Dysmenorrhoea and Chronic pelvic pain

Question 1

Definition of chronic pelvic pain

Answer 1

Must last for 6 months or more and be severe enough to interfere with the woman’s quality of life
Is non-cyclic (if it is then its dysmenorrhoea)

Question 2

Types of Gynaecological pelvic pain (7)

Answer 2

Chronic pelvic pain syndrome (CPPS)
Dysmenorrhoea
Dyspareunia
Mittleshmirtz
Can also be IBS, cystitis or PID (under 40s)

Question 3

Dysmenorrhoea

Answer 3

Pain with menses –> 45% of women have them

Prevalence and severity decreases with age (72% at 19 to 67% at 24) and parity

Question 4

Dyspareunia

Answer 4

Pain during intercourse, may be deep or superficial

Prevalence ranges from 1.5% to 40%

Question 5

Mittleshmirtz

Answer 5

Midcycle or middle pain, lasting hours to days
Occurs in 20% of women
Can be localised to the side which is ovulating

Question 6

Epidemology of gynaecological pelvic pain (GPP)

Answer 6

Commonest cause of gynae referral (15-30% prevalence)–> usually lasts 15months to 2 years
50% of laparoscopies are for GPP, 2/3 are negative
Commonest in 36-40yrs white people

Question 7

Impact of GPP

Answer 7

58% cause a restriction of activities and 33% miss work –> but 41% never see a doctor
40% of those who see a GP are referred
25% never get a diagnosis

Question 8

Endometriosis

Answer 8

Due to Ectopic endometrium–> occurs in 10% of 15-45yos
Looks like a ‘gun-powder’ lesion
Caues inflammation and adhesions

Question 9

Pathology of endometriosis

Answer 9

Endometrial implanation–> due to retrograde menstruation, vascular/lymphatic metastasis, mechanical transport
In situ development–> coelomic metaplasia or induction

Question 10

Dyschesia

Answer 10

Difficulty or pain on defecation

May be related to gynae problems (endometriosis etc)

Question 11

Possible symptoms associated with chronic pelvic pain

Answer 11

Haematuria–>suggests a urinary involvement
Urgency –> urinary involvement or pelvic floor dysfunction
Rectal bleeding –> indicates GI problem
Haemoptysis
Cutaneous nodules and hyperprolactinaemia

Question 12

Pelvic inflammatory disease (PID)

Answer 12

An infection of the upper genital tract

May cause endometritis, parametritis, salpingitis, salpino-oophoritis, peritonitis or pelvic abscesses

Question 13

Chronic pain in PID indicates

Answer 13

Recurrent infections
A single, chronic infection
Adhesions
Women with chronic pain rarely have signs of PID

Question 14

Pelvic Pain syndrome (PPS)

Answer 14

also known as Pelvic venous congestion
Thought to be related to oestrogen, venous congestion and psychological factors (often a background of abuse/emotional trauma)

Question 15

Symptoms of PPS

Answer 15

Aching pains interspersed with acute episodes of sharp pain–> usually on one side
Worse on standing, exercise, pooing or post-coital
Worse in second half of menstral cycle
Eased by lying down and applying heat

Question 16

Findings in PPS

Answer 16

Pelvic tenderness
Pain on palpation of the ovarian site
Bluish discolouration of the vagina
Excess of white, non-infected vaginal discharge

Question 17

Investigations for chronic pelvic pain

Answer 17

USS
Laparoscopy
Pelvic Venography
Serum immunoassays (Ca 125)–> ovarian cancer antigen

Question 18

Frozen pelvis

Answer 18

Widespread inflammation causing sticking and adhesions of pelvic structures

Question 19

Treatment of endometriosis

Answer 19

Symptomatic –> prostaglandin inhibitors, may need assisted conception or psychotherapy
Medical–> COC or progestagens, Danzol, Gestrinone, GnRH agonists
Surgical –> Diathermy, laser vaporisation or excision, ovarian cystostomy, LUNA or hysterectomy/Oopherectomy

Question 20

Danzol

Answer 20

A synthetic modified progestagen with powerful anti-oestrogen and androgenic effects
Limited use due to severe androgenic SEs

Question 21

Gestrinone

Answer 21

A synthetic antiprogestagen which inhibits endometrial growth by androgenic effects

Question 22

LUNA/Presacral neurectomy

Answer 22

surgical removal of the presacral plexus of nerves which transmit pain from the pelvis

Question 23

Treatments for chronic pain from PID (4)

Answer 23

Adhesiolysis
Drainage of masses/abscesses
Antibiotics to remove infection
Surgery

Question 24

Treatments for Pelvic pain syndrome

Answer 24

Counseling
Hormonal treatments–> High dose medroxyprogesterone acetate or GnRH agonists
Radical Surgeries can be considered

Question 25

Presentation of Endometriosis

Answer 25

Commoner in younger women
Will cause cyclic pelvic pain/dysmenorrhoea
Can cause deep dyspareunia and possibly pain on defecation.
If there are deposits near the bowel it can lead to monthly rectal bleeding.

Question 26

Functional Pelvic pain

Answer 26

A complex and unclear concept related to CPP and fibromyalia like disorders. Are likely pain amplification syndromes with some psychological element. For now they can be considered the same.