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ESSENTIALS OF DIAGNOSIS

  • Determine if pain is acute or chronic.

  • Categorize if pain is cyclic or continuous.

  • Consider nongynecologic causes.

1. PRIMARY DYSMENORRHEA

Primary dysmenorrhea is menstrual pain associated with menstrual cycles in the absence of pathologic findings. Primary dysmenorrhea usually begins within 1–2 years after menarche and may become progressively more severe. The frequency of cases increases up to age 20 and then decreases with both increasing age and parity. Fifty percent to 75% of women are affected by dysmenorrhea at some time and 5–6% have incapacitating pain.

Clinical Findings

Primary dysmenorrhea is low, midline, wave-like, cramping pelvic pain often radiating to the back or inner thighs. Cramps may last for 1 or more days and may be associated with nausea, diarrhea, headache, and flushing. The pain is produced by uterine vasoconstriction, anoxia, and sustained contractions mediated by prostaglandins. The pelvic examination is normal between menses; examination during menses may produce discomfort, but there are no pathologic findings.

Treatment

NSAIDs (ibuprofen, ketoprofen, mefenamic acid, naproxen) and the cyclooxygenase (COX)-2 inhibitor (celecoxib) are generally helpful. The medication should be started 1–2 days before expected menses. Symptoms can be suppressed with use of combined hormonal contraceptives, depo-medroxyprogesterone acetate (DMPA), etonogestrel subdermal implant (Nexplanon), or the levonorgestrel-releasing IUD. Oral contraceptives taken continuously can be used to suppress menstruation completely and prevent dysmenorrhea. Other therapies that have shown some benefit include local heat, thiamine 100 mg/day orally, vitamin E 200 units/day orally, and high-frequency transcutaneous electrical nerve stimulation around the time of menses. These options may be offered to patients who desire nonhormonal therapy, although they have less supporting evidence.

2. ENDOMETRIOSIS

General Considerations

Endometriosis is an aberrant growth of endometrium outside of the uterus, particularly in the dependent parts of the pelvis and in the ovaries. Its principal manifestations are chronic pain and infertility (eFigure 18–4). While retrograde menstruation is the most widely accepted cause, its pathogenesis and natural course are not fully understood. The overall prevalence in the United States is 6–10%.

eFigure 18–4.

Common sites of endometrial implants (endometriosis). (Reproduced, with permission, from Way LW [editor]. Current Surgical Diagnosis & Treatment, 10th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

Clinical Findings

The clinical manifestations of endometriosis are variable and unpredictable in both presentation and course. Dysmenorrhea, chronic pelvic pain, and dyspareunia are among the well-recognized symptoms. A significant number of women with endometriosis, however, remain asymptomatic, and most women with endometriosis have a normal pelvic examination. However, in some women, pelvic examination can disclose tender nodules in the cul-de-sac or rectovaginal septum, uterine retroversion with decreased uterine mobility, uterine ...

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