NR 602 Pelvic Pain- Dysmenorrhea Endometriosis

NR 602 Pelvic Pain- Dysmenorrhea Endometriosis

NR 602 Pelvic Pain- Dysmenorrhea Endometriosis

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Chamberlain Co…
COURSE TITLE
NR 602
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Pelvic Pain – Dysmenorrhea Endometriosis

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

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• What are reasonable approaches to
treatment?
Dysmenorrhea
• Dysmenorrhea – severe, painful cramping
sensation in the lower abdomen often accom
by other symptoms – sweating, tachycardia,
headaches, n/v, diarrhea, tremulousness, all
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occurring just before or during menses
– Primary: no obvious pathologic condition,
< 20 years old
– Secondary: associated with pelvic conditio
pathology
Primary Dysmenorrhea
• Pathogenesis: elevated PG F2? in secr
endometrium (increased uterine
contractility)
• Treatment: NSAIDs – PG synthetase
inhibitors – 1st line treatment of choice
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• Other treatment options: OCPs, other
analgesics
Secondary Dysmenorrhea
• Etiologies
– Cervical Stenosis
– Endometriosis and Adenomyosis
– Pelvic Infection
– Adhesions
– Pelvic Congestion
– Stress and Tension
Secondary Dysmenorrhea
• Cervical Stenosis
– Severe narrowing of cervical canal m
impede menstrual outflow – congenital iatrogenic
– can cause an increase in intrauterine
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can cause an increase in intrauterine
pressure during menses
– can lead to endometriosis
Secondary Dysmenorrhea
• Cervical Stenosis
– Hx – scant menstrual flow, severe
cramping throughout menses
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– Dx – inability to pass a thin probe thr
the internal os OR HSG demonstrates t
cx canal
– Tx – cervical dilation via D&C or
laminaria placement
Secondary Dysmenorrhea
• Pelvic Congestion
– Due to engorgement of pelvic vascula
– Hx – burning or throbbing pain, wors
night and after standing
– Dx – Laparoscopic visualization of

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NR 602 Pelvic Pain- Dysmenorrhea Endometriosis
– Dx – Laparoscopic visualization of
engorgement/varicosities of broad ligam
and pelvic sidewall veins
Evaluation of Pelvic Pain
• Detailed history, targeted physical exam, labs
UCx, CBC, HCG, tumor markers), diagnosti
imaging studies (US, MRI, CT) as appropriat
• Consider age of patient
• “OLDCAAR”: onset, location, duration, con

associated sx, aggravating/relieving factors
• Temporal characteristics: cyclic (e.g. dysmenorrhea), intermittent (e.g. dyspareuni
non-cyclic
• Risk factors
• GYN and Non-GYN causes
DDx Pelvic Pain – GYN
• GYN
– Uterus
– fibroids, adenomyosis, endometritis
– Fallopian tubes
– PID/salpingitis, hydrosalpinx, ectopic
– Ovaries

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– cysts – functional, pathological, TOA, torsion; mittleschmerz
– Other
– endometriosis, adhesions, IUD/infectio
severe prolapse
DDx Pelvic Pain – Non-GY
• Urologic
– UTI/urethritis, interstitial cystitis (IC), OAB, ureth
diverticulum, nephrolithiasis, malignancy
• GI
– constipation, IBS, IBD (Crohn’s, UC), bowel obstr
diverticulitis malignancy appendicitis

diverticulitis, malignancy, appendicitis
•