26, F, recurrent chronic pelvic pain before/during periods + sex

Question 1

26, F
PC: 8y hx recurrent pelvic pain, during periods/sex
HPC: lower abdo/back ‘dragging’ pain, ++ during period, occasional N+V, chronic hx of painful periods
No urinary, bowel, vaginal d/c, extra-menstrual bleeding
pain ++ - take days off, codydramol causes dizziness/constipation
COCP contraindicated (Hx DVT)
Sexual hx: Last smear/STI tests negative, uses condoms, partner of 4yrs
SHx: non smoker, non drinker
ICE: relationship, fertility, DVTs - doesn’t want pills

DIFFERENTIALS

Answer 1

• PID
• endometriosis
• ovarian cysts
• IBS

Question 2

26, F
PC: 8y hx recurrent pelvic pain, during periods/sex
HPC: lower abdo/back ‘dragging’ pain, ++ during period, occasional N+V, chronic hx of painful periods

INVESTIGATIONS

Answer 2

Bedside:
1) ABDO EXAM -tenderness across suprapubic region
2) BIMANUAL EXAM - right adnexal mass, fixed uterus
3) SPECULUM (+ cervical swab)
4) PREGNANCY TEST

Lab:
1) BLOODS - FBC, U&Es, b-HCG
2) CERVICAL SWAB

Imaging:
1) PELVIC USS - look for gross disease
2) MRI - look for rectovaginal deposits

Invasive:
1) LAPAROSCOPY + BIOPSY (but not yet clinically indicated!)

Dx: endometriosis

Question 3

26, F
PC: 8y hx recurrent pelvic pain, during periods/sex
HPC: lower abdo/back ‘dragging’ pain, ++ during period, occasional N+V, chronic hx of painful periods

MANAGEMENT

Answer 3

MEDICAL:
1) ANALGESIA
2) HORMONAL - 6 MTH SUPPRESSION OF OVARIAN FUNCTION using ONE of:
- COCP (unless contraindicated)
- progesterone only pill
- androgens (danazol/gestrinone)
- GnRH agonists - induce psuedo-menopause (+HRT if >6 mths due to osteoporosis risk)
- Mirena coil

SURGICAL:
1) CONSERVE FERTILITY (20-50% recurrence in 5 yrs):
- diathermy
- laser ablation
- adhesiolysis
- cyctectomy
- post-op IUS
2) RADICAL SURGERY (curative):
- total hystectomy + bilateral salingo-oophrectomy

Question 4

Alternative presentations of endometriosis?

Answer 4

o Cyclical or chronic pelvic pain, usually occurring before or during
menstruation, which may be associated with deep dyspareunia and heavy
menstrual bleeding.

o Other non-gynaecological symptoms such as rectal pain and bleeding that may
be associated with recto-vaginal endometriosis, or painful micturition
(especially during menses) which may suggest bladder involvement.

o Painful periods at any age (including adolescents) not responding to
nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptive drugs.

o Unexplained subfertility.