Chapter 051. Menstrual Disorders and Pelvic Pain (Part 5) potx

Menstrual Disorders and Pelvic Pain Part 5 Acute Pelvic Pain: Treatment Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic interv

Chapter 051 Menstrual Disorders

and Pelvic Pain

(Part 5)

Acute Pelvic Pain: Treatment

Treatment of acute pelvic pain depends on the suspected etiology but may require surgical or gynecologic intervention Conservative management is an important consideration for ovarian cysts, if torsion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions The majority of unruptured ectopic pregnancies are now treated with methotrexate, which is effective in 84–96% of cases However, surgical treatment may be required

Chronic Pelvic Pain

Some women experience discomfort at the time of ovulation

(mittelschmerz) Pain can be quite intense but is generally of short duration The

mechanism is thought to involve rapid expansion of the dominant follicle, although it may also be caused by peritoneal irritation by follicular fluid released

at the time of ovulation Many women experience premenstrual symptoms such as breast discomfort, food cravings, and abdominal bloating or discomfort These moliminal symptoms are a good predictor of ovulation, although their absence is less helpful

Dysmenorrhea

Dysmenorrhea refers to the crampy lower abdominal discomfort that begins

with the onset of menstrual bleeding and gradually decreases over the next 12–72

h It may be associated with nausea, diarrhea, fatigue, and headache and occurs in 60–93% of adolescents, beginning with the establishment of regular ovulatory cycles Its prevalence decreases after pregnancy and with the use of oral contraceptives

Primary dysmenorrhea results from increased stores of prostaglandin

precursors, which are generated by sequential stimulation of the uterus by estrogen and progesterone During menstruation these precursors are converted to prostaglandins, which cause intense uterine contractions, decreased blood flow, and increased peripheral nerve hypersensitivity, resulting in pain

Secondary dysmenorrhea is caused by underlying pelvic pathology Endometriosis results from the presence of endometrial glands and stroma outside

of the uterus These deposits of ectopic endometrium respond to hormonal stimulation and cause dysmenorrhea, which generally precedes menstruation by several days Endometriosis may also be associated with painful intercourse, painful bowel movements, and tender nodules in the uterosacral ligament Fibrosis and adhesions can produce lateral displacement of the cervix The CA125 level may be increased, but it has low negative predictive value Definitive diagnosis requires laparoscopy Symptomatology does not always predict the extent of endometriosis Other secondary causes of dysmenorrhea include adenomyosis, a condition caused by the presence of ectopic endometrial glands and stroma within the myometrium Cervical stenosis may result from trauma, infection, or surgery

Dysmenorrhea: Treatment

Local application of heat; use of vitamins B1, B6, and E and magnesium; acupuncture; yoga; and exercise are of some benefit for the treatment of dysmenorrhea However, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most effective treatment and provide >80% sustained response rates Ibuprofen, naproxen, ketoprofen, mefanamic acid, and nimesulide are all superior to placebo Treatment should be started a day before expected menses and is generally continued for 2–3 days Oral contraceptives also reduce symptoms of dysmenorrhea Failure of response to NSAIDs and oral contraceptives is

suggestive of a pelvic disorder, such as endometriosis, and diagnostic laparoscopy should be considered to guide further treatment

Further Readings

Dawood MY: Primary dysmenorrhea: Advances in pathogenesis and management Obstet Gynecol 108:428, 2006 [PMID: 16880317]

Genazzani AD et al: Diagnostic and therapeutic approach to hypothalamic amenorrhea Ann NY Acad Sci 1092:103, 2006 [PMID: 17308137]

Hall JE: Neuroendocrine control of the menstrual cycle, in Yen and Jaffe's

Reproductive Endocrinology, 5th ed JF Strauss, RL Barbieri (eds) Philadelphia,

Elsevier, 2004, pp 195–211

Latthe P et al: Factors predisposing women to chronic pelvic pain: Systematic review BMJ 332(7544):749, 2006 [PMID: 16484239]

Pittock ST et al: Mayer-Rokitansky-Kuster-Hauser anomaly and its associated malformations Am J Med Genet A 135:314, 2005 [PMID: 15887261]

Wittenberger MD et al: The FMR1 premutation and reproduction Fertil

Steril 87:456, 2007 [PMID: 17074338]

Bibliography

Murray A: Premature ovarian failure and the FMR1 gene Semin Reprod Med 18:59, 2000 [PMID: 11299521]

Warren MP, Fried JL: Hypothalamic amenorrhea The effects of environmental stresses on the reproductive system: A central effect of the central nervous system Endocrinol Metab Clin North Am 30:611, 2001 [PMID: 11571933]