What can cause Acute and Chronic pelvic pain in a woman ?

Pelvic inflammatory disease (PID)
most commonly presents with bilat-
eral lower abdominal pain. It is generally of recent onset and is exac-
erbated by intercourse or jarring movements.

Fever is present in about
half of these patients; abnormal uterine bleeding occurs in about one-
third. New vaginal discharge, urethritis, and chills may be present but
are less specific signs.

With public health efforts to control sexually
transmitted diseases
, the rate and severity of PID have declined in the
United States and Europe; however, this is not the case in the devel-
oping world.

Subclinical PID with its attendant risks of infertility and
ectopic pregnancy remains a significant problem worldwide. Public
health and professional organizations recommend annual testing for
C. trachomatis in all sexually active women <25 and both C. trachomatis and N. gonorrhea in all women at increased risk.

Adnexal pathology can present acutely and may be due to rupture, bleeding or torsion of cysts, or, much less commonly, the fallopian tubes. Neoplasms of the ovary or fallopian tube are much less common causes. Fever may be present with ovarian torsion. Ectopic pregnancy is associated with right- or left-sided lower abdominal pain, with clinical signs generally appearing 6–8 weeks after the last normal menstrual period.

Vaginal bleeding occurs in ~50% of cases. Orthostatic signs and fever may be present. Risk factors include the presence of known tubal disease, previous ectopic pregnancies, a history of infertility, diethylstilbestrol (DES) exposure of the mother in utero, or a history of pelvic infections.

Rupture of the fallopian tube remains a life-threatening emergency; the incidence depends on access to care but is ~18% in developed countries. Threatened abortion may also present with amenorrhea, abdominal pain, and vaginal bleeding. Although more common than ectopic pregnancy, it is rarely associated with systemic signs. Uterine pathology includes endometritis and, less frequently, degenerating leiomyomas (fibroids).

Endometritis often is associated with vaginal bleeding and systemic signs of infection. It occurs in the setting of sexually transmitted infections, uterine instrumentation, or postpar- tum infection. A sensitive pregnancy test, complete blood count with differential, urinalysis, tests for chlamydial and gonococcal infections, and abdom- inal ultrasound aid in making the diagnosis and directing further management.

TREATMENT Acute Pelvic Pain 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 tor- sion is not suspected, to avoid unnecessary pelvic surgery and the subsequent risk of infertility due to adhesions. Surgical treatment may be required for ectopic pregnancies; however, women present- ing with unruptured ectopic pregnancies may be appropriate for treatment with methotrexate, which is effective in ~90% of cases when multiple doses are used.

TREATMENT Chronic Pelvic Pain Some women experience discomfort at the time of ovulation (mittelschmerz). The pain can be quite intense but is generally of short duration. The mechanism is thought to involve rapid expan- sion of the dominant follicle, although it also may be caused by peri- toneal irritation by follicular fluid released at the time of ovulation. DYSMENORRHEA

Dysmenorrhea refers to the crampy lower abdominal midline discom- fort 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 preva- lence decreases after pregnancy and with the use of oral contraceptives.

Primary dysmenorrhea results, in a majority of cases, from hormone- dependent prostaglandin (PG)-pathway mechanisms that cause intense uterine contractions, decreased blood flow, and increased periph- eral nerve hypersensitivity, resulting in pain. However, variability in response to COX inhibitors suggests that PG-independent pathways, such as platelet activating factor, may also mediate inflammation.

Secondary dysmenorrhea is caused by underlying pelvic pathology. Endometriosis results from the presence of endometrial glands and stroma outside the uterus. These deposits of ectopic endometrium respond to hormonal stimulation and cause dysmenorrhea, which begins several days before menses. Endometriosis also may 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, which is a useful sign on speculum examination. Transvaginal pelvic ultrasound is part of the initial workup and may detect an endometrioma within the ovary, rectovaginal or bladder nodules, or ureteral involvement.

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. The prevalence is lower in black and Hispanic women than in Caucasians and Asians.

Other secondary causes of dysmenorrhea include adenomyo- sis, a condition caused by the presence of ectopic endometrial glands and stroma within the myometrium. Cervical stenosis, which may result from trauma, infection, or surgery also may cause pain asso- ciated with menses.

Pelvic congestion syndrome is associated with pelvic varicosities with low blood flow. TREATMENT Dysmenorrhea Local application of heat is of some benefit. Exercise, sexual activ- ity, a vegetarian diet, use of vitamins D, B1 , B6 , and E and fish oil, acupuncture, and yoga have all been suggested to be of benefit but studies are not adequate to provide recommendations. However, nonsteroidal anti-inflammatory drugs (NSAIDs) are very effective and provide >80% sustained response rates. Ibuprofen, naproxen,
ketoprofen, mefanamic acid, and nimesulide are all superior to

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