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A 24-year-old woman presents to her primary care physician complaining of a deep, achy pain in her lower abdomen. When the pain began just over 3 months ago, she thought it was her usual menstrual cramps. She has had menstrual cramps since menarche at age 12. On several occasions, they were so severe that she had to miss school. Previously, the pain usually lasted for 3 to 4 days and was sometimes improved with ibuprofen. She decided to see the doctor because of persistence of the pain.

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  • What additional questions would you ask to learn more about her pelvic pain?
  • How would you classify the pelvic pain?
  • Can you narrow the differential through an effective history?
  • How can you use the history to decide on the appropriate diagnostic tests?

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Pelvic pain is a common problem plaguing 39% of women in primary care,1 and it accounts for 10% to 40% of gynecologic visits.2 Worldwide, the rate of dysmenorrhea is 16.8% to 81%, that of dyspareunia is 8% to 21.8%, and that of chronic pelvic pain (CPP) is 2.1% to 24%.3 In a study of nearly 300,000 women age 12 to 70 years, the annual prevalence of CPP was similar to that of migraine, asthma, and back pain.4 CPP is the primary reason for 10% to 35% of laparoscopies and 10% to 12% of hysterectomies performed in the United States at an estimated cost of more than $2 billion annually.2

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Acute pelvic pain (APP)Pain symptoms below the umbilicus that have been present for < 3 months.
Chronic pelvic pain (CPP)Nonmenstrual pain below the umbilicus of at least 3 months in duration.
Cyclic pelvic painPain below the umbilicus that is exacerbated before and during menses.
DysmenorrheaRecurrent crampy, lower abdominal pain during menses.
DyspareuniaA deep pain below the umbilicus that occurs with sexual intercourse.
Positive likelihood ratio (LR+)The likelihood of a particular diagnosis if a factor is present.
Negative likelihood ratio (LR-)The likelihood of a particular diagnosis if a factor is absent.
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The most serious causes of pelvic pain present acutely (< 3 months) and can be classified as pregnancy-related causes, gynecologic disorders, and nonreproductive disorders.5 The relative frequencies of these disorders in patients with acute pelvic pain (APP) have not been elucidated, and clinical diagnosis has been notoriously difficult. For example, laparoscopy confirmed pelvic inflammatory disease (PID) in only 46% of cases clinically diagnosed as PID,6 and only 37.8% of cases with a clinical diagnosis of adnexal torsion were confirmed by surgery in another series.7 Diagnosis of CPP is even more challenging. Although pelvic adhesions and endometriosis are frequently found with laparoscopy,8 controlled studies suggest that they may be incidental rather than causal.9 In many patients, CPP may be functional (eg, myofascial pain, irritable bowel syndrome) or psychogenic (eg, depression, anxiety, somatization).9

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Differential Diagnoses of App

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