5. Primary Dysmenorrhea
Pathogenesis: elevated PG F2α in secretory endometrium (increased uterine contractility)
Treatment: NSAIDs – PG synthetase inhibitors – 1st line treatment of choice
Other treatment options: OCPs, other analgesics

6. Secondary Dysmenorrhea
Etiologies
- Cervical Stenosis
- Endometriosis and Adenomyosis
- Pelvic Infection
- Adhesions
- Pelvic Congestion
- Stress and Tension

7. Secondary Dysmenorrhea
Cervical Stenosis
- Severe narrowing of cervical canal may impede menstrual outflow – congenital or iatrogenic
- can cause an increase in intrauterine pressure during menses
- can lead to endometriosis

8. Secondary Dysmenorrhea
Cervical Stenosis
- Hx – scant menstrual flow, severe cramping throughout menses
- Dx – inability to pass a thin probe through the internal os OR HSG demonstrates thin cx canal
- Tx – cervical dilation via D&C or laminaria placement

9. Secondary Dysmenorrhea
Pelvic Congestion
- Due to engorgement of pelvic vasculature
- Hx – burning or throbbing pain, worse at night and after standing
- Dx – Laparoscopic visualization of engorgement/varicosities of broad ligament and pelvic sidewall veins

10. Evaluation of Pelvic Pain
Detailed history, targeted physical exam, labs (UA, UCx, CBC, HCG, tumor markers), diagnostic imaging studies (US, MRI, CT) as appropriate
Consider age of patient
“OLDCAAR”: onset, location, duration, context, associated sx, aggravating/relieving factors
Temporal characteristics: cyclic (e.g. dysmenorrhea), intermittent (e.g. dyspareunia), non-cyclic
Risk factors
GYN and Non-GYN causes

11. DDx Pelvic Pain - GYN GYN - Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA, torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection, severe prolapse

12. DDx Pelvic Pain – Non-GYN
Urologic
- UTI/urethritis, interstitial cystitis (IC), OAB, urethral diverticulum, nephrolithiasis, malignancy GI
- constipation, IBS, IBD (Crohn’s, UC), bowel obstruction, diverticulitis, malignancy, appendicitis
Musculoskeletal
- trigger points, fibromyalgia, hernias, neuralgia, low back pain
Other
- psychiatric – depression, somatization; abdominal cutaneous nerve entrapment in surgical scar; celiac disease

13. Case 1
At the age of 30, the patient presents with a 2 year history of infertility. Her menses are still regular but she has 2-3 days of spotting before her menses are due. She also complains of pain with intercourse and pelvic pain. In reviewing the patient’s history, the gynecologist notes that over the past year the patient was repeatedly treated by her internist with antibiotics for recurrent microscopic hematuria.

14. Case 1 What is the most likely diagnosis?
What are the main theories regarding the pathogenesis in this case?
How would you evaluate and treat this patient?

15. Endometriosis - Symptoms
Variable and unpredictable
- asymptomatic
- dysmenorrhea
- CPP
- deep dyspareunia
- sacral backache w/ menses
- dysuria +/- hematuria (bladder involvement)
- dyschezia/hematochezia (bowel involvement)

16. Endometriosis – Physical Exam
Uterosacral nodularity
Adnexal mass (endometrioma)
Normal exam

17. Endometriosis - Incidence
7-10% of general population
20-50% of infertile women
70-85% in women w/ CPP
No racial predisposition
+Familial association with almost 10x increased risk of endometriosis if affected 1st degree relative

18. Endometriosis - Pathogenesis
Retrograde menstruation (Sampson)
Hematogenous or lymphatic spread (Halban)
Coelomic metaplasia (Meyer/Novack)
Iatrogenic dissemination
Immunologic defects (Dmowski)
Genetic predisposition

19. Endometriosis - Pathogenesis
Retrograde menstruation (Sampson’s theory)
- Monkey experiments – sutured cervix closed to create outflow obstruction  caused development of endometriosis
- Clinical observation of retrograde menstrual flow during laparoscopy in humans
- Increased risk of endometriosis in women with cervical/vaginal atresia, other outflow obstruction
- Increased risk with early menarche, longer and heavier flow
- Decreased risk with decreased estrogen levels e.g. exercise-induced menstrual disorders, decreased body fat, + tobacco use

20. Endometriosis - Pathogenesis
Hematogenous or lymphatic spread
- Endometriosis found in remote sites – lung, nose, spinal cord, pelvic lymph nodes.

21. Endometriosis - Pathogenesis
Coelomic metaplasia
- Mullerian ducts are derived from coelomic epithelium during fetal development
- Hypothesize that coelomic epithelium retains ability for multipotential development
- Endometriosis seen in prepubertal girls, women w/ congenital absence of the uterus, and RARELY in men

22. Endometriosis - Pathogenesis
Iatrogenic dissemination
- Endometriosis has been found in cesarean section scar
Immunologic defects
Genetic predisposition
- polygenic, multi-factorial

23. Endometriosis - Diagnosis
Laparoscopy with biopsy proven histologic diagnosis – standard for dx of endometriosis
Empiric medical treatment with improvement in symptoms
CA 125 – NOT considered to be of clinical utility
Imaging – US, MRI, CT – only useful in the presence of pelvic or adnexal masses (endometriomas)

24. Endometriosis - Diagnosis
Laparoscopy with biopsy proven histologic diagnosis – standard for dx of endometriosis
- Extent of visible lesions do not correlate with severity of sx, but depth of infiltration of lesions seems to correlate best with pain severity
- classic powder-burn lesions, endometriomas
- lesions can be red, clear or white – more commonly seen in adolescents

25. Endometriosis - Diagnosis

26. Endometriosis - Diagnosis
2 or more of the following histologic features are criteria for Dx:
Endometrial epithelium
Endometrial glands
Endometrial stroma
Hemosiderin-laden macrophages

27. Endometriosis - Diagnosis
Imaging – US, MRI, CT – only useful in the presence of pelvic or adnexal masses (endometriomas)
- on US, endometriomas appear as cysts that contain low-level homogeneous internal echoes consistent with old blood (ddx includes hemorrhagic cysts)

28. Endometriosis - Diagnosis

29. Endometriosis - Treatment
Medications
- Progestins
- OCPs – continuous vs. cyclic – if no relief in 3 months, consider tx with Depo Provera or GnRH agonist
- NSAIDs
- GnRH agonists – most expensive
- Danazol – appears to be as effective as GnRH agonist for pain relief but with increased side-effects

30. Endometriosis - Treatment
GnRH agonists – create a state of relative estrogen deficiency – vasomotor side effects and potential decrease in bone density
- 12-month course of GnRH agonist therapy associated with 6% decrease in bone density
- No data regarding extended treatment with GnRH agonists beyond 1 year

31. Endometriosis - Treatment
Add-back therapy is advocated for women undergoing long-term therapy (i.e. > 6 months)
Some evidence to suggest that immediate add-back therapy may result in even less bone loss
- Add-back regimens: progestins alone, progestins + bisphosphonates, low-dose progestins + estrogens, pulsatile PTH

32. Endometriosis – Treatment Considerations in Adolescents
GnRH treatment is NOT recommended for patients < 18 years because the effects of these medications on bone formation and long-term bone density have not been adequately studied
Depo provera used for longer than 2 years has been shown to decrease bone density in adolescents – FDA warning against long-term use

33. Endometriosis – Treatment Considerations in Adolescents
If no improvement in symptoms after 3 months of empiric treatment with NSAIDs and OCPs, diagnostic laparoscopy should be offered

34. Endometriosis - Treatment
Surgery
- Laparoscopic laser vaporization vs. cauterization vs. excision
- Ovarian cystectomy for endometrioma
- Hysterectomy +/- BSO

35. Endometriosis - Treatment
Medications vs. Surgery
- Lack of data to support surgery vs. medical treatment for tx of pain symptoms due to endometriosis
- Starting with empiric medical therapy is appropriate
- Offer GnRH agonist therapy if initial medical treatment with OCPs and NSAIDs not helping
- Cost of comparing empiric medical management with definitive surgical diagnosis is difficult to assess, but 3 months of empiric treatment is less than a laparoscopic procedure

36. Endometriosis - Treatment
Medications vs. Surgery
- Surgery is associated with significant decrease in pain sx during the 1st 6 months following surgery
- Approximately 40% experience recurrent symptoms within 1 yr post-op
- Cumulative 5-yr recurrence rate of pain sx after d/c GnRH tx is ~50%

37. Endometriosis - Treatment
Medications vs. Surgery
- No evidence exists regarding effectiveness of adjunctive tx w/ danazol, OCPs, or progestins post-op in comparison with surgical treatment alone in the management of endometriosis-related pain
- However, 2 studies suuport the use of post-op GnRH agonists to extend the period of pain relief post-op

38. Case 2
A 35 y.o. woman presents to your office with persistent RLQ pain. Her past medical history is unremarkable with the exception of a ruptured appendix 1 year ago requiring emergency surgery. Her abdominal and pelvic exams are also unremarkable with the exception of a well-healed appendectomy scar.

39. Case 2
What questions would be important to ask in evaluating the patient?
What is the most likely diagnosis?
How would you treat this patient?

40. DDx Acute and Chronic Pelvic Pain
- GYN or Non-GYN etiology
- surgical emergency or not?
Chronic
- conservative/medical management or surgery?

41. DDx Pelvic Pain - GYN GYN - Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA, torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection, severe prolapse

42. DDx Pelvic Pain – Non-GYN
Urologic
- UTI/urethritis, interstitial cystitis (IC), OAB, urethral diverticulum, nephrolithiasis, malignancy GI
- constipation, IBS, IBD (Crohn’s, UC), bowel obstruction, diverticulitis, malignancy, appendicitis
Musculoskeletal
- trigger points, fibromyalgia, hernias, neuralgia, low back pain
Other
- psychiatric – depression, somatization; abdominal cutaneous nerve entrapment in surgical scar; celiac disease

43. Pelvic Pain Pain is always subjective
Chronic Pelvic Pain (CPP) – non-cyclic pain of 6 or more months duration that localizes to the anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of sufficient severity to cause functional disability or lead to medical care

44. Pelvic Pain
Approximately 15-20% of women aged years have CPP of greater than 1 year’s duration
20-50% of women who receive care in primary care practices have > 1 diagnosis
Demographic profiles suggest no difference in woman w/ CPP compared to women w/o CPP in terms of age, race and ethnicity, education, socioeconomic status, or employment status

45. Populations at Increased Risk of CPP
Physical and sexual abuse
PID
Endometriosis IC
IBS
OB history
Past surgery
Musculoskeletal disorders

46. Populations at Increased Risk of CPP
Physical and sexual abuse
% of women w/ CPP have a history of abuse
- If a history of abuse is obtained, it is important to ensure that the woman is not currently being abused and in danger

47. Populations at Increased Risk of CPP
PID
- Approximately 18-35% of all women with acute PID develop CPP
- Whether acute PID is treated with outpatient or inpatient regimens does not appear to significantly alter the odds of developing subsequent CPP

48. Populations at Increased Risk of CPP
Endometriosis
- Diagnosed laparoscopically in approximately 33% of women w/ CPP (other dx – adhesions, no visible pathology)
- Abnormal exam findings correlate in 70-90% of cases w/ abnormal laparoscopic findings
- More than half of those w/ abnormal laparoscopic findings have normal pelvic exams

49. Populations at Increased Risk of CPPIC
- Chronic inflammatory condition of the bladder characterized by voiding sx of urgency and frequency in the absence of another cause (such as infection)
- As many as 38-85% of women presenting to gynecologists w/ CPP may have IC

50. Populations at Increased Risk of CPP
IBS
- One of the most common disorders associated w/ CPP
- Chronic relapsing pattern of abdomino-pelvic pain and bowel dysfunction with constipation or diarrhea

51. Populations at Increased Risk of CPP
OB history
- Pregnancy and childbirth can cause trauma to the musculoskeletal system – lumbar lordosis, delivery of a large infant, operative vaginal delivery
- CPP also present in women with infertility – endometriosis, PID, adhesive disease

52. Populations at Increased Risk of CPP
Past surgery
- Adhesive disease – e.g. ruptured appy
- Cervical stenosis from prior cervical surgery

53. Evaluation of Pelvic Pain
Detailed history, targeted physical exam, labs (UA, UCx, CBC, HCG, tumor markers), diagnostic imaging studies (US, MRI, CT) as appropriate
Consider age of patient
“OLDCAAR”: onset, location, duration, context, associated sx, aggravating/relieving factors
Temporal characteristics: cyclic (e.g. dysmenorrhea), intermittent (e.g. dyspareunia), noncyclic
Risk factors
GYN and Non-GYN causes

54. Treatment of Pelvic Pain
Acute
- GYN or Non-GYN etiology
- surgical emergency or not?
Chronic
- conservative/medical management or surgery?

55. DDx Pelvic Pain - GYN GYN - Uterus
- fibroids, adenomyosis, endometritis
- Fallopian tubes
- PID/salpingitis, hydrosalpinx, ectopic
- Ovaries
- cysts – functional, pathological, TOA, torsion; mittleschmerz
- Other
- endometriosis, adhesions, IUD/infection, severe prolapse

56. Treatment of Pelvic Pain
Medications
- Pain medications
- Hormonal Tx – progestins, OCPs, GnRH agonists
- Antibiotics - inpatient vs outpatient – PID, endometritis, TOA
- Antidepressants – insufficient evidence to support tx w/ TCAs or SSRIs for CPP

57. Treatment of Pelvic Pain
Surgery
- Emergent – incomplete sab with active bleeding, ruptured ectopic, ovarian torsion, ruptured TOA
- Laparoscopy - CPP is the indication for at least 40% of all GYN laparoscopies – most common findings are endometriosis, adhesions, normal
- Hysterectomy +/- BSO

58. Treatment of Pelvic Pain
Surgery
- Presacral neurectomy – innervation from the superior hypogastric plexus (presacral nerve) supplies the cervix, uterus and proximal tubes – for primary dysmenorrhea/midline pain
- Uterine nerve ablation – transection of uterosacral ligaments at their insertions into uterus – interrupts cervical sensory fibers

59. Treatment of Pelvic Pain
Nonmedical/Alternative treatment
- Psychotherapy
- Exercise
- Physical therapy
- Accupuncture
- Herbals

60. Case 3
A 28 y.o. woman presents with a 6 hour history of severe RLQ pain, which began suddenly on arising from bed. Since the pain began, she has been nauseated and vomited twice. She reports two other episodes of similar pain in the past week, both of which resolved within 30 minutes.

61. Case 3 What other history would you find helpful?
How would the physical exam findings assist you with your differential diagnosis?
What diagnostic tests would you order?
What is your differential diagnosis?